Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
63 Cards in this Set
- Front
- Back
|
- Inspiration to expiration is reversed - Normal is 1:2 but progresses from 1:1-4:1 - prolonged positive pressure applied increasing inspiration and expands alveoli preventing collapse - INDICATED FOR ARDS - who despite high levels of PEEP continue to be hypoxic - SEDATION required due to nonphysiological breathing pattern |
Pressure controlled INVERSE ration ventilation |
|
|
- allows for spontaneous breathing anytime during resp. cycle - CONTINUOUS positive airway pressure - designed for ARDS pts. who NEED high pressure levels. - helps keep alveoli open for better gas exchange |
Airway Pressure Release Ventilation |
|
|
- positive pressure to airway during EXHALATION - prevents closure of alveoli - pressure is never allowed to return to atmospheric pressure - lung volume is greater than normal thereby increasing functional residual capacity normal peep is 5 cm (can go as high as 18) INDICATIONS: Hypoxemia unresponsive to FIO2 >50%, ARDS pts. |
Positive End-EXPIRATORY Pressure (PEEP) |
|
|
- Similar to PEEP - delivered CONTINUOUSLY during spontaneous breathing preventing airway pressure falling to zero. INDICATIONS: obstructive sleep apnea INCREASES WOB because exhaling against pressure |
Continuous Positive Airway Pressure (CPAP)
|
|
|
- higher INSPIRATORY positive pressure and lower EXPIRATORY pressure - non-invasive - use mask INDICATION: COPD with heart failure, sleep apnea, post extubation to prevent reintubation |
(BIPAP) |
|
|
- delivery of small amounts of VT at RAPID respiratory rates (100-300 bpm) -maintains lung volume INDICATIONS: NICU, ped ICU, adults in refractory ARDS - NEED SEDATION AND PARALYTIC to suppress spontaneous respirations |
High Volume Oscillatory Ventilation (HVOV) |
|
|
- gaseous molecule made intravascularly that participates in regulation of pulmonary vascular tone. - inhibition of NO production results in pulmonary vasoconstriction - continuous INHALED NO results in vasodilation (good for COPD) INDICATION: ARDS, dx screen for pulm HTN |
Nitric Oxide VIAGRA = tx for pulmonary HTN |
|
|
-repositioning from supine to lateral to prone - promotes lung expansion by gravity INDICATION: ARDS - Takes ALOT of nursing effort to put a ventilated pt. in the prone position |
Prone Positioning |
|
|
- increase in intrathoracic pressure - decreased venous return to heart - **DECREASED CARDIAC OUTPUT** - decreased preload - HYPOtension |
associated with positive pressure ventilation |
|
|
-BAROTRAUMA - rupture of alveoli or blebs (because of the pressure) - subq emphysema (crepitis) - pneumothorax - VOLUTRAUMA- little fractures in alveoli allow fluid to move into alveolar spaces causing crackles and possibly pulmonary edema |
Pulmonary Complications associated with Positive Pressure Ventilation |
|
|
- Alveolar HYPOventilation from air leaks or low VT or leaking around cuff - Alveolar HYPERventilation from VT or RR to high |
associated with Positive Pressure Ventilation. |
|
|
- Pneumonia that occurs 48 hours or more after ET intubation - Early VAP = 96 hours - e.coli, klebsiella, steptococus pneumonia and haemophilus influenza -Late VAP = abundant in hospital and GI tract antibiotic resistant organisms pseudomonas and oxacillin-resistant staphylococcus aureus, contaminated respiratory equipment, inadequate hand washing (tell visitors to wash their hands), poor room ventilation and high traffic flow. Use sterile procedure when your supposed to!! |
Ventilator Associated Pneumonia (VAP)
|
|
|
- fever - elevated WBC - purulent or odorous sputum - crackles or rhonchi - pulmonary infiltrates |
Symptoms of VAP |
|
|
- no routine changes of pt. vent. circuits - Continuous "wall" suction above the glottis - STRICT handwashing - always wear gloves when in contact with pt. and change gloves often - always drain water in tubing AWAY from pt. |
Ways to prevent VAP
|
|
|
-Fluid retention due to decrease in CO - diminished renal perfusion (kidneys want to hold onto everything) - activation of RAAS system (na & h20 retention) - insensible water loss (lungs and skin) - stress response- release of antidiuretic hormone and cortisol contribute to sodium and water retention - edema ALL over = anasarca |
Sodium and Water Imbalance - complication of positive pressure ventilation |
|
|
- pts. w/ head injury PPV impairs cerebral blood flow = JVD - increased intrathoracic pressure decreases CBF - HOB - 30 degrees and correct head alignment - **suction cautiously** = ABC (ICP increases because pressure from the vent. intrathoracically causes fluid to remain in the brain = decreases drainage from head) |
Neurologic system complication from positive pressure ventilation |
|
|
- stress of illness, intubation, immobility and discomfort poses a high risk for stomach stress ulcers and GI bleeding - H2 blockers - zantac -PPI - protonics, nexium - pot. to dev. C-diff - enternal nutrition to reduce gastric acidity and reduce risk of ulcers (must place tube feed on HOLD before laying down pt.) - decreased peristalsis & gastric distention = constipation |
Gastrointestinal System Complications of Positive Pressure Ventilation |
|
|
What do you do if you have a vented pt. and alarm is ringing, pt is desating and anxious. You think something may be wrong with machine?
