NURS 424: Exam 3

What lung problems can occur from mechanical ventilation?

- Barotrauma (damage to the lungs by positive pressure) - Volutrauma (damage to the lung by excess volume delivered to one lung over the other) - Atelectrauma (shear injury to alveoli from opening and closing - Biotrauma (inflammatory response-mediated damage to alveoli) - Ventilator-associated lung injury/ventilator-induced lung injury (VALI/VILI) (damage from prolonged ventilation causing loss of surfactant, increased inflammation, fluid leakage, and noncardiac pulmonary edema) - Acid-base imbalance

Extubation: - Procedure

- Before removal, explain the procedure - Set up the prescribed oxygen delivery system at the bedside - Bring in the equipment for emergency reintubation - Hyperoxygenate the client and thoroughly suction both the ET tube and the oral cavity - Then, rapidly deflate the cuff of the ET tube and remove the tube at peak inspiration - Immediately instruct the client to cough *It is normal for large amounts of oral secretions to collect - Give oxygen by facemask or nasal cannula - Monitor vital signs after extubation every 5 minutes at first and assess the ventilatory pattern for signs of respiratory distress *It is common for clients to be hoarse and have a sore throat for a few days after extubation - Education: *Sit in high-Fowler's position *Take deep breaths every 30 minutes *Use an incentive spirometer every 2 hours *Limit speaking - Observe closely for respiratory fatigue and airway obstruction

Tracheostomy: - Complications

- Bleeding - Infection - Ulceration - Dysphonia - Tube obstruction - Development of fistulas

Chest Tube: - Complications

- Bleeding at the insertion site - Risk of infection (empyema) - Subcutaneous emphysema: *A collection of air under the skin, after chest tube placement. Small amounts of air near the chest tube insertion site will likely be absorbed; however, if the air moves into areas of the neck, chest, and face - it will require further attention if painful - Lung trauma - Perforation of the diaphragm - Malposition of the chest tube (most common) *Results in persistent air and fluid in the pleural space until the malposition is identified and resolved

Pneumothorax: - Causes

- Blunt chest trauma - Medical procedures

When is a tracheostomy indicated?

- Clients requiring long-term mechanical ventilation (greater than 21 days) - Clients requiring airway protection - Clients with airway obstruction

ARDS: - Early Manifestations

- Dyspnea - Tachypnea - Rapid, shallow respiratory pattern - Use of accessory muscles - Mottling or cyanosis of skin - Abnormal breath sounds - Dry cough - Change in level of consciousness - Confusion - Restlessness - Retrosternal discomfort - Tachycardia - Fever

What conditions have increased compliance?

- Emphysema - COPD

Mechanical Ventilation: - Nursing Care

- Ensure a manual resuscitation bag and alternate oxygen (O2) supply is available at the bedside at all times - The bedside stock should contain an adequate supply of suction and oral care supplies - The nurse must respond quickly to ventilator alarms - Routine nursing assessments should include: *The level of the tube at the client's lip line *Size of the tube *Oxygen saturation levels *Level of consciousness (or sedation) *Breath sounds *Tolerance of the ventilator *Vital signs - While suctioning or moving the client, the nurse must monitor oxygen saturations and modify activities to ensure adequate oxygenation at all times - The nurse should analyze ABGs (if ordered) and evaluate the adequacy of gas exchange in order to ensure the client is receiving optimal ventilation and oxygenation - The nurse should verify that the prescribed settings are delivered via the ventilator and that tubing is free of kinks - Work with respiratory therapists to maintain appropriate temperature of the delivered gas to prevent mucus plugs - The nurse should ensure the ventilator is connected to an emergency electrical outlet so that, if the power fails, the ventilator will receive power from an alternate power source - Unnecessary disconnection of the ventilator circuit should be avoided - Sputum should be monitored for color, consistency, odor, and amount, and documentation must reflect these characteristics - The nurse should monitor the mouth or nose for signs of ulceration from tube pressure - Where possible, nurses should also evaluate the daily chest x-ray for tube position and the appearance of potential complications

What are common sedative agents utilized during rapid sequence intubation (RSI)?

- Etomidate - Ketamine - Versed (midazolam) - Diprivan (propofol) - Succinylcholine

Ventilar-Induced Lung Injury (VILI): - Causes

- Excessive pressure (barotrauma) - Excessive volume (volutrauma)

What supplies is required for rapid sequence intubation (RSI)?

- GludeScope *Most physicians use this type - Laryngoscope - Macintosh (curved blade) - Miller (straight blade) - Endotracheal tube - Stylet - 10 mL syringe - CO2 detector - Ambu bag - Oral airway - Nasal airway

Cancer of the Larynx:

- Head and neck cancers are usually squamous cell carcinomas - These slow-growing tumors are curable when diagnosed and treated at an early stage - The prognosis for those who have more advanced disease at diagnosis depends on the extent and location of the tumors - Untreated, these cancers are often fatal within 2 years of diagnosis

Chest Tube: - Procedure

- Informed consent is needed - Medicate the client - Provide oxygen - Keep the client supine with the arm of the affected side above the head - Monitor cardiac rhythm as poor oxygenation may cause a dysrhythmia - Thoracotomy tray: *Sterile gloves *Injectable lidocaine *Antiseptic *Scalpel *Hemostats *Chest tube *Suture material *Sterile dressing materials

Mechanical Ventilation: - Ventilator-associated Pneumonia *Ventilator Bundle Sets

- Keep the head of the bed elevated at least 30 degrees - Performing oral care per agency policy, usually: *Brushing teeth Q8H *Antimicrobial rinse (chlorhexidine) Q2H - Ulcer prophylaxis - Preventing aspiration - Pulmonary hygiene, including: *Chest physiotherapy *Postural drainage *Turning and positioning

What equipment is required for endotracheal intubation?

- Laryngoscope (test to ensure bulb is functional) - Endotracheal tube (of choice) - 10-cc syringe to inflate bulb - Sterile lubricant (anesthetic gel may be used) - Stylet (to help tube hold its shape) - Stethoscope (auscultate for placement) - Device or tape to secure tube following placement - Personal protective equipment - Suction with orotracheal suction device - Bag-valve mask - Oxygen source available - Medications for sedation - CO2 detector

ARDS: - Management Requirements

- Maintaining the client's airway - Providing adequate oxygenation - Supporting hemodynamic function

Extubation: - Obstruction *Manifestations

- Mild dyspnea - Coughing - Inability to expectorate secretions Stridor (late sign of narrowed airway) *High-pitched, crowing noise during inspiration caused by laryngospasm or edema around the glottis Racemic epinephrine, a topical aerosol vasoconstrictor, is given, and reintubation may be needed

How is the lower airways protected?

- Mucociliary escalator: *A complex system of cilia that continuously propel respiratory secretions into the upper airways for expulsion - Cough reflex: *Triggered by the presence of foreign substances in the airways *Touching the carina is one method for stimulating this reflex

What are the different types of pharyngeal airways?

- Nasopharyngeal airway - Oropharyngeal airway

Pneumothorax: - Types

- Open: Pleural cavity is exposed to outside air, as through an open wound in the chest wall) - Closed: Such as when a client with COPD has a spontaneous pneumothorax

Acute Respiratory Failure: - Treatment

- Oxygen therapy: *Appropriate for any clients with acute hypoxemia *It is used in acute respiratory failure to keep the arterial oxygen (PaO2) level above 60 mm Hg while treating the cause of the respiratory failure - Medications given systemically, by nebulizer, or by metered dose inhaler (MDI) may be prescribed to dilate the bronchioles and decrease inflammation to promote gas exchange *Corticosteroids *Analgesics (Pain) *Neuromuscular blockade drugs (mechanical ventilation) - Other management strategies depend on the underlying condition(s) that predisposed the client to ARF development, which may include: *Diuretic therapy *Antibiotic therapy - Help the client to a position of comfort that allows easier breathing (i.e., usually a more upright position) - Encourage deep breathing and other breathing exercises

What are examples of conditions that result in shunt units?

- Pneumonia - Atelectasis

What are the indications for the utilization of chest tubes?

- Pneumothorax - Tension pneumothorax - Hemothorax - Hemopneumothorax - Pleural effusions - Chylothorax - Penetrating chest trauma - Pleural empyema - Chemotherapy administration (may be administered through a chest tube)

Other Modes of Ventilation:

- Pressure support - Continuous flow (flow-by) Part of most microprocessor ventilators Both types decrease the work of breathing and are used for weaning clients from mechanical ventilation Other modes are: - Maximum mandatory ventilation (MMV) - Inverse inspiration-expiration (I/E) ratio - Permissive hypercarbia - Airway pressure-release ventilation (APRV) - Proportional assist ventilation - High-frequency oscillation

What are examples of conditions that result in dead space units?

- Pulmonary embolus - Pulmonary infarct Ventilation > Perfusion

Pneumothorax: - Manifestations

- Reduced (or absent) breath sounds on the affected side on auscultation *May appear to be distant breath sounds - Hyperresonance on percussion - Prominence of the involved side of the chest, which moves poorly with respiration - Severe: Deviation of the trachea away from the midline and side of injury toward the unaffected side (indicating pushing of tissues to the unaffected side [a mediastinal shift] from increasing pressure within the injured side)

Tension Pneumothorax: - Manifestations

- Reduced (or absent) breath sounds on the affected side on auscultation *May appear to be distant breath sounds - Hyperresonance on percussion - Prominence of the involved side of the chest, which moves poorly with respiration - Severe: Deviation of the trachea away from the midline and side of injury toward the unaffected side (indicating pushing of tissues to the unaffected side [a mediastinal shift] from increasing pressure within the injured side) Additional assessment findings also may include: - Extreme respiratory distress and cyanosis - Distended neck veins - Hemodynamic instability Powerpoint: - Severe respiratory distress - Tracheal deviation toward the unaffected side - Cyanosis - Muffled heart sounds - Cardiac arrest

What are the desired outcomes of mechanical ventilation?

