Critical Care Vent / Intubation
A patient is admitted to the critical care unit with acute respiratory failure. Upon auscultation, the health care provider hears creaking, leathery, coarse breath sounds in the lower anterolateral chest area during inspiration and expiration. The nurse suspects that the patient has a(n):
pleural friction rub.
What can be caused by overfilling the lungs with too high of a tidal volume setting?
pneumothorax
Aspiration can best be prevented by
positioning a patient in a semirecumbent position.
Nursing management of a patient undergoing a diagnostic procedure involves
positioning the patient for the procedure. monitoring the patient's responses to the procedure. monitoring vital signs. teaching the patient about the procedure. medicating the patient before and after procedure.
What type of pressure is created by mechanical ventilation of all sorts that forces air in to the lungs?
positive (pushing in of air)
What is the major disadvantage to AC volume ventilation?
possible excessive inspiratory pressures
What is the major disadvantage to AC pressure control ventilation?
possible hyper or hypo ventilation with lung resistance/compliance changes
What type of ventilation allows the patient's body to control the respiratory rate and exert a major influence on the duration of inspiration, inspiratory flow rate, and tidal volume?
pressure support
Preset positive pressure used to augment the patient's inspiratory effort is known as
pressure support ventilation (PSV).
ET tubes have inflatable cuffs to:
prevent backflow of oxygen
Nursing management of the patient receiving a neuromuscular blocking agent should include
protecting the patient from the environment.
V/Q scans are ordered to evaluate the possibility of which of the following?
pulmonary emboli
The major hemodynamic consequence of a massive pulmonary embolus is
pulmonary hypertension leading to right heart failure.
How often should a vented patient be assessed?
q 1 hour
How often should oral care be done on a patient that is intubated to prevent VAP?
q 2 hours
What setting on the vent determines how many breaths a minute the patient takes?
rate
What are some teaching points for families before they see their loved one on a vent for the first time?
reasons for sedation, restraints
What is the major advantage of assist control ventilation?
reduced work of breathing
What lab needs to be known before giving ketamine?
renal clearance
Patient safety precautions when working with oxygen involve
restriction of smoking.
What types of lung disease require lower tidal volume settings?
restrictive lung diseases (COPD, fibrosis)
The most common presenting signs and symptoms associated with PEs are
tachycardia and tachypnea. Additional signs and symptoms that may be present include dyspnea, apprehension, increased pulmonic component of the second heart sound (P1), fever, crackles, pleuritic chest pain, cough, evidence of deep vein thrombosis, and hemoptysis.
While conducting a physical assessment, you note that the patient's breathing is rapid and shallow. This type of breathing pattern is known as:
tachypnea.
Diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetrical chest movement are indicative of which of the following disorders?
tension pneumothorax
What is the most notable determining factor in determining the setting of tidal volume?
the disease for which the patient is ventilated
What can the PEEP setting reach in patients undergoing low tidal volume ventilation for ARDS?
20
How high should the head of bed be for an intubated patient if the BP will allow it?
30 degrees or more
What is the default vent setting for PEEP?
5
Place the steps for analyzing arterial blood gases in the proper order. 1. Assess HCO3 level for metabolic abnormalities. 2. Assess PaO2 for hypoxemia. 3. Examine PaCO2 for acidosis or alkalosis. 4. Re-examine pH to determine level of compensation. 5. Examine pH for acidemia or alkalemia.
5, 3, 1, 4, 2
What initial tidal volume settings should be considered in a patient with ARDS?
5-8 mL/kg with increased PEEP
A patient presents with chest trauma from an MVA. Upon assessment, the nurse documents that the patient is complaining of dyspnea, shortness of breath, tachypnea, and tracheal deviation to the right. In addition, the client's tongue is blue-gray. Based on the following data, what the nurse would expect to find?
Absent breath sounds in all left lung fields The clinical picture described is most consistent with left pneumothorax. This would cause the trachea to deviate to the right, away from the increasing pressure of the left. A pneumothorax this severe would completely collapse the right lung, thus causing absent breath sounds in that lung.
What provides a noninvasive pressure support ventilation by nasal or facemask?
