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55 Cards in this Set

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Contents of Ventilator Seminar
-Pulse oximetry
-Manual ventilation with ambu
-Oxygen delivery systems
-Artificial airways
Pulse Oximetry
-Noninvasive measurement of oxygen saturation (SAO2).
-Measures the percent of hemoglobin that is bound.
-Can be used for continuous monitoring or spot check.
-Can reduce the need for frequent ABGs
-Can it completely replace ABGs?
Pulse Oximetry (con't)
-How do you know that your readings are accurate?

-What conditions could interfere with accuracy of measurements?
Manual Ventilation with Ambu Bag
-Proper position make a “C” with the hand.
-Thumb holds mask firmly over the nose to make a seal, 1-2 fingers hold the lower part of the mask firmly over the chin, 4-5 finger reach under the chin and lift opening the airway with a chin lift.
-Compress the bag with your dominate hand.
Ambu Bag
-Avoid overinflation, normal tidal volume 700 ml, ambu bag holds 1500 ml.
-Don’t forget to allow patient to exhale.
-Bag in synchrony with spontaneous breaths.
-Keep at bedside of all ventilated patients
-Connect to oxygen and turn the oxygen up to 15 l/min.
Ambu Bag (con't)
-When the ventilator malfunctions, why is the ambu bag your best friend?
Review oxygen delivery systems
-Great chart on p 602.
-Room air oxygen 21%. If patient develops hypoxemia, supplemental oxygen is needed.
-Some common choices are nasal cannula, face mask, nonrebreather, Venturi mask, trach collar.
Nasal Cannula
-Nasal cannula: flow is measured in l/min. not very precise delivery method.
-Affected by mouth breathing, obstructed nose.
-Advantages simple, patient can mobilize, eat, speak.
-Humidify for flow rates over 3 l/min.
- 1-2 l/min=23-30%
- 3-5 l/min=30-40%
- 6 l/min=42%
Face mask
-Oxygen is collected and stored in the mask.
---Patient breaths oxygen rich environment and exhales CO2 through openings in the sides of the mask.
- 6-8 l/min=40-60%
Nonrebreather mask
-Mask is attached to a reservoir bag. Oxygen enters the mask and bag.
-Patient breaths in oxygen rich environment and one way valves keep CO2 from entering the reservoir on exhalation. CO2 exits through flaps in the side of the mask.
- 12 l/min = 80-100%
-Usually used when high concentrations of oxygen are needed.
Venturi Mask
-High flow system provides most precise oxygen concentrations.
-Nurse dials in the oxygen required and as the dial turns openings in the mask are opened or closed to allow more or less room air to mix.
-Advantage is the accuracy of oxygen flow.
- 4-6 l/min = 24-28%
- 6-8 l/min = 30-40%
Tracheostomy Collar
-Provides humidified oxygen to a tracheostomy tube.
---Plastic collar lies over the tracheostomy opening and is fastened around the neck with elastic ties.
- 8-10 l/min=30-100%
Artificial Airways
-Endotracheal tubes
-Assessing position
--Auscultate equal bilateral breath sounds
--Apply CO2 detector between the endo tube and ambu bag
--Chest x ray to visualize tip 2cm above the carina
--Any others?
Artificial Airways
--Any others?
-
Artificial Airways
(Respiratory Therapist)
-Respiratory therapy will secure the endotracheal tube with tape or ties.
-Document placement by recording the cm mark on the tube at the level of the lips.
-Maintain cuff pressure to prevent aspiration or tissue necrosis on tracheal mucosa.
Artificial airway
(con't)
-Tracheostomy tubes, long term airway needs.
-Fenestrated tubes used for weaning and speech
-Outer cannula has a hole that when the inner cannula is removed and the trach is plugged at the opening in the neck the patient is able to move air through their upper airway.
-Allows air to pass through the vocal cords and speech to be resumed.
-When trach is plugged deflate the cuff and remove the inner cannula.
-Can you plug a nonfenestrated trach?
Advantages to Tracheostomy tube
-
(PART II)
Mechanical Ventilation
-Physiology of normal breathing
-Volume cycled-pressure limited ventilators
-Ventilator settings
-Modes of ventilation
-Troubleshooting alarms
Normal Breathing
-Normally people negative pressure breathe. Our diaphram contracts and pressure inside the chest becomes more negative. Gases move from areas of higher pressure to lower pressure and air rushes into our lungs.
-Exhalation is passive with the diaphram muscle relaxing and elastic properties of the lungs pushing air out of the lungs.
-Placing a patient on a ventilator changes all of the normal dynamics. All of a sudden a machine is forcing air into the lungs.
-Pressure in the ventilator has to be greater than the pressure in a patient’s lungs to cause air to enter.
-Mechanical ventilation is positive pressure breathing.
Volume cycled
- Pressure limited ventilation
-Volume cycled – each breath delivered to the patient has a predetermined volume. For example a Tidal volume of 700 ml means that with each ventilator breath the machine delivers 700 ml.
-Pressure limited – a safety feature that stops a breath if a certain pressure is reached.
-Peak inspiratory pressure - Amount of pressure needed to give a ventilator breath.
Ventilator settings
-Tidal volume – amount of air delivered to the lung with each breath.
-Rate- the number of breaths delivered by the ventilator each minute.
-Oxygen percentage – Percent of oxygen delivered with each breath. Referred to as the Fraction of inspired oxygen (FIO2).
-Peak inspiratory pressure – amount of pressure required to deliver a breath.
Modes of ventilation
-Control mode or assist control - CMV
-Synchronized intermittent mandatory ventilation (SIMV)
-Continuous Positive airway Pressure (CPAP)
-Positive end expiratory pressure (PEEP)
-Pressure support (PS)
Control mode ventilation or assist control