- Relief of symptoms of respiratory distress - Rest for fatigued muscles of respiration - Decrease in the work of breathing (WOB) - Improvement in oxygenation - Improvement in ventilation - Restoration of acid-base balance - Stabilization of the chest wall - Provision of sedation/anesthesia

Chest Tube: - Nursing Responsibilities

- Secure the chest tube site and dressing - Palpate the site of chest insertion for crepitus, document the extent of crepitus, and reassess for changes - Maintain the level of the drainage system below the level of the chest and ensure that the tubes are free flowing (unkinked with no dependent loops) - Maintain suction at the prescribed level -Monitor the amount of drainage at least hourly immediately after insertion - the drainage should decrease over each hour *The nurse should notify the physician if the expected decrease in drainage does not occur - Identify the presence of fluctuation in the drainage tubing (sometimes called tidaling) and gentle bubbling in the water seal chamber with respiration *When tidaling ceases, it may indicate that the lung has fully expanded or there is a blockage in the chest tube, so a chest x-ray may be indicated - Monitor the system for an air leak which is identified by continuous bubbling in the water seal and/or collection chamber. In the event of a leak, the nurse identifies the source (e.g., a cracked chamber, disconnected tubing, nonocclusive dressing at the insertion site) and fixes it (e.g., replaces the chest drainage system)

What are examples of conditions that result in silent units?

- Severe ARDS - Pneumothorax

What are common paralytic agents utilized during rapid sequence intubation (RSI)?

- Succinylcholine - Rocuronium - Vecuronium

Pneumothorax/Hemothorax: - Diagnosis

- Symptomatology - CXR - CT scan - Ultrasonography

Hypoxia: - Manifestations

- Tachypnea - Tachycardia - Hypertension - Increased work of breathing (WOB) - Shortness of breath (SOB) - Restlessness - Confusion - Lethargy - Dysrhythmias

Mechanical Ventilation: - Airway Maintenance

- The nurse must suction the client's endotracheal tube to clear secretions as needed *Suctioning decreases the risk of consolidation and atelectasis, but also carries risks including hypoxemia, dysrhythmias, and tracheal tissue trauma - Suctioning should only be performed when necessary to reduce these complications. Indications for suctioning include: *Coarse crackles over the trachea *Elevated PIP *Decreased tidal volume *Decrease in oxygen saturation *Visible secretions *Coughing or inability to generate a cough *Acute respiratory distress *Suspected aspiration *Need to obtain a sputum specimen The need for suctioning should be assessed every 2-4 hours using the indications listed above

Head and Neck Cancer: - Etiology

- Tobacco use - Alcohol use - Voice abuse - Chronic laryngitis - Exposure to chemicals or dusts - Poor oral hygiene - Long-term GERD - Oral infection with HPV.

What can high oxygen settings cause if used for prolonged periods?

- Tracheobronchitis - Absorptive atelectasis - Diffuse alveolar damage

What are lung complications of transfusion?

- Transfusion-related acute lung injury (TRALI) - Transfusion-associated circulatory overload (TACO) - Transfusion-related immunomodulation (TRIM)

ARDS: - Prone Positioning (Disadvantages)

- Tube dislodgement - Client desaturation - Skin breakdown - Facial edema With diligent nursing care and awareness, you can prevent or treat most of these complications

What are the 2 functions of the respiratory system?

- Ventilation: *The mechanical act of moving air in and out of the respiratory tree and involves the musculoskeletal and nervous systems - Respiration: *The transport of oxygen and carbon dioxide between the alveoli and the pulmonary capillaries Disruption of either of these processes results in respiratory failure

What are the different components of an ABG?

- pH - PaO2 - SaO2 - CO2 - HCO3

ARDS: - Stages

1.) Exudative 2.) Fibroproliferative 3.) Recovery During these stages, a complex series of extreme immune and inflammatory responses damages the alveolar capillary membrane (ACM). This injury results in a cascade of cellular mediators and an amassing of neutrophils, macrophages, and platelets in the damaged ACM. Humoral mediators follow the cellular mediators, resulting in further damage to the ACM

What are the 5 P's of ARDS therapy?

1.) Perfusion 2.) Positioning 3.) Protective Lung Ventilation 4.) Protocol Weaning 5.) Preventing Complications

HCO3: - Normal Range

22-26

PaCO2: - Normal Range

35-45

Simple Masks: - LPM

8-12 LPM

Acute Respiratory Failure (ARF): - PaO2/FiO2 Ratio

<300

What is pleural empyema?

A collection of purulent material from an infection like pneumonia

Hemothorax:

A hemothorax differs from a pneumothorax because it is blood rather than air that is filling the pleural space, causing the area of lung to shrink and the work of breathing to become increasingly difficult and ineffective This injury may be caused by blunt or penetrating trauma Because most hemothoraces are the result of rib fractures and lung parenchymal or venous injury, the bleeding is usually self-limiting The classic signs of a hemothorax are: - Decreased chest expansion - Dullness to percussion - Reduced breath sounds on the affected side There is usually not a mediastinal or tracheal deviation unless there is a massive hemothorax The signs may be subtle in the supine trauma client in the ED, and many smaller hemothoraces will be diagnosed only after imaging studies Not all hemothoraces need chest tube insertion Since the bleeding from the majority of hemothoraces is self-limiting, chest tube drainage is usually all that is required to treat the client. However, if the initial output is over 1500 mL or the chest tube drains greater than 200 mL/hr for 4 hours, emergent operative intervention may be necessary. Therefore, the nurse must be vigilant in monitoring and reporting the drainage

What is a pneumothorax?

A pneumothorax is air in the pleural space causing a loss of negative pressure in the chest cavity, a rise in chest pressure, and a reduction in vital capacity, which can lead to a lung collapse *May be complete or partial collapse of the lung

Acute Respiratory Distress Syndrome (ARDS):

A severe form of acute respiratory failure that occurs in response to pulmonary or systemic insults ARDS is characterized by noncardiogenic pulmonary edema caused by inflammatory damage to alveolar and capillary walls Many disorders may precipitate ARDS, although sepsis is the most common

What is a tension pneumothorax?

A tension pneumothorax is a life-threatening complication of pneumothorax in which air continues to enter the pleural space during inspiration and does not exit during expiration As a result, air collects under pressure, completely collapsing the lung and compressing blood vessels, which limits blood return to the heart. This process leads to decreased filling of the heart and reduced cardiac output If not promptly detected and treated, tension pneumothorax is quickly fatal

A-a Gradient: - Calculation

A-a Gradient = PAO2 - PaO2 Normal value is less than 20

Lovenox (enoxaparin): - Action - Indications - Nursing Considerations

Action: - Anticoagulant with a decrease binding to plasma proteins and cells - More predictable anticoagulant effect - Longer half-life - Lower incidence of thrombocytopenia Indications: - Clients with limited movements - Treatment of pulmonary embolism - DVT prophylaxis Nursing Considerations: - Ask for allergy history: *Pork *Benzyl alcohol *Lovenox (enoxaparin) - Ask if: *Bleeding disorder *Vasculopathy *Hypertension *Heart infections *Liver disease *Kidney disease *Septic shock *Active peptic ulcer *Threatened miscarriage - Monitor for: *Bruising *Bleeding *Bloody or black/tarry stools *Hypotension *Back pain *Weakness in legs *Numbness *Paralysis *Changes in bowels or GU (blood in urine) *Bleeding with teeth brushing *Epistaxis - Monitor bleedings times (PTT) and platelet count

Diprivan (Propofol): - Action - Indication - Time Profile - Nursing Consideration

Action: - Hypnotic - Amnesic with not analgesic properties Indication: - General anesthesia - It is indicated when sedation is required but rapid awakening to perform neurological assessment or extubation is necessary Time Profile: - Onset: 40 seconds - Peak: Unknown - Duration: 3-5 minutes Nursing Considerations: - A large vein is recommended for the infusion because propofol may result in burning or stinging at the IV site - It is administered as a continuous IV infusion due to the short duration of action - The client should be monitored for the development of hypotension, especially during the first 60 minutes - An analgesic will be required for pain management because it has no analgesic properties - Allergies; contraindicated with hypersensitivity to: *Propofol *Soybean oil *Egg lecithin *Glycerol - Initial infusion dose is often 5 mcg/kg/minute - Cautious use with: *Cardiovascular disease *Dyslipidemia *Increased ICP *Lipid disorders *Hypovolemia - Can cause: *Apnea *Bradycardia *Hypotension - Can turn urine green - Assess neurologic status, respiratory status, and hemodynamics - Maintain patent airway - Assess level of sedation - Because propofol is not soluble in water, it is formulated in the same lipid emulsion used for TPN solutions. Therefore: *The caloric content of the infusion must be included in the total calories that the client receives and adjustments should be made to the rate of any feeding to prevent overfeeding *Lipid monitoring is required; triglyceride levels should be monitored after 2 days of propofol infusion *Strict aseptic technique is essential because the lipid solution is an excellent medium for bacterial growth. All bottles must be discarded within 12 hours of being opened. IV tubing must be changed every 12 hours - Propofol may result in zinc deficiencies; therefore, this may need to be monitored - Assess respiratory status, pulse, and blood pressure continuously throughout propofol therapy *Frequently causes apnea lasting ≥60 seconds *Maintain patent airway and adequate ventilation - Assess level of sedation and level of consciousness throughout and following administration

Morphine: - Action - Desired Effects - Dosage - Duration - Nursing Considerations