BiPAP
A patient is admitted with acute respiratory failure attributable to pneumonia. Smoking history reveals that the patient smoked two packs of cigarettes a day for 25 years, stopping 10 years ago. ABG values on the current ventilator settings are pH, 7.37; PaCO2, 50 mm Hg; and HCO3, 27 mEq/L. Chest radiograph reveals a large right pleural effusion. Intrapulmonary shunting value of 35% indicates
a serious and potentially life-threatening condition.
What type of ventilation is used to let the lungs rest and it does all breathing for the patient?
assist control
What causes ventilator dependence if a patient is sedated and vented for too long?
atrophy of the respiratory muscles
Which of the following patients would be considered hypoxemic? a. A 70-year-old man with a PaO2 of 72 b. A 50-year-old woman with a PaO2 of 65 c. An 84-year-old man with a PaO2 of 96 d. A 68-year-old woman with a PaO2 of 80
b
What can be changed on a vent to fix alkalosis?
decrease RR
A patient has been admitted to the critical care unit with the diagnosis of acute respiratory distress syndrome (ARDS). Arterial blood gasses (ABGs) revealed an elevated pH and decreased PaCO2. The patient is becoming fatigued, and the health care provider orders a repeat ABG. The nurse anticipates the following results
decreased pH and elevated PaCO2 Arterial blood gas analysis reveals a low PaO2 despite increases in supplemental oxygen administration (refractory hypoxemia). Initially, the PaCO2 is low as a result of hyperventilation, but eventually the PaCO2 increases as the patient fatigues. The pH is high initially but decreases as respiratory acidosis develops.
What are some causes of low peak pressure alarms on the vent?
disconnected tube, hole in tube / hose
What is the device that changes from purple to yellow when hooked to the end of an ET tube that confirms placement?
end tidal CO2 detector
What should be at the bedside during extubation?
equipment for emergency reintubation
the removal of the ET tube when the need for the tube no longer remains
extubation
What is a sign that succylcholine is working?
fasiculations in the chest (and other muscles)
Why can an OPA not be used in a conscious patient?
gag reflex
What is the major advantage to AC volume (AC) ventilation?
guaranteed delivery of set tidal volume
A patient was admitted to the critical care unit after a left pneumonectomy. The patient is receiving 40% oxygen via a simple facemask. The morning chest radiography study reveals right lower lobe pneumonia. After eating breakfast, the patient suddenly vomits and aspirates. The single most important measure to prevent the spread of infection between staff and patients is
hand washing.
Use of oxygen therapy in the patient who is hypercapnic may result in
carbon dioxide retention.
What type of monitoring is required during the intubation process?
cardiac
Risk factors that need to be considered with a thoracentesis include
coagulation defects. intra-aortic balloon pump. uncooperative patient.
On admission, a patient presents as follows: pH, 7.38; respiratory rate, 24 breaths/min, regular, pursed-lip breathing; PaO2, 66 mm Hg; heart rate, 112 beats/min, sinus tachycardia; PaCO2, 52 mm Hg; blood pressure, 110/68 mm Hg; HCO3, 34 mEq/L; and SpO2, 90% on O2 2 L/min nasal cannula. These gases show
compensated respiratory acidosis.
What labs are drawn before intubation if possible due to the meds used as a neurochemical block?
creatinine, K+
What is the balloon on the end of the ET tube called?
cuff
Which of the following arterial blood gas values would indicate a need for oxygen therapy? a. PaO2 of 80 mm Hg b. PaCO2 of 35 mm Hg c. HCO3 of 24 mEq d. SaO2 of 87%
d
Determination of oxygenation status by oxygen saturation alone is inadequate. What other value must be known?
hemoglobin
A patient was taken to surgery for a left lung resection earlier today. The patient has been in the postoperative care unit for 30 minutes. When you are completing your assessment, you notice that the chest tube has drained 125 cc of red fluid in the past 30 minutes. The nurse contacts the physician and suspects that the patient has developed
hemorrhage.
What is a contraindication for the use of succylcholine?
hyperkalemia
Nursing interventions to limit the complications of suctioning include
hyperoxygenating the patient with 100% oxygen.
What can be changed on a vent to fix acidosis?
increase RR
What happens when a patient gets hypoxic during intubation?
increased HR initially that leads to bradycardia and death when the heart wears out
What are some indicators for the need of intubation?
increased WOB, poor ventilation or oxygenation, need for controlled CO2 blow off
What are the side effects of increasing PEEP?
increased intrathoracic pressure, increased cardiac workload, decreased HR
What is the major disadvantage to SIMV?
increased work of breathing compared to AC
How does PEEP increase oxygenation?
increasing alveolar surface area
A pneumothorax greater than 15% requires
interventions to evacuate the air from the pleural space and facilitate re-expansion of the collapsed lung.
