NUR 203 RESPIRATORY

Between an ET tube & a trache, which one is used for *long-term* mechanical ventilation and is more comfortable for the patient and has a *lower risk for VAP*?

trache *easier oral care* as well

True or False: Changing the vent. settings requires MD orders

true

True or False: If the output of a patient with a hemothorax was previously dark red, but is now bright red, this indicates a problem and the MD should be notified ASAP

true

True or False: PaO2 in patients with ARDS will be *low* but the RN should still notify the MD with any changes in PaO2 or any significant drops

true

True or False: Patients can ambulate with chest tubes

true

True or False: Older adults or those who have decreased muscle tone are harder to wean off the ventilator

true

True or False: The pleth wave should coordinate with the HR wave so it is important to monitor this when turning a patient with ARDS

true (make sure probe is attached securely)

True or False: A patient can have a hemothorax and a pneumothorax at the same time and can have multiple chest tubes/drainage systems

true -if multiple drainage systems, keep up with output appropriately (number systems and document each)

What should the RN monitor for if he is requiring increased PEEP?

-PEEP could cause decreased CO so monitor for *hypotension* (esp. if on diuretics too) -PEEP could rupture alveoli & cause *pneumothorax* so do thorough resp. assessment (lung sounds)

After *extubation*, what are patients at risk for?

-bronchospasms -airway edema -*stridor* *Tx = Racemic epinephrine* (IH) --> do resp. assessment to determine effectiveness (if doesn't work, re-intubate)

True or False: Patients with a drainage systems should have the fluid assessed *HOURLY* for the first 24 hr

true -measure the fluid --> it should never come into contact with any tubes (empty before it does) *after first 24 hrs, assess drainage q8hr*

How is a pleural effusion treated?

*thoracentesis* (aspirates fluid out) (RN can assist) (b/c it's developed slowly, typically chest tubes are not commonly used)

What is the treatment involved with *flail chest*?

- *PEEP on mechanical vent* (stabilizes it) - surgery in severe cases - pain meds (but be careful not to O/D) - humidified O2 *prevent worsening O2, pneumothorax/hemothorax, and pain*

What are the different treatment options for lung cancer?

- *surgery to remove the mass* - radiation - chemotherapy

What are the 3 most common mechanical vent settings?

- CMV (controlled mandatory ventilation) - ACV (assist control) - SIMV (synchronized intermittent mandatory vent)

What are the clinical manifestations of a *tension pneumothorax*?

- asymmetry of the thorax - tracheal movement away from the midline *toward the unaffected side* - *extreme resp distress* - absence of breath sounds on affected side - *distended neck veins* - cyanosis - hemodynamic instability -*resp alkalosis* *this causes decreased filling of the heart and decreased CO*

What are the complications associated with chest tubes?

- bleeding - organ perforation - intercostal neuralgia - tube blockage (pt. may be causing a kink in the tubing) - subcutaneous emphysema - reexpansion pulmonary edema - local infection and empyema

What are the different methods used for determining correct ETT placement?

- end-tidal CO2 - equal rise and fall of the chest when breathing for pt - auscultating lung sounds bilaterally - chest x-ray (blue line shows up) *after placement is confirmed, then secure it (don't wait for chest x-ray to confirm*

What are the clinical manifestations of *lung cancer*?

- persistent cough (dry or bloody) - *weight loss* - wheezing (b/c it could be obstructive) - dyspnea - chest pain/tightness - recurring pneumonia/pleural effusion/bronchitis - excess/bloody sputum (or sputum could be blocked from getting out) - sore throat/hoarseness -SOB -fatigue (*ask how long s/s have occurred*)

What types of medications are used to pre-medicate a patient prior to intubation?

- sedatives (propofol & midazolam) - paralytics (rocuronium & succinylcholine)

What are the different surgical approaches for removing a tumor in the lung?

- wedge resection: removes a small portion of the lobe - segment resection: removes a larger portion of the lobe - lobectomy: removes an entire lobe - pneumonectomy: removes the entire lung

What do you do if your patient self extubates?