Action: Analgesic Desired Effects: - Relief of moderate to severe pain - Sedative effects - Vasodilation - Relief of air hunger Dosage: - Dose is usually 2-4 mg IV Q5MIN until pain relief - Then intermittent doses of 2.5-15 mg Q2-4H *15 mg doses need to be given over 4-5 minutes Duration: 1-2 hours Nursing Considerations - Check for allergies - Assess for: *Orientation *Reflexes *Strength affect *Perfusion *Respiratory *Urinary output *EKG *Pulse oximetry *Liver function *Renal function - Assess pain level before and after - Assess hemodynamic response - Documentation of client's response to initial dose and any subsequent doses - Monitor laboratory: *Hepatic function *Renal function - Monitor blood pressure closely related to histamine release causing vasodilation and hypotension - Monitor oxygen saturation and respiratory rate The duration of morphine sulfate is longer in clients with renal or hepatic impairment

Sublimaze (Fentanyl): - Action - Desired Effects - Time Profile - Nursing Considerations - Side and/or Toxic Effects

Action: Opiate analgesic Desired Effects: - Analgesia - Sedation Time Profile: - Onset: 1-2 minutes - Peak: 3-5 minutes - Duration: 30-60 minutes Nursing Considerations: - Assess for allergies: *Morphine allergy *Fentanyl - Assess: *Pain level (3-5 minutes after the dose) *History *Orientation *Reflexes *Bilateral grip strength *Affect *Pupil size *Vision *Lungs *Vital signs *Liver function *Renal function - Monitor: *Respiratory rate *Respiratory effort *Blood pressure Side and/or Toxic Effects: - Too rapid administration of fentanyl may result in apnea or respiratory paralysis, muscle rigidity, bradycardia, or hypotension *The respiratory depressant effects of fentanyl may outlast its analgesic effects *Fentanyl is 100 times more potent than morphine *It has a faster onset of action than morphine and a shorter duration of action *It is the analgesic of choice in acutely distressed clients and clients with renal dysfunction, morphine allergy, or ongoing hemodynamic instability because it does not produce histamine release, vasodilation, or hypotension *Fentanyl is metabolized by the liver and may accumulate in clients with hepatic disease *Prolonged drug effect does not occur in renal failure

Acute Respiratory Distress Syndrome (ARDS):

Acute respiratory distress syndrome (ARDS) is acute respiratory failure with these features: - Refractory hypoxemia: Hypoxemia that persists when 100% oxygen is given - Decreased pulmonary compliance - Dyspnea - Noncardiac-associated bilateral pulmonary edema - Dense pulmonary infiltrates on x-ray (ground-glass appearance Often ARDS occurs after an acute lung injury (ALI) in people who have no pulmonary disease as a result of other conditions such as: - Sepsis - Burns - Pancreatitis - Trauma - Transfusion Despite different causes of ALI in ARDS, the trigger is a systemic inflammatory response. As a result, ARDS symptoms are similar regardless of the cause The main site of injury in the lungs is the alveolar-capillary membrane (ACM), which normally is permeable only to small molecules. It can be injured during sepsis, pulmonary embolism, shock, aspiration, or inhalation injury. When injured, this membrane becomes more permeable to large molecules, which allows debris, proteins, and fluid into the alveoli. Lung tissue normally remains relatively dry, but in clients with ARDS lung fluid increases and contains more proteins Normally the type II pneumocytes produce surfactant, a substance that increases lung compliance (elasticity) and prevents alveolar collapse. Surfactant activity is reduced in ARDS because type II pneumocytes are damaged and because the surfactant is diluted by excess lung fluids. As a result, the alveoli, become unstable and tend to collapse unless they are filled with fluid. - These fluid-filled and collapsed alveoli cannot participate in gas exchange Other terms for ARDS include: - Adult respiratory distress syndrome - Shock lung

Acute Respiratory Failure: - Types

Acute respiratory failure (ARF) can be: - Ventilatory failure (Hypercapnic hypoxemic RF) - Oxygenation failure (Gas exchange failure) - Combination of both ventilatory and oxygenation failure

What are the causes of acute respiratory failure (ARF)?

Acute respiratory failure (ARF) has many causes, but the most severe respiratory disorders are: - Acute lung injury (ALI) - Acute respiratory distress syndrome (ARDS)

What is acute respiratory failure (ARF)?

Acute respiratory failure (ARF) occurs when the pulmonary system is unable to adequately exchange oxygen and remove carbon dioxide

Chest Tube: - Tube Sizes

Adult sizes: 24FR - 32FR Larger adult sizes: 36FR - 40FR

PAO2:

Alveolar oxygen content

Amidate (etomidate):

Amidate (etomidate) is an ultrashort-acting, non-barbiturate hypnotic intravenous anesthetic agent It is administered only by the intravenous (IV) route Etomidate has a very favorable hemodynamic profile on induction, with a minimal amount of blood pressure depression, making it an ideal choice for shock trauma, hypovolemic clients, or clients with significant cardiovascular disease Etomidate does not have any analgesic properties

What is an alveolar dead space unit?

An alveolar dead space unit occurs when an alveolus is not perfused - due to no gas exchange occurring

What is a silent unit?

An alveolus is inadequately ventilated and perfused <Ventilation <Perfusion

What is a shunt unit?

An alveolus is inadequately ventilated in the presence of perfusion The retention of CO2 results in vasoconstriction, resulting in blood/oxygen not traveling to the constricted vessel Perfusion > Ventilation

PaO2:

Arterial partial pressure of oxygen Normal range: 80-100 mmHg

Mechanical Ventilation: - Best Practice for Client Safety, and Quality Care (QSEN)

Assess the patient's respiratory status and gas exchange at least every 4 hours for the first 24 hours and then as needed: · Take vs at least every 4 hours · Assess the patient color (esp lips and nail beds) · Observe the patient's chest for bilateral expansion · Assess the placement of the nasotracheal or endotracheal tube · Obtain pulse Ox readings · Evaluate ABG as available · Maintain the HOB more than 30 degrees when patient is supine to prevent aspiration and · VAP Document pertinent observations in the patient's medical record Check at least every 8 hours to be sure that the ventilator setting is as prescribed Check to be sure that alarms are set (esp: low pressure and low exhaled volume) If on PEEP observe the peak airway pressure dial to determine the proper level of PEEP Check the exhaled volume digital display to be sure the patient is receiving the prescribed volume Empty ventilator tubing when moisture collects. Never empty fluid in the tubing back into the cascade Ensure humidity by keeping delivered air temperature maintained at body temperature Be sure the tracheostomy cuff (or endotracheal cuff) is adequately inflated to ensure tidal volume Auscultate the lungs for crackles, wheezes, equal breath sounds, and decreased or absent breath sounds Check the patient's need for tracheal, oral, or nasal suctioning every 2 hours and suction PRN Assess the patient's mouth around the ET tube for pressure injuries Perform mouth care every 2 hours Change tracheostomy tube holder or tape or ET tube holder or tape as needed: - Carefully move the oral ET tube to the opposite side of the mouth once daily to prevent pressure ulcers - Provide tracheostomy care every 8 hours Assess ventilated patients for GI distress (diarrhea, constipation, tarry stools) Maintain accurate intake and output records to monitor fluid balance Turn the patient at least every 2 hours and get the patient out of the bed as prescribed to promote pulmonary hygiene and prevent complications of mobility Schedule treatments and nursing care at intervals for rest Monitor the patient's progress on current ventilator setting and make appropriate changes as indicated Monitor the patient for effectiveness of mechanical ventilation in terms of his or her physiologic and psychologic status Monitor for adverse effects of mechanical ventilation infections, barotrauma, reduced cardiac output Position the patient to facilitate ventilation-perfusion (V/Q) matching Monitor the effects of ventilator changes on gas exchange and the patient's subjective responses Monitor readiness to wean Explain all procedures and treatments, provide access to a call light, visit the patient frequently Provide a method of communication. Request consultation with a speech-language pathologist for assistance if necessary Initiate relaxation techniques as appropriate Administer muscle-paralyzing agents, sedatives, and narcotics analgesics as prescribed Include the patient and family whenever possible (esp. during suctioning and tracheostomy care)

Assist-control (AC) Ventilation:

Assist-control (AC) ventilation is the mode used most often as a resting mode The ventilator takes over the work of breathing for the client The tidal volume and ventilatory rate are preset *If the client does not trigger spontaneous breaths, a ventilatory pattern is established by the ventilator It is programmed to respond to the client's inspiratory effort if he or she begins a breath - In this case, the ventilator delivers the preset tidal volume while allowing the client to control the rate of breathing Disadvantage: - The ventilator continues to deliver a preset tidal volume even when then client's spontaneous breathing rate increases This can cause hyperventilation and respiratory alkalosis *Investigate and correct causes of hyperventilation, such as: 1.) Pain 2.) Anxiety 3.) Acid-base imbalances

What is barotrauma?