What is the major advantage to SIMV (synchronized intermittent mandatory ventilation)?
less interference with normal cardiovascular function
Psychologic factors that may contribute to long-term mechanical ventilation dependence include
loss of breathing pattern control (anxiety, fear, dyspnea, pain, ventilator asynchrony, lack of confidence in ability to breathe), lack of motivation and confidence (inadequate trust in staff, depersonalization, hopelessness, powerlessness, depression, inadequate communication), and delirium (sensory overload, sensory deprivation, sleep deprivation, pain medications).
What amount of FiO2 should be used?
lowest possible for patient condition
Indications to support a pneumonectomy are
malignant lesions, unilateral tuberculosis, extensive unilateral bronchiectasis, multiple lung abscesses, massive hemoptysis, and bronchopleural fistula.
What is documented in relation to the length of the ET tube in the patient?
placement at the lips / teeth
A patient was admitted to the critical care unit after a left pneumonectomy. The patient is receiving 40% oxygen via a simple facemask. The morning chest radiography study reveals right lower lobe pneumonia. After eating breakfast, the patient suddenly vomits and aspirates. The patient becomes agitated, has decreased level of consciousness, and has an inability to maintain saturation. The nurse expects the next action will include
placing the patient on a mechanical ventilator.
A patient presents moderately short of breath and dyspneic. A chest radiographic examination reveals a large right pleural effusion with significant atelectasis. The physician or nurse practitioner would be most likely to order which of the following procedures?
thoracentesis
What is the vent setting that determines the volume of air/gas delivered with each breath?
tidal volume
Long-term ventilator management over 21 days is best handled through use of a(n)
tracheostomy tube.
The ventilator variable that causes inspiration is called the
trigger
What setting on the vent is used to supplement the patient's own attempt at breathing (to maximize the breath)?
trigger mode
Complications of ETT tubes include
tube obstruction, tube displacement, sinusitis and nasal injury, tracheoesophageal fistula, mucosal lesions, laryngeal or tracheal stenosis, and cricoid abscess.
A patient presents with the following values: pH, 7.20; paO2, 106 mm Hg; paCO2, 35 mm Hg; and HCO3, 11 mEq/L. These values are most consistent with
uncompensated metabolic acidosis.
A patient's assessment data present as follows: pH, 7.10; PaCO2, 60 mm Hg; PaO2, 40 mm Hg; HCO3, 24 mEq/L; RR, 34 breaths/min; HR, 128 beats/min; and BP, 180/92 mm Hg. This condition is best described as
uncompensated respiratory acidosis.
Supplemental oxygen administration is usually effective in treating hypoxemia related to
ventilation/perfusion mismatching.
What should be done in reference to assessment s/p extubation?
vs q 5 minutes and thorough respiratory assessments
the process of going from ventilator dependence to spontaneous breathing that occurs over time
weaning
What process is SIMV often used for?
weaning from the vent
When is intubation performed?
when the patient fails all types of non invasive ventilation
The Passy-Muir valve is contraindicated in patients
with laryngeal or pharyngeal dysfunction.
What is the average I:E ratio? (Inhalation:exhalation)
1:2
During tracheostomy tube suctioning, each pass should be no longer than _____ seconds.
10 seconds
The therapeutic blood level for theophylline (Xanthines) is
10 to 20 mg/dL.
What is the average size tube used in intubation of an adult?
7-7.5
A GSC score of what is a certain indicator of a need to intubate?
8
A low-flow oxygen delivery system provides supplemental oxygen directly into the patient's airway at a flow of _____________________.
8 L/min or less and would be delivered via NC.
What should the initial tidal volumes be set at on initiation of mechanical ventilation?
8-10 mL/kg
Name some findings that confirm the diagnosis of a PE?
A definitive diagnosis of a pulmonary embolus requires confirmation by a high-probability V/Q scan, an abnormal pulmonary angiogram or computed tomography scan, or strong clinical suspicion coupled with abnormal findings on lower extremity deep venous thrombosis studies.
What is an important concept for the nurse to understand in regards to endotracheal tube cuff management?