|
Use Ambubag to ventilate!
|
|
|
- Prevent contractures - Prevent pressure ulcers' - good body alignment - turn q2h - but prioritize pt. care if they can't breath, turning and bathing is NOT a priority |
Musculoskeletal system Complications of Positive Pressure Ventilation |
|
|
- pt needs to feel safe, have hope and trust, regain control and know whats going on = tell the pt. what your doing and what's going on. - Sedation and Analgesics - Propofol and Fentanyl Neuromuscular blocking agents- nimbex (pt. must also be sedated because pt. can hear, see, think and feel but cannot move) ** Train of four** - checks to see "how" paralized a pt. is - 0 twitches = too much paralytic |
Psychosocial needs |
|
|
- be certain alarms are set - DO NOT LEAVE with alarms off!!! - always be prepared to manually ventilate a pt if necessary - power outage - RED outlet |
Malfunction |
|
|
- secretions - coughing - "fighting" - condensation or kinked tubing (biting) - bronchospasm (spasm in the lungs) - increased resistance- pulmonary edema or pneumothorax |
Things that will cause a HIGH Pressure Limit ALARM |
|
|
- total or partial ventilator disconnect - partial or total extubation - ET tube or trach tube cuff leak - pt. speaking or grunting |
Things that will cause a LOW pressure limit ALARM |
|
|
- Respiratory arrest - oversedation - change in pt. condition - loss of airway (extubation) |
Things that cause "APNEA" ALARM
|
|
|
-pain, anxiety - change in pt. condition - excess condensation in tubing |
Things that cause "HIGH TIDAL VOLUME, MINUTE VENTILATION OR RESPIRATORY RATE" ALARM |
|
|
- Change in pt. breathing efforts, rate or volume - pt. disconnected or leak in circuit - cuff leak - insufficient gas flow |
Things that cause a LOW TIDAL VOLUME OR MINUTE VENTILATION ALARM
|
|
|
- Machine malfunction - unplugged, power failure or internal battery NOT charged |
Things that cause a "VENTILATOR INOPERATIVE OR LOW BATTERY" ALARM |
|
|
- ET tube eliminates normal route for eating - Trach pts may be able to eat normally once stoma heals. MUST have a swallow study before eating. - nutritional assessment completed within 24-48 hours of admission - small bowel feeing tube (j-tube or dub-huff) - limit carbs content - inadequate nutrition can delay weaning, decrease resistance to infection and slow down recovery. |
Nutritional Therapy for pt. receiving Positive Pressure Ventilation |
|
|
- reducing ventilator support and resuming spontaneous ventilation Pre-weaning phase: - determine pts. ability to breath - may take hours or days - assess muscle strength, endurance, vital capacity, minute ventilation (is the pt. tolerating being weaned) and breathing pattern - Lungs should be clear to auscultation and on x-ray - alert & oriented, no fever, hemodynamically stable |
|
|
|
Spontaneous breathing trial - AC, SIMV, low level Cpap, Pressure Support or T-piece - Tolerance - 30 min. or more may extubate - May try during day and leave on vent at night - allows muscles to rest between weaning - Always watch for respiratory distress when weaning. Signs of not tolerating weaning: decrease Spo2, ABGs, accessory muscle use, increase HR & BP |
WEANING a pt. from Positive Pressure Ventilation |
|
|
- Once ready for extubation - suction ET and Oral pharyngeal - preoxygenate - inst. pt to take a deep breath - deflate cuff - have pt. cough, then remove ET tube - administer O2 - Monitor for respiratory distress (not doing well after weaning) - if difficulty weaning >10-14 days a tracheostomy is usually performed. - more comfortable for the pt. |
Weaning from Positive Pressure Ventilation |
|
|