Barotrauma is the perforation or rupture of an alveolus that allows air to enter the pleural space or the mediastinum

Endotracheal Intubation: - Intubation Preparation

Basic life support measures, such as obtaining a patent airway and delivering 100% oxygen by a manual resuscitation bag with a facemask, are crucial to survival until help arrives Monitor clients at risk for airway obstruction and impaired ventilation When you recognize the need for emergency intubation and ventilation, respond by bringing: - The code ("crash") cart - Airway equipment box - Suction equipment Maintain a patent airway through positioning (head-tilt, chin-lift) and the insertion of an oral or nasopharyngeal airway until the client is intubated Delivering manual breaths with a bag-valve-mask may also be required During intubation, the nurse coordinates the rescue response and continuously monitors the client for: - Changes in vital signs - Signs of hypoxia or hypoxemia - Dysrhythmias - Aspiration Ensure that each intubation attempt lasts no longer than 30 seconds, preferably less than 15 seconds. After 30 seconds, provide oxygen by means of a mask and manual resuscitation bag to prevent hypoxia and cardiac arrest Suction as necessary

Bilevel Positive Airway Pressure (BiPAP):

BiPAP allows the clinician to a set a higher inspiratory pressure (IPAP) and a lower expiratory pressure (EPAP). Frequently these settings are reported as a ratio of IPAP/EPAP, for example 15/5, is 15 cm H2O IPAP and 5 cm H2O EPAP Theoretically, adding IPAP reduces the work of breathing further and is more effective than CPAP

Bilevel Positive Airway Pressure (BiPAP):

Bilevel positive airway pressure (BiPAP) provides noninvasive pressure support ventilation by nasal mask or facemask It is often used for clients with sleep apnea but also may be used for clients with respiratory muscle fatigue or impending respiratory failure to avoid more invasive ventilation methods

Continuous Positive Airway Pressure (CPAP):

CPAP delivers one continuous positive pressure throughout inspiration and expiration - the entire respiratory cycle Typical pressure settings are between 5-15 cm H2O CPAP helps recruit or open alveoli and prevents atelectasis during expiration. This allows more lung units to be available for gas exchange and increases the partial pressure of oxygen in the alveoli (PAO2) facilitating oxygen diffusion into the bloodstream *Sedating drugs are given lightly or not at all when the client is receiving CPAP so respiratory effort is not suppressed This process increases functional residual capacity (FRC) and improves gas exchange and oxygenation CPAP is commonly used to help in the weaning process During CPAP, no ventilator breaths are delivered. The ventilator just delivers oxygen and provides monitoring and an alarm system The respiratory pattern is determined by the client's efforts If no pressure is set, the client receive no positive pressure

Vecuronium: - Category - Indication - Dose - Onset - Duration

Category: - Paralytic Indication: Rapid sequence intubation (RSI) Dose: 0.1 mg/kg Onset: 60-90 seconds Duration: 65 minutes with 95% complete recovery The agent of choice for prolonged paralysis

Rocuronium: - Category - Indication - Dose - Onset - Duration

Category: - Paralytic Indication: Rapid sequence intubation (RSI) Dose: 1.2 mg/kg (intubation RSI dosage) Onset: 60 seconds Duration: 25-60 minutes

Amidate (etomidate): - Category - Indication - Dose - Onset - Duration

Category: - Sedative Indication: - Induction of general anesthesia - Rapid sequence intubation (RSI) Dose: 0.2-0.4 mg/kg Onset: 1 minute Duration: 30-60 minutes

Versed (midazolam): - Category - Indication - Dose - Onset - Duration

Category: - Sedative Indication: Rapid sequence intubation (RSI) Dose: 0.2-0.3 mg/kg Onset: 1-2 minutes Duration: 30-60 minutes

Ketamine: - Category - Indication - Dose - Duration

Category: - Sedative Indication: Rapid sequence intubation (RSI) Dose: 1-2 mg/kg IV Duration: 30

Succinylcholine: - Category - Indication - Dose - Onset - Duration

Category: - Sedative - Paralytic Indication: Rapid sequence intubation (RSI) Dose: 1.5 mg/kg Onset: 45 seconds Duration: 4-6 minutes

Diprivan (propofol): - Category - Indication - Dose - Duration

Category: - Sedative Indication: Rapid sequence intubation (RSI) Dose: 1-3 mg/kg Duration: 10-15 minutes

Ventilator Alarms: - Low Pressure Alarm *Causes *Interventions

Causes: - Air leak in ventilator circuit or in the ET tube cuff Interventions: - Locate leak in ventilator system - Check pilot balloon as indicator of ET tube cuff failure

Ventilator Alarms: - High PIP *Causes *Interventions

Causes: - Blockage of ET tube *Secretions *Food *Kinked tubing *Client biting ET tube - Coughing - Bronchospasms - Lower airway obstruction - Pulmonary edema - Pneumothorax - Ventilator/Client dyssynchrony Interventions: - Assess lung sounds - Suction airway for secretions - Insert bite block or administer sedation per orders if client is agitated or biting on ET tube - Assess breath sounds for increased consolidation, wheezing, and bronchospasm; treat as ordered

Ventilator: - Infection *Causes *Interventions

Causes: - Breaks in ventilatory circuit - Decreased mobility - Impaired cough reflex Interventions: - Use aseptic technique - Provide frequent mouth care - Support proper nutritional status

Ventilator Alarms: - Apnea *Causes *Interventions

Causes: - Breaths are not being taken by the client or triggered on the ventilator Interventions: - Assess client effort - Check system for disconnections

Ventilator: - Cardiovascular Issues *Causes *Interventions

Causes: - High PEEP *Decrease in venous return to the heart due to positive pressure applied to the lungs Interventions: - Assess for adequate volume status by checking: *HR *BP *CVP *Urine output

Ventilator Alarms: - Low Minute Ventilation *Causes *Interventions

Causes: - Low air exchange due to shallow breathing or too few respirations Interventions: - Check for disconnection or leak in the system - Assess client for decreased respiratory effort

Ventilator: - Barotrauma/Pneumonia *Causes *Interventions

Causes: - Positive pressure applied to the lungs - Elevated mean airway pressures may rupture alveoli Interventions: - Notify the healthcare provider - Prepare client for possible chest tube insertion - Avoid high pressure settings for clients with COPD, ARDS, or history of pneumothorax

Ventilator Alarms: - Low Oxygen Saturation *Causes *Interventions

Causes: - Pulse oximeter malfunction - SpO2 cable unplugged - Connective tissue disorder, such as Raynaud's disease or scleroderma Interventions: - Ensure ventilator oxygen supply is connected *Observe pulse oximeter waveform on the monitor - Ensure pulse oximeter is positioned correctly - Verify all cables are plugged in - Assess client for respiratory distress

What are chest tubes?

Chest tubes are drainage systems that allow air, as in a pneumothorax, or fluid/blood, as in a hemothorax, to drain out of the pleural space A chest tube is a tube inserted in the chest cavity attached to a closed drainage system that is usually attached to suction. The suction allows material (the air, blood, or fluid) to be removed from the lung without allowing air to be sucked into the pleural space There are 2 types of chest tubes: 1.) Water seal 2.) Dry

Lasix (Furosemide): - Class - Action - Nursing Considerations

Class: Loop diuretic Action: - Inhibits reabsorption of sodium and chloride from the loop of Henle and distal renal tubule - Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium Nursing Considerations: - Contraindicated in: *Hepatic coma *Anuria - Use cautiously with: *Severe liver disease *Electrolyte depletion *Diabetes mellitus *Hypoproteinemia *Severe renal impairment due to increased risk for ototoxicity - Monitor potassium and sodium levels, hydration status, hemodynamic status (blood pressure, heart rate, orthostatic changes, dizziness, headache, tinnitus, excessive urination) - Safety concerns with position changes, fall risk, excessive urination

ARDS: - Positioning

Client positioning affects perfusion If a client is standing, blood flow moves to the base of the lung and away from the apex If a client is supine, the posterior area of the lung will more perfused than the anterior area Because the better aerate surfaces of the lungs are the nondependent (anterior chest in supine position), the result is a ventilation/perfusion mismatch PEEP: - Primarily aerates the anterior, nondependent areas of the lungs instead of the dependent areas that would benefit the most Immobility, a major cause of pulmonary complications, greatly influences perfusion distribution. 3 positioning therapies can decrease these complications and improve perfusion in ARDS clients: 1.) Kinetic therapy: Bilateral turning of client 40 degrees or more per side 2.) Continuous lateral rotational therapy: Bilateral turning of a client no more than 40 degrees per side 3.) Prone positioning These therapies improve oxygenation by mobilizing secretions, resolving atelectasis, improving V/Q ratio, recruiting functional but collapsed or consolidated alveolar units, and decreasing interstitial fluid accumulation Rotational therapy reduces nosocomial pneumonia, skin breakdown, ICU length of stay, and the number of ventilator days Prone positioning: - Improves the V/Q ratio - Aeration improves because the heart no longer compresses the posterior area of the left lung as it does in the supine position - With the client in prone position, most lung tissue, which is in the posterior areas, moves toward the anterior, clearing the airway of debris, decreasing atelectasis, reducing lung inflammation, and producing more efficient oxygenation and perfusion Outcomes are better when positioning starts early in the course of ARDS

What is compliance?