-*assess resp. status* --> if apneic: *call code* // if breathing fine: *may leave extubated* -ambu bag -call resp. therapist (if tube starts to come out/go in further, don't be manipulating it....uh-uh don't be shoving that thang in)

What are the treatment options/RN care involved with the 3rd phase of ARDS?

-*mechanical ventilation* -*increased PEEP* (can go up to *20* - will help increase gas exchange & keep alveoli open) -resp. assessment -positioning (can be in *prone* // lateral rotation bed) -continue other Tx from previous phases *these pts lose O2 quickly/take longer to recover so LIMIT TURNING and GROUP TASKS*

What are the potential cardiac problems that result from mechanical ventilation?

-HoTN -fluid retention *both due to DECREASED CO*

What is a treatment option that is used only for *pneumothorax*?

*3-sided dressing* (3 sides taped down, one side left untaped) -air is pushed out but not pulled back in (similar to a one-way valve dressing)

What mechanical vent setting is used when the pt is beginning to breathe on their own but may still require additional help by the machine?

*ACV* --> the pt is still receiving a prescribed rate, TV, and FiO2 amount but is able to breathe over the vent on their own *the machine still controls TV for the breaths that the pt. breathes on their own*

What is the *progressive*, *reversible* syndrome that results from an inflammatory response in the lungs?

*ARDS* ---> important to treat the *cause* of the inflammatory response (no drugs prevent ARDS)

What does *continuous* bubbling in the water-seal chamber of a chest tube drainage system indicate?

*LEAK!* -assess tubing -look for holes

What is the vent setting that is used on *expiration* to *prevent lung collapse*?

*PEEP* --> positive end expiratory pressure (pressure left inside the lungs to prevent alveoli from collapsing)

What setting is used to wean patients off mechanical ventilation (like if only used for surgery)/ when moving towards extubation (*almost awake*)?

*SIMV* (synchronized intermittent mandatory ventilation) -pt's *mandatory R* is *lower* b/c we want the pt to breathe on their own (if not, change setting to AC) -seeing if the diaphragm is strong enough/if patient can breathe on their own like before surgery -pt decides their own TV for each breath they breathe on their own (but the vent still has a set TV for the breaths that are given by the machine)

What is the *definitive diagnosis* for lung cancer?

*biopsy* (other dx tools: x-ray, PET scan, CT scan, s/s) (x-ray shows presence)

What is the treatment used for both pneumothorax and hemothorax?

*chest tube* -allows air/fluid to escape so lung can re-expand and heal -prevents from becoming oxygenation problem

You assess your pt. and notice that their chest tube has come out of their chest. What do you do *first*?

*cover with dry, sterile gauze* --> then call MD (if the chest tube disconnects from the drainage system put the end of the tube in sterile water and keep it below the level of the pt. chest)

What alarm will sound when the ventilator meets resistance while trying to push air in?

*high pressure alarm* - increased amount of secretions (*suction PRN*) - pt coughs, gags, or bites the ET tube - anxious or fighting the ventilator (*re-orient them so you don't have to admin meds --> least invasive options first*) - pneumothorax occurs - artificial airway is displaced (may have slipped into the right bronchus) -kink in the tubing - non-compliant lungs *this decreases oxygenation b/c they are messing with the vent*

What is the main concern with chemotherapy?

*increased risk for infection* RN care --> pt on neutropenic precautions, nutrition, private room, dispose of urine in special way, watch site

If a patient has atelectasis in the right lung and a left pneumonectomy, how do you position this patient after surgery?

*left* side (on affected side) (gravity allows fluid to fill the empty space on left side and the good lung is up/can expand)

______ ________ alarm will sound when it is not meeting the minimal pressure to expand the lungs.

*low pressure* --> decreased oxygenation b/c they are not getting any air* - deflated cuff/hole - tube has come out - vent becomes disconnected from the airway

What is done usually *q2h* (or q4h) to prevent VAP?

*oral care & TCDB* -involves suctioning mouth to avoid secretions going to lungs and developing PNA -suction goes to right above the cuff

Explain what is going on in phase 1 of ARDS.