- When one or both gas exchanging functions are inadequate - insufficient O2 is transferred to the blood (hypoxemia) - inadequate CO2 is removed (hypercapnia) from the lungs - symptoms of underlying pathological condition |
Acute Respiratory Failure |
|
|
- PaO2 < 60% when patient is receiving 60% of > of O2 - insufficient O2 to blood (Normal PaO2 80-100) |
Hypoxemia Respiratory Failure |
|
|
- inadequate CO2 removed from the lungs - PACO2 >45% with ph <7.35 (normal PACO2 45-35) |
Hypercapnic Respiratory Failure |
|
|
Four physiological mechanisms can cause hypoxemia respiratory failure - mismatch between ventilation and perfusion (V/Q mismatch) - Shunt MOST COMMON - Diffision limitation - Alveolar hypoventilation - O2 failure problem - PO2 <60% even on 60% O2 |
Hypoxemic Respiratory Failure |
|
|
- When the match of blood perfusing the lungs and gas that reaches the alveoli isn't matched 1:1 ratio, there is a "mismatch" Causes: secretions in airway (pneumonia)= Perfusion is still occurring but lungs can't pick it up - affects vent. not perfusion COPD/Bronchospasms: Alveoli are being perfused but lungs aren't able to get rid of CO2 - affects vent. not perfusion Pulmonary Embolism: clots block gas exchange; affect perfusion not airflow - ADMINISTER O2 |
V/Q Mismatch |
|
|
- Occurs when blood exits the heart without having participated in gas exchange Two types: - blood leaves heart and bypasses lungs (ventricular septal defect) - blood passes through pulmonary capillaries without participating in gas exchange (fluid filled alveoli, ARDS, pneumonia - O2 IS USUALLY NOT ENOUGH, MAY REQUIRE MECHANICAL VENTILATION |
SHUNT **MOST COMMON**
|
|
|
- Occurs when gas exchange across alveolar-capillary is compromised due to alveoli that is thicken, damaged or destroyed - worse in COPD and recurrent pulmonary emboli - some diseases cause alveolar-capillary to become thicker (ARDs, pulmonary fibrosis and interstitial lung disease) Classic Signs: hypoxemia that is present during exercise but NOT at rest. |
Diffusion Limitation |
|
|
- restrictive lung disease - CNS disease - Generalized decrease in ventilation |
ALVEOLAR HYPOventilation |
|
|
- Combination of 2 or more: V/Q mismatch, Shunt, Diffision, Alveolar Hypoventilation - Pneumonia: hypoxemia d/t, V/Q mismatch, and shunt Ex: secretions obstruct airway produce exudate (shunt) |
Interrelationship of Mechanism |
|
|
- in NORMAL lungs supply far exceeds the demand - Resp. system inability to remove CO2 to maintain normal PaCO2 levels (will be elevated 4 types: abnormalities of the airway & alveoli, abnormalities of the CNS, abmormalities of the chest wall & neuromuscular conditions |
(ventilation problem) |
|
|
- asthma, COPD, cystic fibrosis - high risk for hypercapnic respiratory failure - Airflow obstruction - increased WOB against resistance AND air trapping |
(HYPERCAPNIC RESPIRATORY FAILURE) |
|
|
- Overdose of drugs (opioids, benzos) - They decrease CO2 reactivity in the brain causing CO2 levels to rise - Brain DOES NOT respond by altering the respiratory rate to get rid of CO2 |
(hypercapnic respiratory failure) |
|
|
- Flail chest, fractures, hyphoscoliosis & severe obesity |
(hypercapnic respiratory failure) |
|
|
- anything that causes MUSCLE WEAKNESS OR PARALYSIS - Guillain-Barre, muscular dystrophy, myasthenia gravis, multiple sclerosis |
(hypercapnic respiratory failure) |
|
|
- sudden decrease in PaO2 and increase in PaCO2 (gradual allows renal system to compensate) - 1st sign- CHANGE IN MENTAL STATUS - restless, confusion, agitation and combative - tachycardia, tachypnea, increase in BP |
|
|
|
Severe morning headache - hypercapnia occurred during the night, which causes vasodilation and mild increase in ICP - Cyanosis is late sign - PaO2 <45 - Hypoxemia leads to hypoxia |