Compliance refers to the ability of the lungs and thorax to stretch and expand given a change in pressure

Noninvasive Mechanical Ventilation: - Contraindications - Caution

Contraindications: - Clients with apnea - Clients who have had recent airway or gastrointestinal surgery Caution: - Clients with an increased risk of aspiration - Clients with excessive secretions - Clients with swallowing impairment - Clients with inadequate airway protection - Clients with severe hypoxemia or acidosis - Clients with multi-organ failure - Clients with hepatic congestion - Clients with low cardiac output - When an adequate interface fit is not possible

Endotracheal Intubation: - Decreased Gas Exchange *DOPE

D: Disconnected tube O: Obstructed tube (most often with secretions) P: Pneumothorax E: Equipment problems

Flow Rate: - Description - Standard Range

Description: - Rate at which tidal volume is delivered to the client Standard Range: 60-100 liters/minute

Oxygen Concentration (FiO2): - Description - Standard Range

Description: Amount of oxygen in gas delivered to client Standard Range: 21-60% Current ventilator strategies call for the lowest FiO2 setting to achieve: - SaO2 over 90% - PaO2 greater than 60

Acute Respiratory Failure: - Oxygenation Failure *Description *Causes

Description: In oxygenation (gas exchange) failure, chest pressure changes are normal, and air moves in and out without difficulty but does not oxygenate the pulmonary blood sufficiently It occurs in the type of V/Q mismatch in which air movement and oxygen intake (ventilation) are normal but lung blood flow (perfusion) is decreased Causes: - Impaired diffusion of oxygen at the alveolar level - Right-to-left shunting of blood in the pulmonary vessels - V/Q mismatch - Breathing air with a low oxygen level - Abnormal hemoglobin that fails to bind oxygen

Rate: - Description - Standard Range

Description: Minimal number of breaths per minute Standard Range: 6-12 breaths per minute

Positive End-Expiratory Pressure (PEEP): - Description - Standard Range

Description: Positive pressure left in lungs at end of expiration Prevents atelectasis and may enhance oxygenation at higher levels Standard Range: 3-10 cm H2O

Pressure Support: - Description - Standard Range

Description: Positive pressure used to decrease client's work of breathing Standard Range: 5-10 cm H2O

Inspiratory:Expiratory Ratio (I:E Ratio): - Description - Standard Range

Description: Ratio of time of inspiration to time of expiration May be reversed in conditions where lungs are noncompliant Standard Range: 1:2

Transfusion Reaction ALI: - Description - Onset - Manifestations - Associated Risk Factors - Treatment

Description: Serious pulmonary syndrome that occurs following transfusion Onset: Sudden onset of symptoms usually 1-2 hours following transfusion but are fully manifested within 6 hours Manifestations: - Dyspnea - Hypotension - Fever Associated Risk Factors: Treatment:

Sensitivity: - Description - Standard Range

Description: The negative inspiratory pressure or flow a client must generate in order to trigger the ventilator to deliver a breath Standard Range: -1 to -2 cm H2O

High-Pressure Limit: - Description - Standard Range

Description: Ventilator will not exceed this pressure in delivering volume; pop-off mechanism prevents excessive pressure Standard Range: 10-20 cm H2O above inspiratory pressure

Acute Respiratory Failure: - Ventilatory Failure *Description *Causes *Definition

Description: Ventilatory failure is a problem in oxygen intake (air movement or ventilation) and blood flow (perfusion) that causes a ventilation-perfusion (V/Q) mismatch in which blood flow (perfusion) is normal but air movement (ventilation) is inadequate It occurs when the chest pressure does not change enough to permit air movement into and out of the lungs. As a result, too little oxygen reaches the alveoli, and carbon dioxide is retained Perfusion is wasted in this area of no air movement from either inadequate oxygen intake or excessive carbon dioxide retention, leading to poor gas exchange and hypoxemia Causes: - Physical problem of the lungs/chest wall - Defect in the respiratory control center in the brain - Poor function of the respiratory muscles, especially the diaphragm Definition: - PaCO2: >45 mm Hg - Acidemia (pH <7.35) *In clients who have otherwise healthy lungs

Tidal Volume (VT): - Description - Standard Range

Description: Volume of gas delivered in one cycle: - Inspiratory tidal volume - Expiratory tidal volume Standard Range: 6-10 mL/kg of predicted body weight

Lorazepam: - Desired Effects - Class - Nursing Considerations

Desired Effects: - Anxiolysis - Analgesic adjunct - Sedative - Anticonvulsant Class: Benzodiazepine Nursing Considerations: - Can dilute immediately before given with equal parts of sterile water, D5W, or saline - Gently swirl to proportionately mix Ativan with diluent - 2mg should be administered over 2-5 minutes - Monitor: *BP *Neurologic status *Respiratory status *Heart rate - Place client on telemetry - Laboratory: *Renal function *Liver function *Hematologic function - Have flumazenil on hand for emergency reversal if needed - Side Effects: *Slow IVP is needed, or it can cause apnea and cardiac arrest, bradycardia and hypotension *Can cause dizziness and excessive drowsiness (safety measures), if habit forming

Acute Lung Injury (ALI)/Acute Respiratory Distress Syndrome (ARDS): - Direct Injury Causes - Indirect Injury Causes

Direct Injury: - Chest trauma - Pneumonia - Aspiration of pneumonitis - Pulmonary contusion - Near drowning - Inhalation injury - Pulmonary embolus - Radiation - Eclampsia of pregnancy Indirect Injury: - Sepsis (most common cause) - Burns - Severe trauma with multiple blood transfusions - Drug overdose - Cardiopulmonary bypass - Acute pancreatitis - Intracranial hypertension

ARDS: - Protective Lung Ventilation

During the early stages of ARDS, use mechanical ventilation to open collapsed alveoli Goal: - Support organ function by providing adequate ventilation and oxygenation while decreasing the client's work of breathing *However, mechanical ventilation itself can damage the alveoli, making protective lung ventilation necessary High tidal volumes (VTs) overstretch the alveoli, causing shearing forces on them and thus increasing the inflammatory response. The less affected lung regions must then accommodate most of the tidal volume, which can lead to ventilator-induced lung injury (VILI) - a condition that exacerbates the physiologic responses to ARDS PEEP: - Opens collapsed alveoli and prevents end-tidal alveolar collapse - Keeps the alveoli clear of fluid - Can increase intrathoracic pressure that lowers cardiac output, you should use hemodynamic monitoring to determine the best PEEP setting for each ARDS client Current recommendations: - Plateau pressure: <30 cm H2O - Maintaining PEEP - Reducing FiO2: 50-60% - Low tidal volumes (VTs): 6 mL/kg of ideal body weight Be sure to monitor the client for changes in respiratory status - such as increased respiratory rate, adventitious breath sounds, decreased oxygen saturation, and dyspnea - at least every 4 hours and after every change in PEEP or VT

ARDS: - Exudative Phase

During the exudative phase (usually the first 2-4 days) the capillary membrane begins to leak, and protein-rich fluid fills the alveoli, reducing gas exchange This fluid appears on radiography as bilateral infiltrates ALI does not affect left ventricular function directly, pulmonary occlusive pressures stay below 18 mm Hg As capillary permeability continues to worsen, neutrophils begin to attach to the damaged membrane and may cross into the alveoli, further impairing gas exchange

What is the vital capacity (VC)?

ERV + VT + IRV

If the ventilator alarm sounds, what should you do?

Examine the client for: - Breathing - Color - Oxygen saturation Then, assess the ventilator

Neuromuscular Blocking Agents: - Examples - Classification - Desired Effects - Nursing Considerations

Examples: - Anectine (succinylcholine) - Vecuronium Classification: - Neuromuscular blocking agents (depolarizing) Action: - Blocks the effect of acetylcholine at the myoneural junction (neuromuscular junction), causes muscle paralysis Nursing Considerations: - History of malignant hyperthermia (family or self) and/or skeletal myopathies - Assess respiratory status continuously throughout therapy with vecuronium *Should be used only to facilitate intubation or in clients already intubated - Neuromuscular response should be monitored with a peripheral nerve stimulator intraoperatively. *Paralysis is initially selective and usually occurs sequentially in the following muscles: levator muscles of eyelids, muscles of mastication, limb muscles, abdominal muscles, muscles of the glottis, intercostal muscles, and the diaphragm. Recovery of muscle function usually occurs in reverse order - Monitor ECG, heart rate, and BP throughout administration *Need to schedule eye care related to inability to blink with administration - Observe for residual muscle weakness and respiratory distress during the recovery period - Monitor infusion site frequently. If signs of tissue irritation or extravasation occur, discontinue and restart in another vein - Administration of fluids and vasopressors may be necessary to treat severe hypotension or shock - Anectine is often associated with acute rhabdomyolysis followed with ventricular dysrhythmias, cardiac arrest, and death to healthy children. Often presents with peaked T-waves and sudden cardiac arrest within minutes after administration

Bronchodilators: - Examples - Action - Nursing Considerations

Examples: - Beta-adrenoreceptor agonists: *Albuterol *Levalbuterol - Anti-cholinergic: *Atrovent (ipratropium) Action: - Bronchodilation by relaxing bronchiolar smooth muscle of the airways by stimulating the beta2-adrenoreceptors - Bronchodilation by relaxing bronchiolar smooth muscle of the airways by blocking the cholinergic receptors on the surface of the muscle cells Nursing Considerations: - Monitor HR Q15MIN - Monitor respiration (pattern, rate, effort) - Monitor oxygen saturation - Monitor potassium levels - Monitor anxiety/anxiousness related to the effects on the nervous system (shaky hands/tremors/insomnia/headache/jitters/difficulty concentrating) - Monitor glucose levels - Monitor BP Q4H in an acute situation - Monitor for fluid retention and not if the client experiences: *Increasing SOB *Dry cough *Anginal pain/discomfort *Tachycardic - Use cautiously with cardiac clients (not recommended for clients with angina) - Monitor diet - Monitor bowel sounds

Corticosteroids: - Examples - Action - Nursing Considerations

Examples: - Solu-Medrol (methylprednisolone) - Dexamethasone Action: - Reduces WBC migration - Decreases inflammation - Assists stabilize the alveolar-capillary membrane during ARDS Nursing Considerations: - Discontinue medication gradually - Administer with an antiulcer medication to prevent peptic ulcer formation - Monitor weight and blood pressure - Monitor glucose and electrolytes - Advise the client to take oral doses with food and avoid stopping the medication abruptly Corticosteroids may result in an increase in the WBC count

Mechanical Ventilation: - Fluid Retention Complication

Fluid is retained because of decreased cardiac output The kidneys receive less blood flow, which stimulates the RAAS system to retain fluid Humidified air in the ventilator system contributes to fluid retention Monitor the client's fluid intake and output, weight, hydration status, and indications of hypovolemia

Pneumothorax: - Treatment

For a stable client with a small pneumothorax who has mild symptoms and no continuing air leak, no treatment may be needed For more severe pneumothorax, tension pneumothorax, and hemothorax, chest tube therapy is essential