*phase 1*: -capillaries have *increased permeability* = leak -neutrophils are released (endothelium damaged) -hyaline membranes *start* to form around alveoli = decreased compliance = *decreased gas exchange* *pt in the phase:* increased WOB, slightly decreased O2 sat, wet lung sounds (b/c of leaky caps), *pulmonary edema*

Explain what is going on in phase 2 of ARDS.

*phase 2*: -cap permeability worsens = *worsened pulm. edema* -hyaline membrane formation worsens = even more *decreased gas exchange* (RT decreased compliance) - atelectasis may occur (no gas exchange) - right sided HF may develop *pt in this phase:* double increased WOB, double decreased O2 sat, *increased RR/HR*, crackles, *restless/anxious*, decreased BS

What occurs during the 3rd phase of ARDS?

*phase 3* (everything is worsened) -more cap permeability = even more pulm. edema -even more hyaline membrane formation = triple decreased compliance & triple decreased gas exchange - decreased TV - shocky VS *pt in this phase*: crackles or diminished lung sounds, altered LOC RT decreased O2, *organ fx decreases* RT decreased perfusion, increased HR (could cause *decreased CO*), decreased BS, *PaO2 <80%*

Which respiratory problem is similar to hemothorax but occurs more gradually over time as fluid takes up space?

*pleural effusion* (lung can't expand) --> may pick up on *decreased lung sounds* (not RT resp. issues) or a *slight* drop in O2 sat ---> *recommend chest x-ray* -*transudate fluid* RT to heart failure (hydrostatic pressure/leaky capillaries) *exudate fluid* RT pulm. infection/sepsis (infectious drainage)

Which vent setting is used to push air in during *inspiration*?

*pressure support* -can *weaken diaphragm* and result in difficulty extubating -can also *decrease RR* -> assess pt response

What is the role of the RN in regards to chest tube insertion/management?

-can assist w/ sterile field but NOT the procedure -anticipate pain management (local anesthetic) -sterile procedure (gown, mask, gloves, drapes, towels, gauze) -chlorhexadine to clean site -petroleum gauze & adhesive bandage after insertion -get sterile drainage system -placement confirmed w/ chest x-ray -site secured w/ *pressure dressing* -RN does *dressing changes* (monitor for infection/skin damage RT tape) -RN manages/monitors *drainage system*

What are the potential compilations of mechanical ventilation?

-damage to lungs/airway -decreased CO -increased risk for VAP -nutrition deficiencies (enteral/parental feedings) -stress ulcers -fall risk w/ ambulation -displacement of tube -communication issues

What are the treatment options/RN care for a patient in phase 1 of ARDS?

-diuretics (for pulm edema) - monitor UOP (foley) -apply O2 -raise HOB -monitor VS -ABGs -chest x-ray maybe -suction maybe

What does the RN do after chest tube removal?

-dress immediately -assess for drainage -auscultate lung sounds (establish new baseline - compare to sounds before removal) -full resp. status assessment -TCDB -ICS q 1hr while awake (ensure proper use)

What are the treatment options/RN care for a patient in phase 2 of ARDS?

-elevate HOB - apply increased O2 (but only so much gas exchange takes place due to decreased compliance --> may require intubation) -diuretics (monitor UOP - foley) -VS -suction maybe/probably - frequent resp. assessments -feed/check BG level -ABGs

What is the role of the RN when intubating a patient?

-ensure consent (if not emergent) -educate patient (if not emergent) -remove dentures/ assess teeth -continuous oxygenation (ambu) -continuous monitoring of O2 sat/chest rise & fall -after insertion & placement is confirmed, assess resp. status & teeth

What are the steps involved in *extubation*?