A small leak should be heard on inspiration if the cuff has been inflated using the minimal leak technique.
Which of the following therapeutic measures would be the most effective in treating hypoxemia in the presence of intrapulmonary shunting associated with ARDS?
Administering positive-end expiratory pressure (PEEP) The purpose of using positive-end expiratory pressure (PEEP) in a patient with acute respiratory distress syndrome is to improve oxygenation while reducing FiO2 to less toxic levels. PEEP has several positive effects on the lungs, including opening collapsed alveoli, stabilizing flooded alveoli, and increasing functional residual capacity. Thus, PEEP decreases intrapulmonary shunting and increases compliance.
What is important that SIMV be set for so that the patient is not trying to breath against the machine?
synchronized
What are the reasons for sedation r/t mechanical ventilation?
synchronous breathing, pain management
an elastic tube that is about 2 feet long used by anesthesia in intubation; used as a guidewire
Bougie
Medical management of patient with status asthmaticus that supports oxygenation and ventilation include
Bronchodilators, corticosteroids, oxygen therapy, and intubation and mechanical ventilation
A patient with acute respiratory failure may require a bronchodilator if which of the following occurs?
Bronchospasms
A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure alarm keeps going off. When you enter the room, the ventilator inoperative alarm sounds. Which of the following criteria would indicate that the patient is ready to be weaned?
Rapid shallow breathing index less than 105
Severe coughing and shortness of breath during a thoracentesis are indicative of which of the following complications?
Re-expansion pulmonary edema
A patient was admitted to the critical care unit after a left pneumonectomy. The patient is receiving 40% oxygen via a simple facemask. The morning chest radiography study reveals right lower lobe pneumonia. After eating breakfast, the patient suddenly vomits and aspirates. Which test would the nurse expect the health care provider to order to identify the infectious pathogen?
Sputum Gram stain and culture
On admission, a patient presents as follows: pH, 7.38; respiratory rate, 24 breaths/min, regular, pursed-lip breathing; PaO2, 66 mm Hg; heart rate, 112 beats/min, sinus tachycardia; PaCO2, 52 mm Hg; blood pressure, 110/68 mm Hg; HCO3, 24 mEq/L; and SpO2, 90% on O2 2 L/min nasal cannula. Which of the following diagnoses would be most consistent with the above arterial blood gas values?
COPD
What is a disease process that makes it very difficult to wean a patient from the ventilator?
COPD
What is the most confirmative method to know placement of ET tube?
CXR
A client has a new tracheostomy and is receiving 60% oxygen via tracheostomy collar. Which assessment finding requires immediate action by the nurse?
Constant, nonproductive coughing Causes and manifestations of lung injury from oxygen toxicity include nonproductive cough, substernal chest pain, GI upset, and dyspnea.
The nurse is caring for a client with a new tracheostomy. Which assessment finding requires the nurse's immediate action?
Crackling sensation around the neck when skin is palpated. Subcutaneous emphysema occurs when an opening or tear occurs in the trachea and air escapes into fresh tissue planes of the neck. Air can also progress through the chest and other tissues into the face. Inspect and palpate for air under the skin around the new tracheostomy. If the skin is puffy and you can feel a crackling sensation, notify the physician immediately. Cuff pressures should be maintained between 14 and 20 mm Hg or between 20 and 28 cm H2O.
A patient is admitted to the unit in respiratory distress secondary to pneumonia. The nurse knows that obtaining a history is very important. What is the appropriate intervention at this time for obtaining this data?
Curtail the history to just a few questions about the client's chief complaint and precipitating events.
A patient's pulse oximeter alarm goes off. The monitor reads 82%. What is the first action the nurse should perform?
assess pts. condition
A patient is intubated, and sputum for culture and sensitivity is ordered. Which of the following is important for obtaining the best specimen?
Do not apply suction while the catheter is being withdrawn because this can contaminate the sample with sputum left in the endotracheal tube.
In a patient who is hemodynamically stable, which procedure can be used to estimate the PaCO2 levels?
End-tidal CO2
A patient with chronic obstructive pulmonary disease requires intubation. After the physician intubates the patient, the nurse auscultates for breath sounds. Breath sounds are questionable in this patient. Which action would best assist in determining endotracheal tube placement in this patient?