Laryngeal Cancer: - Categories

Glottic (true vocal cords) - 2/3 of cancer cases occur in the glottic area Supraglottic (false vocal cords) - 1/3 of cancer cases occur in the supraglottic area Subglottic (down extension of disease from glottic area) - 1% of cancer cases occur in the subglottic area

ARDS: - Perfusion

Goal: The goal of care for ARDS clients is to maximize perfusion in the pulmonary capillary system by increasing oxygen transport between the alveoli and pulmonary capillaries Interventions: - Increase fluid volume without overloading the client - to replace the fluids that have leaked from the capillaries into the alveolar spaces: *Crystalloids *Colloids - Evaluate the client's volume status by: *Measuring BP *Measuring respiratory variations of pulmonary and systemic arterial pulse pressure *Measuring CVP/RAP *Measuring urine output - Confirm intravascular status with: *Pulmonary artery catheter data *Cardiac output *Cardiac index *Pulmonary vascular resistance *Venous oxygen saturation (SvO2) Medication(s): - Dobutamine: *Can increase cardiac output to boost oxygenation - Primacor (milrinone): *Improves perfusion by causing vasodilation in the pulmonary bed - Norepinephrine/Dopamine: *Promote systemic vasoconstriction, thus increasing blood pressure and perfusion *When administering these drugs, monitor vital signs, skin color and temperature, and the client's tolerance to therapy

Head and Neck Cancer:

Head and neck cancers are usually squamous cell carcinomas These slow-growing tumors are curable when diagnosed and treated at an early stage The prognosis for those who more advanced disease at diagnosis depends on the extent and location of the tumors Untreated, these cancers are often fatal within 2 years of diagnosis The lesions may then be seen as: - White, patchy lesions (leukoplakia) - Red, velvety patches (erythroplakia) Metastasis: - Head and neck cancer first spreads (metastasizes) into local lymph nodes, muscle, and bone - Later spread is systemic to distant sites, usually to the lungs or liver

Mechanical Ventilation: - Cardiac Complications

Hypotension Hypotension is caused by positive pressure that increases chest pressure and inhibits blood return to the heart The decreased blood return reduces cardiac output, causing hypotension, especially in clients who are dehydrated or need high PIP for ventilation Teach the client to avoid a Valsalva maneuver (bearing down while holding the breath)

Type II Respiratory Failure: - Causes - Signs/Symptoms - Desire Outcomes - Treatment

Hypoxemic Hypercapnic Respiratory Failure Causes: - COPD - Neurological system failure to stimulate respiration: *Excess narcotic administration *Head injury - Muscular failure: *Muscular dystrophy *Amyotrophic lateral sclerosis *Guillain-Barré - Skeletal alterations: *Kyphosis *Fractures due to trauma Signs/Symptoms: - Increased PaCO2 - Decreased pH - Decreased SaO2 - Decreased PaO2 - RR may be increased or decreased Desired Outcomes: - PaCO2 35-45 mmHg with spontaneous breathing - Spontaneous tidal volume of 7 mL/kg Treatment: - Provide mechanical ventilation as needed - Treat causes of alveolar hypoventilation - Optimize musculoskeletal dysfunctions - Optimize neurologic deficits

Type I Respiratory Failure: - Causes - Signs/Symptoms - Desire Outcomes - Treatment

Hypoxemic Respiratory Failure Causes: - Cardiogenic pulmonary edema - Aspiration - Pneumonia - ARDS - Atelectasis Signs/Symptoms: - Decreased SaO2 - Decreased PaO2 - Increased RR Desired Outcomes: - PaO2 ≥80 mmHg on room air - SaO2 ≥90% on room air Treatment: - Provide supplemental oxygen - Optimal positioning - Maintain airway patency - Treat underlying causes of ACM alterations, VQ mismatches

Endotracheal Intubation: - Tube Placement Verification

Immediately after an ET tube is inserted, placement should be verified The most accurate ways to verify placement are by: - Checking end-tidal carbon dioxide (EtCO2) levels - Chest x-ray Assess for breath sounds bilaterally, sounds over the gastric area, symmetric chest movement, and air emerging from the ET tube If breath sounds and chest wall movement are absent on the left side, the tube may be in the right mainstem bronchus - The person intubating the client should be able to reposition the tube without repeating the entire intubation procedure If the tube is in the stomach, the abdomen may be distended and must be decompressed with a nasogastric (NG) tube after the ET tube is replaced/moved Monitor chest wall movement and breath sounds until tube placement is verified by chest x-ray

What is a water seal closed drainage system?

In a water seal closed drainage system, there are 3 chambers: 1.) A collection chamber 2.) A water seal chamber 3.) Suction control chamber

How do you know if the goal of oxygen therapy has been met?

Increase in the PaO2 to acceptable levels with a concurrent reduction in the respiratory rate (RR) and work of breathing (WOB)

2,3 Diphosphoglycerate (2,3 DPG): - Increased - Decreased

Increased: - In response to an acute need for more tissue oxygen (causing the hemoglobin to release the oxygen more readily) Decreased: - Septic shock - Hypophosphatemia - Blood transfusions

What is a pleurodesis?

Infusion of an irritative agent (bleomycin or talcum powder) into the pleural space. It inflames the pleura, causing fibrosis so the lung sticks to chest wall. This eliminates the pleural space so effusions can't reaccumulate

Ventilator-Associated Pneumonia (VAP): - Preventive Strategies

Key Components: - Elevation of the head of the bed at 30 degrees or higher - Daily "sedation vacations" and assessment of readiness to extubate - Peptic ulcer prophylaxis - Daily oral care with chlorhexidine - Deep venous thrombosis prophylaxis Additional Interventions: - Washing hands before and after contact with each client - Use of continuous subglottic suctioning - Change of the ventilator circuit no more often than every 48 hours or no longer routinely changing the client's ventilator circuit

Nasal Cannula: - LPM - Advantages - Disadvantages

LPM: 1-6 LPM Advantages: - Ease of administration - Client comfort Disadvantages: - The inability to quantify the FiO2 being administered due to variation in breathing pattern/respiratory rate

Ideal Body Weight: - Calculation *Male Female

Male: IBW = 50 + 2.3(height in inches - 60) Female: IBW = 45.5 + 2.3(height in inches - 60) When calculating tidal volume on a client use IBW as opposed to actual body weight because a person will lose or gain weight but the height and lung size doesn't change. Therefore, ideal body weight (IBW) is better calculated and results in less possibility of barotrauma or ventilar-associated lung injury (VALI) Tidal Volume: - If no lung injury: Use 12 BPM - If underlying lung or respiratory problem: Use 10 BPM

Mechanical Ventilation: - Malnutrition

Malnutrition is an extreme problem for clients that are mechanically ventilated and is a cause of failing to wean from the ventilator In malnutrition, the respiratory muscles lose mass and strength. The diaphragm, the major muscle of inspiration, is affected early. When it and other respiratory muscles are weak, ineffective breathing results, fatigue occurs, and the client cannot be weaned Balanced nutrition, whether by diet, enteral feedings, or parenteral feeding, is essential during ventilation and is often started within 48 hours of intubation Electrolyte replacement: - Monitor potassium, calcium, magnesium, and phosphate levels and replace them as prescribed

What is the purpose of mechanical ventilation?

Mechanical ventilation assists the breathing process in clients who cannot effectively ventilate independently Current technology allows for noninvasive and invasive ventilatory support While ventilation does not guarantee improved gas exchange by ensuring ventilation, oxygenation may improve, and carbon dioxide levels may be reduced

Laryngeal Cancer: - Demographics

Men > Women African Americans > Caucasian Americans Most common in people ages >65 years of age

Minute Volume:

Minute volume is determined by totaling the tidal volume (VTs) over 1 minute and is indicative of readiness to wean

Positive-Pressure Ventilators:

Most ventilators are positive-pressure ventilators During inspiration, pressure is generated that pushes air into the lungs and expands the chest Usually an endotracheal (ET) tube or tracheostomy is needed Positive-pressure ventilators are classified by the mechanism that ends inspiration and starts expiration. Inspiration is cycled in 3 major ways: 1.) Pressure-cycled 2.) Time-cycled 3.) Volume-cycled

Noninvasive Mechanical Ventilation (NIV): - Complications

NIV reduces preload and afterload by decreasing venous return and decreasing left ventricular systolic wall stress These hemodynamic effects improve stroke volume without increasing myocardial oxygen consumption, but can reduce cardiac output and lead to hypotension, especially in hypovolemic clients Complications: - Hypotension - Aspiration - Skin breakdown - Gastric insufflation - Barotrauma - Dryness - Discomfort - Anxiety

Nasopharyngeal Airway: - How do you select the correct size for an adult? - What is a benefit of using this type of pharyngeal airway?

Nasopharyngeal airway tubes are made of either plastic or rubber and are available in sizes ranging from infant to adult To select the correct size for an adult, the nurse should measure the airway and ensure it reaches from the earlobe to the tip of the nose The tube should be lubricated prior to insertion and guided through the nares toward the posterior pharynx Benefit: - The nasopharyngeal airway can be used in a conscious client

Non-rebreather Mask:

Non-rebreather masks have valves over the ports that allow exhaled air to escape but prevent room air from being inhaled This mask is capable of delivering up to 100% O2

Mechanical Ventilation: - COPD *Nutrition

Nutrition for the client with COPD requires a reduction of dietary carbohydrates During metabolism, carbohydrates are broken down to glucose, which then produces energy, carbon dioxide, and water. Excessive carbohydrate loads increase carbon dioxide production, which the client with COPD may be unable to exhale - Hypercarbic respiratory failure results

Alveolar Oxygen Content: - Calculation

PAO2 = FiO2(Pb+PH2O) - PaCO2/RQ FiO2: Decimal Pb: Barometric pressure (760) PH20: Pressure of water vapor (47) RQ: Respiratory quotient (0.8)

Peak Inspiratory Pressure (PIP):

Peak inspiratory pressure (PIP) is the highest pressure during inspiration It is the highest pressure reached during inspiration An increased PIP reading means increased airway resistance in the client or the ventilator tubing (bronchospasm or pinched tubing, client biting the ET tube), increased secretions, pulmonary edema, or decreased pulmonary compliance (the lungs or chest wall is "stiffer" and harder to inflate) An upper pressure limit is set to prevent barotrauma. When the limit is reached, the high-pressure alarm sounds, and the remaining volume is not given

What are pharyngeal airways?

