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51 Cards in this Set
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- Process by which oxygen (FIO2) is moved in and out of the lungs by a mechanical ventilator - Indications: apnea, acute resp. failure, severe hypoxia and resp. muscle fatigue |
Mechanical Ventilation |
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- Gets O2 to the alveoli - exchange for CO2 |
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Actually getting the O2 down into the alveoli, lungs, etc... |
Ventilation |
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- ORAL intubation is the preferred route - Usually done by anesthesia or CRNA |
Endotracheal Tubes |
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-used for upper airway obstruction, apnea, risk for aspiration, ineffective airway clearance and respiratory distress |
Indications for Endotracheal Tubes |
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- should be placed 2-6 cm (1-2") above the carina: pt. will cough/gag a lot - if only the Right Side of chest is rising the trach is inside the R. mainstem bronchus ... must withdraw a little |
Indications for having a Endotracheal Tube inserted: |
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- difficult to place if head or neck mobility is limited ex: spinal cord injury - can cause chipped teeth - increased salivation/difficulty swallowing - Biting on ET tube: may need a bite blook or oral pharyngeal airway and oral care is difficult due to limited space. |
Risk with Oral Intubation |
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- contraindicated in facial injuries or basilar skull fractures - WOB more difficult because of smaller tube - can get kinked - linked to increase incidence of sinus infections and VAP. |
Risk with Nasal Intubation |
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- AMBUbag connected to O2 delivers 90-95% of O2 - suction equipment (make sure its working) - communication can be very difficult |
Explain Intubation procedure to patient |
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- remove dentures, sedation (versed, fentanyl, succinylcholine), pt. supine with neck flexed (sniffing position) **- pre-oxygenate for 3-5 min.)** - each try is limited to 30 seconds -ventilate between each attempt |
Intubation Procedures (con't) |
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- inflate cuff and confirm placement - continue to manually ventilate - listen to bilateral breath sounds **- End tidal CO2 detector** FIRST If NO CO2 detected, tube is in the esophagus) - secure ET tube - Tape or Velcro holder - assess for rise and fall of chest |
intubation Procedure (con't)
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- once proper placement is confirmed - mark position on ET tube at lip line - 21 for women and 23 for men. - ET tube connected to ventilator or O2 - OBTAIN ABG: baseline then to guide ventilator adjustments |
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- check marked LIP line - document in cm - symmetric chest wall movement - Auscultate bilateral breath sounds |
Maintaining Correct Tube Placement of Endo Tubes |
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- balloon cuff on ET tube: - seals the trachea - prevents escape of oxygen - excess inflation can cause tissue damage to trachea - use manometer to maintain cuff pressure between 20-25 cm of H20 |
Maintaining proper cuff inflation |
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- place steth over trachea and inflate until no air leak is present - Minimal leak technique (MLT) - place steth over trachea and remove air- a slight air leak is noted at peak inflation. |
Maintain proper cuff inflation |
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- assess ABGs & Spo2 - lower values may be seen in COPD pts. - assess for sign of hypoxemia - mental status changes, anxiety, dusky skin, dysrhythmias, KEEP HOB 30-45 (helps prevent VAP) |
Best ways to Monitor Oxygenation while pt. has an endotube |
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- monitor RR, accessory muscle use, and PaCO2 - PaCO2 is the best indicator of alveolar ventilation - indicates hypo/hyperventilation (45-35 is normal) |
Best ways to Monitor Ventilation while pt. has an endotube
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- looks to see how well CO2 is being removed from the body - analyzes gas directly - assess patency of airway and ventilation and gradual changes in CO2 - CO2 increases = sepsis, hypoventilation - CO2 decrease = hypothermia, decreases in CO |
Capnography |
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- visible secretions - suspected aspirations of secretions (ask the pt.) - sudden onset respiratory distress (pt. anxious) - increase in peak airway pressure - ausc. for adventitious breath sounds - increase in RR or sustained coughing - sudden or gradual decrease in PaO2 or SpO2 |
Maintaining Tube Patency |
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- non-sterile - inline suctioning - stays on the patient 24-48 hours - flush to clear |
Closed suctioning |
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- sterile technique - pre O2 before suction |
Open suctioning |
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- PT. HAS TO HAVE AN OPEN AIRWAY - SUCTION CAUTIOUSLY |
Complications associated with suctioning |
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- provide adequate hydration (is the pt. getting enough IV fluids), humidification, mobilization (turn q2h), postural drainage, percussion |
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- moisten lips, tongue and gums with saline and water to prevent drying (H202 2-4hours, & chlorhexidine - 2/day) - meticulous skin care to prevent breakdown - reposition tube q2h and re-tape - remove bite block and provide oral care |
Providing Oral Care and Maintaining Skin integrity |
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- check cuff inflation - manometer or stethoscope (minimally occlusive or minimal leak) - secure tube - tape/tube holder - use 2 people to reposition ET tube For NASAL intubation - clean skin and re-tape q24h |
Providing oral care and maintaining skin integrity |
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- major stressor- can cause stomach stress ulcers - pt. should be on protonix or other PPI - provide: communication boards, note pads, I pads, explain procedures, present a calm reassurance - Even if pt. is unconscious (coma) talk to pt. and explain what you are doing |