End-tidal CO2 monitor
Which of the following lung sounds would be most likely heard in a client experiencing an asthma attack?
Expiratory wheezes
The ventilator setting that determines the measure of oxygen the vent is delivering during inspiration?
FiO2 (fraction of inspired oxygen)
The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action?
Ventilate the client manually If at anytime an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected.
What does the acronym HOLD stand for?
H - high alarm O - obstruction L - low alarm D - disconnect
Which blood gas parameter is the acid-base component that reflects kidney function?
HCO3
What is the acronym to remember vent trouble shooting?
HOLD
The most important action the nurse should do before and after suctioning a client is:
Hyperventilating the client with 100% oxygen
Which of the following causes of hypoxemia is the result of blood passing through unventilated portions of the lungs?
Intrapulmonary shunting: occurs when blood passes through a portion of a lung that is not ventilated.
The assist-control mode of ventilation functions in which of the following manners?
It delivers gas at preset volume, at a set rate, and in response to the patient's inspiratory efforts.
What is a curved blade that is used for intubation called?
Macintosh
What is a straight blade that is used for intubation called?
Miller
Which medication may be administered with a bronchodilator because it can cause bronchospasms?
Mucloytics
Which of the following oxygen administration devices can deliver oxygen concentrations of 90%?
Nonrebreathing mask
List some conditions that will commonly reveal breath sounds with inspiration greater than expiration on assessment?
Normal lung Bronchiectasis Acute bronchitis
What is also inserted into the patient right after intubation to prevent aspiration of stomach contents?
OG tube
What are some nursing interventions to prevent VAP?
OGT vs NGT, daily weaning trials, early trach, oral care, limit reintubation, control GERD, HOB elevated, hand washing
What is used to pull the tongue forward and out of the way during intubation of an unconscious patient?
OPA (oropharyngeal airway)
Patients with left-sided pneumonia may benefit from placing them in which of the following positions?
On the right side
Which route for ETT placement is used in an emergency?
Orotracheal
What setting on the vent is used to keep the alveoli open for oxygen / CO2 exchange by raising the amount of pressure in the lungs?
PEEP (positive end-expiratory pressure)
Which of the following diagnostic criteria is indicative of ARDS?
PaO2/FiO2 ratio less than or equal to 200 mm Hg
The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions?
Percussion and vibration (Chest physiotherapy )
Describe the effect of positive-pressure ventilation on cardiac output:
Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return and cardiac output. Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return to the right side of the heart. Impaired venous return decreases preload, which results in a decrease in cardiac output.
Deviation of the trachea occurs in which of the following conditions?
Pneumothorax Pulmonary fibrosis Pleural effusion
Nursing management of the patient with acute lung failure includes which of the following interventions?
Positioning the patient with the least affected side down Providing adequate rest between treatments Controlling fever Pharmaceutical medications to control anxiety
Which of the following nursing interventions should be used to optimize oxygenation and ventilation in the patient with acute respiratory failure?
Provide adequate rest and recovery time between procedures which prevents desaturation and optimizes oxygenation.
Which of the following regarding the client history will assist the nurse in developing the plan of management?
Provides direction for the rest of the assessment Exposes key clinical manifestations Aids in developing the plan of care The degree of the client's distress determines the extent of the interview
On admission, a patient presents as follows: pH, 7.38; respiratory rate, 24 breaths/min, regular, pursed-lip breathing; PaO2, 66 mm Hg; heart rate, 112 beats/min, sinus tachycardia; PaCO2, 52 mm Hg; blood pressure, 110/68 mm Hg; HCO3, 24 mEq/L; and SpO2, 90% on O2 2 L/min nasal cannula. What treatment would the physician or nurse practitioner likely order for this patient?
Repeat ABG testing in 4 hours. Increasing the FiO2 on this patient could decrease the respiratory rate and increase the severity of the patient's CO2 retention. The patient's arterial blood gas (ABG) values do not warrant intubation at this time.
What type of ventilation senses the breaths the patient is taking and adds to get the desired volume / rate of breathing?
SIMV (synchronized intermittent mandatory ventilation)
Weaning methods that are used in combination with each other include
SIMV with CPAP. SIMV with PSV. CPAP with PSV. T-piece and PSV.
Which of the following chest radiography findings is consistent with a left pneumothorax?
Shifting of the mediastinum to the right
The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate?