Pharyngeal airways are designed to prevent the tongue from occluding the upper airway

Positive End-Expiratory Pressure (PEEP):

Positive end-expiratory pressure is positive pressure left in the lungs at the end of expiration This setting usually ranges from 3-10 cm H2O, and the pressure helps keep the alveoli open, preventing atelectasis Higher levels of PEEP may be used to recruit collapsed alveoli and improve oxygenation in clients with severe lung dysfunction but this comes with an increased risk of barotrauma This higher pressure distends the alveolus, providing a greater surface area for gas exchange Nurses must monitor client blood pressure during increases in PEEP as the increased intrathoracic pressure may cause compression of the vena cava and decreased preload It is used to treat persistent hypoxemia that does not improve with an acceptable oxygen delivery level It may be added when the arterial oxygen pressure (PaO2) remains low with an FiO2 of 50%-70% or greater The need for PEEP indicates a severe gas exchange problem

Pressure-cycled Ventilators:

Pressure-cycled ventilators push air into the lungs until a preset airway pressure is reached Tidal volumes and inspiratory time vary These ventilators are used for short periods, such as just after surgery and for respiratory therapy Bilevel positive airway pressure (BiPAP) ventilators are a newer form of pressure-cycled ventilators in which the ventilator provides a preset inspiratory pressure and an expiratory pressure similar to positive end-expiratory pressure (PEEP)

Endotracheal Intubation: - Nursing Care

Priority: Maintaining a patent airway Regularly assess: - Tube placement - Cuff leak - Breath sounds - Indications of adequate gas exchange and oxygenation - Chest wall movement Prevent the client from pulling or tugging on the tube to avoid tube dislodgement and check the pilot balloon to ensure that the cuff is inflated - Suctioning, coughing, and speaking can cause dislodgement - Neck flexion, neck extension, and rotation of the head can cause the tube to move - Tongue movement can change the tube's position *When other measures fail, obtain a prescription for soft wrist restraints and apply these for the client who is pulling on the tube *Adequate sedation (chemical restraint) may be needed to decrease agitation or prevent extubation Monitor the pressure within the cuff to ensure that it is maintained between 20-30 cm H2O to stabilize the tube without causing tracheal injury

Propofol-Related Infusion Syndrome (PRIS):

Propofol-related infusion syndrome (PRIS) is a rare yet often fatal syndrome that has been observed in critically ill clients receiving propofol for sedation PRIS is characterized by: - Severe, unexplained metabolic acidosis - Dysrhythmias - Acute renal failure - Rhabdomyolysis - Hyperkalemia - Cardiovascular collapse The syndrome occurs more frequently in clients who are also receiving catecholamines or glucocorticoids

What conditions have decreased compliance?

Pulmonary fibrosis

Vancomycin: - Purpose - Important Information - Nursing Considerations

Purpose: Antibiotic Important Information: - If taken orally, it does not treat infections in other parts of the body other than the intestines - Can cause temporary or permanent hearing loss Nursing Considerations: - Always inquire about allergies to vancomycin or other -mycins - Administer vancomycin with a final concentration not to exceed 5 mg/mL by IV intermittent infusion over at least 60 minutes (recommended infusion period of ≥30 minutes for every 500 mg administered) - Extravasation and thrombophlebitis: *IV vancomycin is an irritant *Ensure proper needle or catheter placement prior to and during infusion *Avoid extravasation *Pain, tenderness, and necrosis may occur with extravasation *If thrombophlebitis occurs, slow infusion rates, dilute solution - Infusion reactions: *Rapid IV administration (e.g., over <60 minutes) may result in hypotension, flushing, erythema, urticaria, pruritus, wheezing, dyspnea, and, rarely, cardiac arrest *Reactions usually cease promptly after infusion is stopped Vancomycin flushing syndrome (previously known as Red Man Syndrome) is rate-related

Mechanical Ventilation: - Weaning Criteria

RR: ≤35 BPM Tidal volume: >5 mL/kg SaO2: >90 with an FiO2 of 40% or less PaO2/FiO2 ratio or higher - Increased from baseline

Readiness for Weaning from Mechanical Ventilation: - Indicators

RSBI ≤ 105 Respiratory rate ≤35 Maximum inspiratory pressure ≤-20 Tidal volume (VT) greater than 5 mL/kg Vital capacity greater than 10 mL/kg SaO2 > 90 with FiO2 of 40% or less PaO2/FiO2 ratio of 150 or higher

What is extubation?

Removal of the nasotracheal or endotracheal tube

Rapid Shallow Breathing Index (RSBI):

Respiratory rate/Tidal volume (liters) Scores equal to or greater than 105 are associated with a higher extubation failure risk

Sensitivity:

Sensitivity determines how much negative pressure the client must generate before the ventilator will deliver a breath This setting prevents the ventilator from hyperventilating a client taking very shallow breaths and helps synchronize the client's intrinsic respiratory rate with mechanical support

Hemothorax: - Simple Hemothorax - Massive Hemothorax

Simple hemothorax: Blood loss of less than 1L into the chest cavity Massive hemothorax: Blood loss of more than 1L into the chest cavity

Synchronized Intermittent Mandatory Ventilation (SIMV):

Synchronized intermittent mandatory ventilation (SIMV) is similar to assist-control (AC) ventilation in that tidal volume and ventilatory rate are preset If the client does not breathe, a ventilatory pattern is established by the ventilator Unlike the assist-control (AC) ventilation mode, SIMV allows spontaneous breathing at the client's own rate and tidal volume between the ventilator breaths It can be used as a main ventilator mode or as a weaning mode: - When used for weaning, the number of mechanical breaths (SIMV breaths) is gradually decreased (e.g., from 12 to 2) as the client resumes spontaneous breathing - The mandatory ventilator breaths are delivered when the client is ready to inspire *This action coordinates breathing between the ventilator and the client

Tension Pneumothorax:

Tension pneumothorax is a surgical emergency An injury, often a lung laceration, allows air to enter the pleural space but not to exit, resulting in progressive accumulation of air in the pleural space The pressure from the accumulating air may become so great that the client may have a total lung collapse, and mediastinal shift may occur Because the pressure in the chest is elevated, tension pneumothorax leads to impairment of venous return to the heart and a fall in cardiac output. The classic signs of a tension pneumothorax are: - Deviation of the trachea away from the side with the tension - One hyperexpanded side of the chest that moves little with respiration - Absent breath sounds on the affected side - Hyperresonance to percussion on the affected side - Acute respiratory distress - Crepitus - Elevated central venous pressure/right atrial pressure The client is almost always tachycardic and tachypneic and may be hypoxic. These signs are followed by hypotension and circulatory collapse with the possibility of traumatic arrest and pulseless electrical activity (PEA) Treatment: - Chest tube insertion - If there is no time for chest tube insertion, needle decompression is the emergency procedure utilized to reinflate the collapsing lung - When it is not possible for chest tube to be inserted immediately, needle thoracotomy can be a live-saving option

Mechanical Ventilation: - Infection

The ET or tracheostomy tube bypasses the body's filtering process and provides a direct access for bacteria to enter the lower respiratory system The artificial airway is colonized with bacteria within 48 hours, which promotes pneumonia development and increases morbidity Aspiration of colonized fluid from the mouth or stomach can be a source of infection

What is a chylothorax?

The accumulation of lymphatic fluid in the pleural space

Type II Pneumocytes:

The alveolar walls have cells called type II pneumocytes that secrete surfactant, a fatty protein that reduces surface tension in the alveoli. Without surfactant, atelectasis (alveolar collapse) occurs, reducing gas exchange because the alveolar surface area is reduced

Flow Rate:

The flow rate of the ventilator determines the speed at which the tidal volume (VT) is delivered - The flow rate is how fast each breath is delivered and is usually set at 40 L/minute Normal rates are 60-100 liters/minute, generally estimating the peak flow at 4 times the minute flow If a client is agitated or restless, has a widely fluctuating inspiratory pressure reading, or has other signs of air hunger, the flow may be set too low. Increasing the flow rate should be tried before using chemical restraints

What is the goal of utilizing chest tubes?

The goal is to remove the air, blood, or fluid from the pleural space, thereby reestablishing subatmospheric intrapleural pressure The lung will then reexpand

What is the goal of oxygen therapy?