Clinical Manifestations of Respiratory Failure |
|
|
- hypoxemia - PaO2 <80% - hypoxia occurs when you get symptoms - if hypoxia is severe the cells shift from aerobic to anaerobic - anaerobic uses MORE fuel and produces less energy and is much LESS efficient - the waste product is Lactic Acid |
Consequences of Hypoxemia and Hypoxia |
|
|
- lactic acid is difficult to remove from the body because it has to be buffered (sodium bicarb) - Lactic acid causes tissue and cellular dysfunction and cellular death - to much Lactic acid causes METABOLIC ACIDOSIS - as the body tries to compensate: HR & CO increase - eventually becomes ineffective- permanent brain damage and renal impairment |
Consequences of Hypoxemia & Hypoxia |
|
|
- RR increase to blow off CO2 - causes increase in muscle fatigue - decrease RR - because of inability to remove CO2 - change from a rapid RR to a decreased RR - pt at risk for respiratory arrest - mild to severe respiratory distress (dyspnea) - inability to speak indicates severe distress |
Clinical manifestations of Hypoxemia & Hypoxia |
|
|
- I:E ratio may change from 1:2 to 1:3 or 1:4 - retraction - retraction of intercostal muscles & accessory muscle use - paradoxical breathing (severe distress) - Crackles (pulmonary edema) - Rhonchi (pneumonia, COPD) - absent (atelectasis) |
Clinical Manifestations of Hypoxemia & Hypoxia |
|
|
- chest x-ray - ABGs - CBC - Serum Electrolytes - Urinalysis - ECG - Blood and sputum cultures - CT scan (pulmonary embolism) -VQ scan |
Diagnostic Tests for Hypoxemia & Hypoxia |
|
|
- start 1-3L/min. or venti mask 23% to 32% - may require mechanical ventilation (PPV) - High O2 levels cause instability in the alveoli - intubated pts. with FIO2 >60% for longer than 48 hours leads to O2 toxicity (will probably add PEEP to open airway) |
Nursing Care for Hypoxic pt. |
|
|
Mobilization of secretions - cough and deep breath - hydration & humidification - chest physiotherapy - Airway suctioning |
Nursing Care for hypoxic pt. |
|
|
- raise HOB - auscultate - Pre O2 - Suction (if PO2 doesn't go up) - call RT |
Nursing Care for hypoxic pt. |
|
|
Pallor, sweating, nausea, vomiting, seizures, muscle twitching, vertigo, tinnitus, hallucinations, visual changes, anxiety, resp. changes, reduced LOC
|
CNS manifestations oxygen toxicity
|
|
|
Positive Pressure Ventilation - Mechanical ventilation - non-invasive positive pressure ventilation (BiPap/Cpap) |
Nursing Care for hypoxic pt. |
|
|
-Reduction of Airway inflammation - Corticosteroids (solu-medrol) -Reduction of pulmonary congestion - Diuretics - Treatment of pulmonary infections - Ax (Rocephin or Zithromax) if pt. has dysrhythmias pt CANNOT have z-pack is PROdysrythmic |
Drug Therapy for hypoxic pt. |
|
|
-Reduction of pain, anxiety, & agitation - propofol (mechanical ventilation) - Benzos (lorazepam) - Midazolam (versed) - Neuromuscular blockage (Nimbex) ([t receiving this must also receive sedation and analgesia) |
Drug Therapy for hypoxic pt. |
|
|
- maintain protein and caloric needs - loss of muscle mass and muscle weakness - ideally parenteral nutrition starts within 24 hours if malnourished |
Nutrition for hypoxic pt. |
|
|
- changes in alveoli - diminished recoil within airways - decreased chest wall compliance - decreased muscle strength - poor nutritional status - vulnerable to delirium - develop ICU psychosis |
Gerontologic Considerations |
|
|
- open the blinds during day - bundle activities - write day/date on board - reorient pt. - quiet at night - turn off tv - encourage family to get rest |
To Prevent ICU psychosis in aging pt. |
|
|
|
|