-explain procedure -have ambu-bag & O2 ready -hyperoxygenate pt -suction tube & oral cavity -rapidly deflate cuff -remove at peak inspiration -instruct pt to cough after extubation (avoid talking --> causes stridor) -pt starts on *high/humidified O2* (NRB/venturi) -monitor VS *q 5 min* at first -instruct pt to sit semi-fowler's, *take deep breaths q 30 min*, and use *ICS q 2 hrs* *orders:* -ABGs *30 min* post-extubation -*NPO until gag reflex returns* (may need *swallow test*) *what to monitor for:* -resp. distress/dyspnea -decreased O2 sat -decreased LOC -spasms -stridor -pallor/cyanosis

How does one get a hemothorax/pneumothorax?

-external chest trauma (*open* --> atmospheric air getting pulled in = *SUCKING* wound) -internal trauma (ex. *broken rib* --> no exit = *closed* pneumothorax --> lung tissue damaged) -spontaneous pneumothorax (asthma, COPD, emphysema, tall/white males)

Why is a tension pneumothorax very dangerous?

-impaired gas exchange (*decreased O2*) -increased thoracic pressure = *decreased CO* -*decreased BP* (it is a resp/oxygenation problem as well as a cardiac problem --> can be *fatal*) *** air builds up in pleural space, pressure causes tissue to push over to unaffected side --> trachea gets pushed over, pressure gets put on the heart, heart can't fill like it's supposed to, decreased CO, then unaffected side can't expand like it is supposed to which worsens oxygenation problem

What are some indications that a chest tube can be removed?

-intermittent bubbles in water seal have stopped -drainage/output has decreased (<200 mL in 24 hrs) -output is pleural fluid color (serous instead of blood) -clear lung sounds -chest x-ray confirms pneumo/hemothorax is gone -no output in 8 hr (MD may attempt clamping tube) -pt can tolerate clamped chest tube (MD order) -pt is receiving only 1-2 breaths per min on vent.

What should the nurse expect about the lung sounds and chest rise/fall of a post-pneumonectomy patient?

-lung sounds are *absent* -chest rise/fall is *unequal*

If your patient develops stridor, caused by inflammation in the airway, what interventions should the nurse implement?

-raise HOB -100% O2 -Racemic epinephrine (IH) / bronchodilators -contact HCP

Explain the thoracentesis procedure.

-requires informed consent -estimate how much fluid pre-op -done at bedside (pt sitting up) -auscultate/x-ray to find fluid -needle/catheter inserted through back -fluid drains out into -send aspirated fluid for culture (could start on broad-spectrum ab'tics until results are back) -covered with a band-aid (apply pressure) -pt could cough/become lightheaded as gas exchange improves (safety concern) -auscultate lung sounds after (assess for *pneumo/hemothorax*) -monitor site for bleeding/infection -TCDB -assess resp. status / pain

When weaning a patient off of the vent, or to lower vent settings (decreased O2), what should the nurse monitor?

-resp. status/ patient response -ABG's

What are the potential GI complications RT mechanical ventilation?

-stress ulcer (*use PPI/H2 antagonists* prophylaxis) -inadequate nutrition (plus r/f aspiration)

How is the drainage system of a chest tube managed?

-tape connection to chest tube -sit below bed (40 in.) but not in the way -suction is applied usually for hemothorax (indicated when float thing is present, ordered by MD) -water seal chamber acts as 1-way valve to suck air out (*bubbles* in correlation to breathing for pneumothorax --> *report constant bubbling*) -at change of shift, tell RN the *"zero-point"* b/c system is not emptied (it is completely changed out when full)

Where does the ET tube stop in the patient's airway?

3-5 cm above the carina (so air can go into both lungs)

Your pt. is on the ACV setting with a prescribed R of 12. You assess them and find that their RR = 20. How many times per minute are they breathing on their own?

8

Which mechanical vent setting requires the patient to be completely sedated so that it can completely control pt. breathing?

CMV (used for pt's who are *sedated* or who have been given *paralytics*) --> gives a prescribed *rate, tidal volume, and % of O2 to the pt.* (alarms will go off if the pt tries to breathe over the vent) *the diaphragm is not used at all* (if they are breathing on this setting they need more meds or to step down to ACV) Ex: RR = 12 (spaced evenly over 1 minute) TV = 450 mL FiO2 = 0.8 (80% oxygen w/ each breath)

What is the biggest difference between CMV and ACV?