CMV
-Preset tidal volume is delivered at a preset rate.
-If the patient attempts to breath between breaths the ventilator will give a ventilator breath.
-Generally used on patients with most severe oxygenation problems.
-Should only be used for a short time due to potential respiratory muscle atrophy.
-Cannot wean in this mode.
Synchronized Intermittent Mandatory Ventilation (SIMV)
-Ventilator delivers a preset volume at a preset rate.
-If the patient tries to breathe between ventilator breaths the ventilator allows them to take as many additional breaths as they like.
-Best weaning mode, rate can be reduced gradually allowing the patient to breathe more on their own.
-Patient retains respiratory muscle strength.
Continuous positive airway pressure (CPAP)
-No preset mechanical breaths
-Patient must have spontaneous respirations.
-Can apply PEEP to this mode to help prevent atelectasis.
-CPAP trial – short test before extubation
-Different than CPAP machines for sleep apnea.
Positive end expiratory Pressure (PEEP)
-Improves oxygenation by providing some resistance to alveoli at the end of expiration. This maintains alveoli in slightly open position.
-Added to other modes of ventilation in increments of 3 cm of water to improve oxygenation.
-Optimum PEEP increasing PEEP improves oxygenation only to a point. At a certain point alveolar distention may compress capillary bed impairing perfusion, and oxygenation deteriorates.
-Side effects of PEEP, increased intrathoracic pressure, decreased venous return, decreased cardiac output.
-Increases cardiac workload
-Detrimental in hypovolemic shock
Purpose of adding PEEP
-Improve oxygen level
Pressure support (PS)
-Augments patient’s spontaneous respirations.
-Pressure is increased on inspiration to boost patient’s efforts.
-Used with other ventilator modes like SIMV and CPAP
Troubleshooting alarms
-High pressure alarms
-Low pressure alarms
High Pressure Alarms
Patient coughing
-Needs suctioning
-Circuit kinked
-Patient biting on tube
-Tension pneumothorax
Low Pressure Alarms
-Disconnected circuit
-Leak in circuit or cuff
-Underinflated cuff
-Patient extubated
Can pulse ox completely replace ABG's
-
How do you know that your readings with a pulse ox are accurate?
-
What conditions could interfere with accuracy of measurements?
-
A nurse is explaining to a student how to ventilate with an Ambu bag. What does she say?
make a C with your hand
thumb holds mask firmly over the nose
1 &2 fingers hold the mask over the chin and the other fingers lift the chin to open the airway
compress the airbag with dominant hand
allow the patient to exhale
bag with spontaneous breaths
keep at bedside of all ventilate ptes
then connect pt to O2 up to 15 L/min
When the ventilator malfunctions, why is the ambu bag your best friend?
-
What are the flow rates and percentages for nasal cannula?
room air is 21% so...
1-2 L/min = 23-30%
3-5 L/min = 30-40%
6L/min = 42%
What is the flow rate and percentage for a face mask?
6-8 L/min = 40-60%
What is the flow rate and percentage for a non-rebreather mask?
12 L/min = 80-100%
mask and reservior bag
What is the flow rate and percentage for a Venturi mask?
4-6 L/min = 24-28%
6-8 L/min = 30-40%
Which type of ventilation method delivers the most accuracy of O2 flow?
Venturi mask- most precise O2 concentrations
What type of ventilator is used on a trach patient?
Trach collar
What is the rate and percentage for a trach collar?
8-10 L/min = 30% -100%
What is the major difference between normal breathing and ventilator breathing?
normal breathing is negative pressure and ventilation is positive pressure
A pt is recieving Volume cycled ventilation. The nurse knows this means?
that each breath delivered to the pt has a predetermined volume
How can the nurse be sure that a Volume cycled ventalater is not going to deliver over the tidal volume required?
these are Pressure limited- a safety feature that stops the breath when a certain pressure is reached
When is a CMV ventilator used?

Can you wean a pt off of a CMV?
on the most severe O2 problems
and should be used for only a short time-

no
Explain to a pt what a CPAP is?
no preset mechanical breaths

pt must be able to breath on own

Can be used with PEEP (prevents atelectasis)

not same machine used for apnea
When should PEEP not be used?
for a pt in hypovolemic shock
The nurse knows that side effects of PEEP are?
decreased venous return (supine, legs up?) decreased cardiac output, increased cardiac workload, increased intrathoraic pressure
When does PEEP quit being an improvement on oxygenation?
at a certain point alveolar distention may compress capillary beds impairing perfusion and oxygenation deteriotes
A pt is put on PEEP. The nurse knows this is to?
improve oxygen levels
A pt is put on PS support. The nurse explains to the pt that this will?
augument the pt's spontaneous respirations. It is sometimes used with SIMV and CPAP
What will set off a highpressure alarm?
pt coughing
needs suctioning
kink in circuit
pt biting on tube
tension pneumothorax

anything that occuldes the tube
What will set off a low pressure alarm?
anything disconnected
or leaking or underinflated cuff