The goal of oxygen therapy is to correct alveolar and tissue hypoxia

High-pressure Limit:

The high-pressure limit sets a cap on the amount of pressure that can be delivered to the lungs in a breath If this set amount of pressure is increased, whether by secretions, coughing, or lung compliance, a pop-off valve allows the excess pressure to escape to the atmosphere This safety setting is very important for protecting the client's lungs from barotrauma High-pressure alarms should signal the nurse to check the client to determine if suctioning is needed, whether the client is biting the tube or has rolled onto it, and to determine if a client is experiencing bronchospasm or mucous plug

Chest Tube: - Insertion Site

The insertion site of the chest tube depends on the type of drainage Chest tubes from which air will be draining are placed high and anterior between the ribs - Air tends to rise Chest tubes from which fluid will be draining are placed low and posterior - Fluid tends to fall to the basal region of the pleural space The most common complication of chest tubes is malposition. Therefore, chest tube placement should be confirmed with an x-ray

Inspiratory:Expiratory Ratio (I:E Ratio):

The inspiratory:expiratory ratio (I:E ratio) compares the time spent in inspiration to that in expiration Normally, a person spends twice as much time in exhalation as in inspiration, so the ratio would be 1:2 In disorders where the lungs are "stiff" or noncompliant, the I:E ratio may be reversed in order to allow a slower delivery of tidal volume (VT) - This more gradual introduction permits the lungs to adjust to the distention while decreasing the risk of barotrauma - Called inverse ratio ventilation, this setting is very uncomfortable for the client, and nurses should ensure the clients are adequately sedated

Acute Respiratory Failure: - Manifestations

The manifestations of ARF are related to the systemic effects of hypoxia, hypercapnia, and acidosis - Dyspnea (hallmark of respiratory failure) - Orthopnea - Assess for changes in respiratory rate or pattern and changes in lung sounds - Pulse oximetry may show: *Decreased oxygen saturation, but end-tidal CO2 (ETCO2 or PETCO2) monitoring may be more valuable for monitoring the client with ARF Hypoxic Respiratory Failure: - Restless - Irritability/Agitation - Confusion - Tachycardia Hypercapnic Hypoxemic Respiratory Failure: - Decreased level of consciousness (LOC) - Headache - Drowsiness - Lethargy - Seizures Acidosis: - Decreased level of consciousness - Drowsiness - Confusion - Hypotension - Bradycardia - Weak peripheral pulses

What is total lung capacity (TLC)?

The maximum volume the lungs can hold

What is ventilation?

The mechanical act of moving air in and out of the respiratory tree and involves the musculoskeletal and nervous systems

What does the mode of ventilation refer to?

The mode of ventilation is the way in which the client receives breaths from the ventilator The most common modes are: 1.) Assist-control (AC) ventilation 2.) Synchronized intermittent mandatory ventilation (SIMV) 3.) Bilevel positive airway pressure (BiPAP) ventilation

ARDS: - Preventing Complications

The most common complications are: - VILI - DVT - Pressure ulcers - Decreased nutritional status - VAP DVT: - DVT is an acute condition characterized by inflammation and thrombus formation in the deep veins that may lead to pulmonary embolism - Prevention: *Range-of-motion exercises *Frequent position changes *Anticoagulant prophylaxis *Sequential compression devices and thromboembolic stockings - Treatment: *Applying warm, moist compresses *Elevating the affected leg *Administering anticoagulants, thrombolytics, and analgesics Pressure Ulcers: - Relieve pressure with frequent position changes, restoring circulation with mobility, and promoting adequate nutrition Nutrition: - Start nutritional support as soon as possible - within 24 hours of admission, if possible - The preferred method is enteral nutrition because it causes fewer complications than parenteral nutrition - Consult with a nutrition expert VAP: - Nosocomial pneumonia that develops after 48 hours or more of mechanical ventilation

Oropharyngeal Airway: - How do you select the correct size? - What are contradictions to its use? - How do you insert the oropharyngeal airway?

The nurse should measure the size by placing the airway at the corner of the mouth and seeing that it reaches the corner of the jaw Oropharyngeal airways are contraindicated in clients who are alert and have an intact gag reflex To insert the airway, the nurse displaces the client's tongue downward using a tongue depressor and slides the airway over the client's tongue into the oropharynx. It is easier to insert the airway with the distal end pointed up toward the nose and flip it 180 degrees once inside the mouth

Endotracheal Intubation: - Tube Stabilization

The nurse, respiratory therapist, or anesthesia provider stabilizes the ET tube at the mouth or nose The tube is marked at the level where it touches the incisor tooth or naris Two people working together use a head halter technique to secure the tube An oral airway also may be inserted, or a commercial bit block placed to keep the client from biting an oral ET tube One person stabilizes the tube at the correct position and prevents head movement while a second person applies the tube holding device - Commercial tube holders are preferred over securing the tube with tape After the procedure is completed, verify and document the presence of bilateral and equal breath sounds and the level of the tube

Partial Rebreather Mask:

The partial rebreather mask has a reservoir bag to capture the 100% oxygen coming through the tubing that blends with expired air Vents on either side of the mask allow the majority of exhaled air to escape, which provides between 40%-60% FiO2

Rate:

The rate is the number of breaths the ventilator provides in 1 minute The mode and client's CO2 level factors into determining the best rate When CO2 is elevated, the rate may be increased to allow the client to "blow off" excess

ARDS: - Protocol Weaning

The rule of thumb is: The client either needs full ventilatory support or should be weaning Evidence-based Guidelines: - Use spontaneous breathing trials instead of SIMV

What is respiration?

The transport of oxygen and carbon dioxide between the alveoli and the pulmonary capillaries

What is the inspiratory reserve volume (IRV)?

The volume of air one is able to inhale in addition to the tidal volume (VT)

What is the residual volume (RV)

The volume of air that remains in the lungs following forced expiration beyond normal expiration Also referred to as the expiratory reserve volume (ERV)

What is tidal volume (VT)?

The volume of one inhalation/exhalation cycle

What is functional residual capacity (FRC)?

The volume remaining in the lungs after a normal exhalation

Mechanical Ventilation: - Stress Ulceration

These ulcers complicate the nutrition status and, because the mucosa is not intact, increase the risk for systemic infection Medication(s): - Antacids - Sucralfate - Histamine blockers - Proton-pump inhibitors *These medications may be prescribed as soon as the client is intubated

Fraction of Inspired Oxygen (FiO2):

This is the percentage of oxygen (O2) in the mix of air delivered to clients The FiO2 of room air is 21%. FiO2 is also expressed as a decimal: for example, room air is 0.21 Current ventilator strategies call for the lowest FiO2 settings to achieve PaO2 and SaO2 The oxygen delivered to the client is warmed to body temperature (98.6) and humidified to 100%. This is need because upper airways of the respiratory tree, which normally warm and humidify, are bypassed - Humidifying and warming prevent mucosal damage

What is the inspiratory capacity?

Tidal volume (VT) + Inspiratory reserve volume (IRV)

Tidal Volume (VT):

Tidal volume (VT) is the volume of gas delivered in one ventilatory cycle Tidal volume is normally 7 mL/kg of body weight or around 500 mL In mechanical ventilation, the volume is kept at 5-8 mL/kg in order to prevent trauma to lung tissues In ALI, lower volumes are preferred

Time-cycled Ventilators:

Time-cycled ventilators push air into the lungs until a preset time has elapsed Tidal volume and pressure vary, depending on the needs of the client and the type of ventilator

Transfusion-related Acute Lung Injury (TRALI):

Transfusion-related acute lung injury (TRALI) is the sudden onset (within 6 hours of a transfusion) of hypoxemic lung disease along with infiltrates on x-ray without cardiac problems TRALI is associated with the activation of the inflammatory response caused by a recent transfusion of plasma-containing blood products such as: - Packed red blood cells (PRBCs) - Platelets - Fresh frozen plasma (FFP)

Type I Respiratory Failure:

Type I respiratory failure, or hypoxemic failure, stems from a disruption of oxygen transport from the alveolus to arterial flow Respiration is impeded. It may be a blockage of mucus or fluid or disease in the basement membrane of the capillaries

Type II Respiratory Failure:

Type II respiratory failure, or hypoxemic hypercapneic failure, originates in musculoskeletal or anatomical lung dysfunction or suppression Ventilation is not sufficient. This may be due to alterations in lung anatomy (COPD), failure of the neurological system to stimulate respiration (excess narcotic administration, head injury), muscular failure (muscular dystrophy, amyotrophic lateral sclerosis, or Guillain-Barré), or skeletal alterations (kyphosis or fractures due to trauma) These conditions result in failure to adequately blow off carbon dioxide and take in oxygen-rich air from the environment. Carbon dioxide is trapped in the alveoli, resulting in the rise of PaCO2 Although the body is capable of oxygen transport, the high concentration of carbon dioxide in the alveolus causes hypercapnia, and the inability to replace the carbon dioxide with oxygen results in hypoxemia

Stryker Frame:

Used 2 boards that "sandwich" the client to maintain the prone position However, this device doesn't offer and pressure relief or safety features

Mechanical Ventilation: - Ventilator Dependence

Ventilator dependence is the inability to wean off the ventilator and can have both a physiologic and a psychologic basis The longer a client uses a ventilator, the more difficult the weaning process is because the respiratory muscles fatigue and cannot assume breathing The health care team uses every method of weaning before a client is declared "unweanable"

Volume-cycled Ventilators:

Volume-cycled ventilators push air into the lungs until a preset volume is delivered A constant tidal volume is delivered, regardless of the pressure needed to deliver the tidal volume However, a set pressure limit prevents excess pressure from being exerted on the lungs The advantage of this type of ventilator is that a constant tidal volume is delivered, regardless of changes in lung or chest wall compliance or airway resistance

What is volutrauma?

Volutrauma is over-distention of the alveoli that results in inflammation and can reduce the client's ability to recover respiratory function

Mechanical Ventilation: - Weaning

Weaning (liberation) is the process of going from ventilatory dependence to spontaneous breathing It is a complicated and may be a prolonged process Many complications can be avoided with appropriate nursing care such as turning and positioning the client not only for comfort and prevention of skin breakdown, but to improve gas exchange and prevention of pneumonia and atelectasis

What is weaning from mechanical ventilation?

Weaning is the process in which support from the mechanical ventilator is reduced and the work of breathing is assumed by the client