CMV --> the patient does *NOT* help breathe ACV --> the patient helps breathe with the vent

What are the 2 most common artificial airways?

ET tube & trache *used when pt can't breathe adequately on their own/if airway is impaired, obstructed, incompetent* *RNs DO NOT INTUBATE* (ex. surgery/gen anesthesia, trauma, disease, anaphylaxis, inhalation injuries, etc.)

What type of oxygen delivery is used after a pt. has been extubated?

NRB or venturi *humidified air --> prevents tissues from swelling*

What is BiPap?

O2 (air) blowing in when the pt breaths -pressure on *both inspiration & expiration* (similar to PS / PEEP) (*cpap* is same pressure at all times - doesn't stop)

What effect does PEEP have on CO?

PEEP = *increased* thoracic pressure which causes *decreased CO*

What happens to the TV & PEEP in patients with ARDS?

TV = *lower* (can't handle as much/might damage lungs RT decreased compliance) PEEP = *higher* (to improve gas exchange/keep alveoli open)

The RN caring for a client who is intubated and receiving mechanical ventilation notes that her oxygen saturation is 89%, HR=120, and she is increasingly agitated and restless. On auscultation, the RN finds that the lung sounds are diminished on one side. Which action does the RN perform *first*? a) notify the HCP, and prepare for re-intubation or repositioning the tube b) document the findings, and request sedation from the HCP c) call respiratory therapy to obtain a set of ABG's d) reposition the tube, and call radiology STAT for a chest x-ray

a

What is the medical condition that results from fractures of at least 2 neighboring ribs in *2 or more places* that causes *paradoxical chest wall movement* (chest sinks as lungs expand)?

flail chest --> usually caused by blunt force trauma and is seen *unilaterally* (car crashes) *b/c the force required to produce a flail chest is great, always assess for underlying injuries* (this affects gas exchange and is extremely painful)

How is pressure in the ET tube cuff measured?

aneroid pressure manometer (must be trained to use it --> green area is how much pressure should be in it) -*too much pressure* = decreased blood flow --> tissue damage/necrosis in trachea -*too little pressure* = air leaks out

How often should patients with traches be sunctioned?

as needed (prn)

As the MD treats a *hemothorax*, output in the drainage system should start to *decrease*. However, what should you do if you notice a sudden *increase* in output?

assess *VS* & patient status for *HYPOVOLEMIA* then call MD -get data (lab results) before calling -also call MD if *change in color* (see if new meds were started before calling so MD doesn't waste time ordering med already on)

Which method of confirming ET tube placement is used immediately because it is the quickest?

end-tidal CO2 monitor (if "yes" or green - air is going into lungs)

What is the main goal for an intubated pt?

extubate them/get them back to pre-hospital breathing (RA --> but may require O2 for life) *important to know baseline*

Why should the nurse check an intubated patient's teeth after insertion of the ET tube?

because the tongue blade can damage/chip the teeth -document any teeth missing (before & after so you know if it was related to insertion)

The chest tube of a client 16 hours post-op from a lobectomy is accidentally pulled out by a portable x-ray machine. What is the nurse's best *first* action? a) clamp the tubing with the padded clamps as close as possible to the insertion site b) reposition the client on the non-operative side and support the tube(s) with pillows c) cover the insertion site with a sterile occlusive dressing and tape down on three sides d) don sterile gloves and attempt to reinsert the chest tube at the original insertion site

c

True or False: Pt's on mechanical ventilation are not allowed to ambulate

false --> just more precautions used and the risk of ETT tube/trache being dislodged increases - need an order by MD to be out of bed - safety precautions (slip resistant socks, decrease clutter, etc.) - make sure they can tolerate (elevate HOB, ask if dizzy, check HR/BP/RR, then slide them to edge of bed and repeat) - need more than 1 person to help in case of falls - passive ROM - continuously monitor airway (ET tube/trache) *pt on CMV setting cannot ambulate*