Fostering Comfort |
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- pt. talking, low pressure alarms, diminished breath sounds, respiratory distress - assess security of ET tube - PREVENTION: sedation and soft restraints - HOB 35-40 - stay with pt. and prepare to reintubate - prior to planned extubation - suction to prevent aspiration |
- nurses can extubate with an order, however, must suction tube & mouth, back of throat to prevent aspiration |
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- epiglottis constantly open due to ET - High risk for aspiration (excessive salivation or gastric secretions, oral suctioning) - ET balloon inflation - BLUE TIP IS ALWAYS FOR AIR INFLATION. |
Complications of endotracheal intubation- ASPIRATION |
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old fashioned - chambers that encase the chest or body and surround it with intermittent subatmospheric pressure - iron lung, polio epidemic - more for neuromuscular disease
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NEGATIVE pressure ventilation |
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- used for acutely ill patient - during inspiration the ventilator PUSHES air into lungs under positive pressure |
Positive Pressure Ventilation PPV |
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- predetermined tidal volume(Vt) is delivered with each inspiration but the amount of pressure needed to deliver the breath varies on compliance and resistance of the patient-ventilator system - CONSISTENT FROM BREATH TO BREATH BUT THE AIRWAY PRESSURE WILL VARY - Alarms sound if pressure gets to high or low |
VOLUME ventilation |
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- PRESSURE is consistent but the tidal volume (Vt) varies. |
PRESSURE ventilation |
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- BASED ON ABGs - ideal body weight - LOC - Muscle strength - FINE TUNE to reach optimal ventilator support - Check all alarms to assess function = nurse - ABGs drawn q15m until optimal ventilation support is reached |
How the settings on a Mechanical Ventilator are adjusts (Nurses don't adjust setting - this is done by RT) |
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Number of breaths the ventilator delivers per minutes - 6-20 bpm |
RR |
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- 6-10 ml/kg - 400-800 normal |
VT = Tidal Volume |
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Fraction of inspired O2
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21% = room air 100% = what the ventilator is normally set at when first set up |
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- OPENS up alveoli to allow for better gas exchange - 5 cm H20 is normal physiological peep - can go as high at 18 |
Positive End Expiratory Pressure = PEEP |
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- can cause cardiovascular problems by increasing intrathoracic pressure which decreases Cardiac Output = increase HR, decrease BP
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Problems with PEEP |
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- 6-18 cm H20 |
Pressure Support |
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- 1:2 is normal - machine can change this and reserve - patient MUST be sedated because is goes against our normal breathing pattern |
I:E ratio |
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Speed with which the VT is delievered - 40-80 L/min or 0.8- 1.2 seconds |
Inspiratory flow rate & time |
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Determines amount of effort the patient must generate to initiate a ventilator breath |
Sensitivity |
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- what kind of PRESSURE has to be applied to deliver VT (tidal volume) (VT= volume of gas delievered to pt. during each ventilator breath) |
High Pressure Limit |
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- Based on WOB the pt. can perform - WOB: is the inspiratory effort needed to overcome the elasticity and viscosity of the lungs along with airway resistance - MODE is determined by ventilator status, ABGs & resp. drive (if a pt. has NO resp. drive they can't go on some ventilator modes) HIGH WOB= Pt. is trying really hard but unable to move much air (THINK ASTHMA) |
How the MODES of VOLUME VENTILATION are determined
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- vent is doing most of the work but the patient can breath OVER the setting. - pt. can breath faster than the setting but not slower - ventilator delivers a preset VT at a preset frequency - no matter how many breaths the pt takes the preset VT will deliver amount for EACH BREATH Ex: VT of 500X12 breaths= 500 w/each breath - this can cause HYPERVENTILATION!! |
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Indicated for: pt. with weakened or NO respiratory effort - high level spinal cord injury, Guillain-Barre, pulmonary edema & ARF Complications: hyperventilation-alkalosis hypoventilation-acidosis. - Ventilatory Asynchrony (fighting/bucking vent) pt will be coughing/agitated Interventions: talk pt. down, Are you in pain?, try to get them back into synch w/vent - If unable - must sedate |
Assist Control Ventilation (ACV)
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- vent. senses that the pt. wants to breath on their own -delivers preset VT at a preset # of breaths in synch with pt. spontaneous breathing PT will receive preset O2 but self-regulates rate and volume, thereby reducing chance of hyperventilation |
Synchronized Intermittent Mandatory Ventilation (SIMV) |
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Indication: weaning from vent. norm resp. drive but muscles too weak to perform all WOB - improves synchrony w/pt. breaths and prevents muscle atrophy - Complications: if spontaneous breathing decreased or rate gets to low hypoventilation will result. - may cause increased muscle fatigue |
SIMV |
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- positive pressure to airway ONLY during inspiration - Airway pressure is preset so gas flow rate is GREATER than pts. inspiratory flow rate. - pt. determines inspiratory length and RR |
PRESSURE SUPPORT VENTILATION |
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Indications: Weaning Advantages: increased pt. comfort, decreased WOB (inspiration is augmented), decreased O2 consumption, increased endurance NOT indicated for pts. in respiratory failure WEANING CAN TAKE HOURS TO DAYS! |
PRESSURE SUPPORT VENTILATION |
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