While on SIMV, you give your pt. morphine b/c they are post-op. Vent settings: R=6, TV=450 mL, FiO2= 80%. Before pain meds, their RR= 12. After meds, RR=8. You wake them up and it goes back up only to drop when they fall back asleep. How is *SBAR* implemented?

call MD and recommend that they be put on previous vent setting (AC) to allow the pt to rest and let meds wear off

What is the main difference between the different stages of lung cancer?

stages 1-4 (RN don't do staging but need to know differences to know treatment) *1:* localized (*not metastasized*) *4:* *metastatisized* (unlikely treatable)

A student nurse is working with a client in the ICU on a pt who is intubated and being mechanically ventilated. What action by the student causes the RN to intervene? a) repositioning the client q2hr b) providing oral care with chlorhexidene rinse c) checking tube placement at the client's incisor d) turning off ventilator alarms while working in the room

d

What is the treatment option for lung cancer that involves using *lower doses* of radiation while hitting the tumor from several *different angles*?

stereotactic radiosurgery / gamma knife -going at several different angles results in a *reduced risk for skin damage* b/c it isn't a high dose in one spot (mark spots where tumor is & keep pt from moving)

What is the term used to describe how much air is being pushed into the lungs with each breath?

tidal volume (400-500 mL is used for adults)

Why is it important to remove dentures before inserting an ET tube?

to reduce aspiration risk

What type of alarm would *asynchronous breathing* set off?

high pressure ex: when a patient coughs/talks it causes resistance against the ET tube*

How often should patency & sterility of the chest tube system be assessed?

hourly

What does PaO2 tell us & what is the normal range?

how much oxygen is in the blood *normal = 80%-100%*

What is the main complication following radiation?

impaired skin integrity (RN cares for site/skin) (potential organ damage)

What position are patients placed in prior to intubation?

laying flat with their head tilted back *may also see a towel roll behind their shoulders --> opens airway*

What happens to the lung sounds on a patient with a pneumo/hemothorax?

lung sounds are *diminished* on the *affected* side

How is oxygenation impaired in patients with ARDS?

lung tissue becomes *fibrotic* = *less compliant* --> can't expand = *decreased O2*

Which part of a trache is important have at the bedside at all times?

obturator (helps it go back in)

What is the build up of *air* or *blood* in the pleural space that keeps the lungs from being able to expand and results in oxygenation issues?

pneumothorax/ hemothorax (not getting the amount of air that is needed b/c the build up of air/blood is taking up space) (hemothorax = bleeding from inside - try to stop & get rid of it)

If too much fluid is removed via thoracentesis, what could it cause?

pulmonary edema

True or False: After a trache has been inserted, it is important to leave trache ties alone for 24 hrs (make sure they stay tied)

true -monitor for *edema*/*redness*/necrosis -holds trache in place until skin forms around *if a trache comes out within 72 hours after insertion, begin to use ambu bag to administer breaths --> reinserting it could cause tissue trauma*

True or False: It is important to establish a method of communication with patients that are intubated because they *cannot talk* (cuff cuts off air below vocal chords)

true (white boards, movements, etc.) *talk to patient/EDUCATE pt even if sedated* -when assessing *A&O*, ask them directly and then tell pt to indicate yes/no (squeeze, blink, etc.)

True or False: The RN is responsible for pre-oxygenating the patient with an ambu-bag before & after insertion of an ET tube

true --> *100% O2* (will hear O2) -will have a moment of no O2 during intubation --> this is why we want to limit the number of seconds for each attempt (no longer than 30 seconds)

True or False: You should call the MD if your pt. chest tube has between *70-100 mL/hr* output

true --> but really call MD with *any increase in output*

True or False: A chest tube is not inserted following a pneumonectomy

true --> there is no lung left to collapse so it is pointless *wedge, segment, and lobectomy may have chest tubes on affected side*

What is the purpose of the *cuff* on an ET tube?

when inflated it forms a *seal* that keeps air from leaking back out through the mouth & *allows lungs to be expanded*