Stop the procedure and reoxygenate the client During suctioning, the nurse should monitor the client closely for adverse effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.
Identify the clinical manifestations associated with oxygen toxicity.
Substernal chest pain that increases with deep breathing Pleuritic pain occurring on inhalation, followed by dyspnea Sore throat and eye and ear discomfort
Describe the major difference between tachypnea and hyperventilation?
Tachypnea has decreased depth; hyperventilation has increased depth.
A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure alarm keeps going off. When you enter the room, the ventilator inoperative alarm sounds. What is the primary action the nurse would take?
Take the patient off the ventilator and manually ventilate her.
A patient receiving mechanical ventilation is very anxious and agitated, and neuromuscular blocking agents are used to promote ventilation. The nurse recognizes that:
The client should always be addressed and explanations of care given. Neuromuscular blocking agents produce a paralysis that facilitates ventilation, but they do not sedate the patient. It is important for the nurse to remember that the client can hear, see, think, and feel and should be addressed and given explanations accordingly. Communication with the patient is possible, especially from the nurse, but visitors for an anxious, agitated client should provide a calming, restful effect on the client.
A client has an endotracheal tube (ET) inserted to relieve an upper airway obstruction and to facilitate secretion removal. The first responsibility of the nurse immediately following placement of the tube is to:
The first action of the nurse it to use an end-tidal CO2 detector. If no CO2 is detected, the tube is in the esophagus. The second action by the nurse following ET intubation is to auscultate the chest to confirm bilateral breath sounds and observe to confirm bilateral chest expansion. If this evidence is present, the tube is secured and connected to an O2 source. Then the placement is confirmed immediately with x-ray, and the rube is marked where it exits the mouth. The the patient should be suction as needed.
Which of the following should be used when suctioning a mechanically ventilated patient?
Three hyperoxygenation breaths (breaths at 100% FiO2) Hyperinflation (breaths at 150% tidal volume) Limit the number of passes to three.
Why would the nurse perform an inspection of the oral cavity during a complete pulmonary assessment?
To provide evidence of hypoxia
The nurse uses the minimal occluding volume to inflate the cuff on an endotracheal tube to minimize incidence of:
Tracheal necrosis The minimal occluding volume involves adding air to the ET tube cuff until no leak is heard at peak inspiratory pressure but ensures that minimal pressure is applied to the tracheal wall to prevent pressure necrosis of the trachea. The minimal occluding volume apply should between 20-25 mmHg of pressure on the trachea to prevent injury.
You have just admitted a client with respiratory failure that was placed on mechanical ventilation in the Emergency Department. You know that your client is at risk for:
Ventilator Associated Pneumonia (VAP)
An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client?
Venturi Mask The venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation, such as COPD, because it delivers a precise oxygen concentration.
A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure alarm keeps going off. When you enter the room, the ventilator inoperative alarm sounds. Which of the following criteria would indicate that the patient is not tolerating weaning?
Weaning intolerance indicators include (1) a decrease in level of consciousness; (2) a systolic blood pressure increased or decreased by 20 mm Hg; (3) a diastolic blood pressure greater than 100 mm Hg; (4) a heart rate increased by 20 beats/min; (5) premature ventricular contractions greater than 6/min, couplets, or runs of ventricular tachycardia; (6) changes in ST segment (usually elevation); (7) a respiratory rate greater than 30 breaths/min or less than 10 breaths/min; (8) a respiratory rate increased by 10 breaths/min; (9) a spontaneous tidal volume less than 250 mL; (10) a PaCO2 increased by 5 to 8 mm Hg or pH less than 7.30; (11) an SpO2less than 90%; (12) use of accessory muscles of ventilation; (13) complaints of dyspnea, fatigue, or pain; (14) paradoxical chest wall motion or chest abdominal asynchrony; (15) diaphoresis; and (16) severe agitation or anxiety unrelieved with reassurance.
A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure alarm keeps going off. When you enter the room, the ventilator inoperative alarm sounds. List some conditions that would set off the high-pressure alarm:
a kink in the ET tubing coughing increased secretions in the patient's airway High Obstruction Low Disconnect/Dislodge
What is the risk of intubating someone that you don't know when the last meal was (or other history)?
aspiration pneumonia
A client just involved in a motor vehicle accident has sustained blunt chest trauma as part of his injuries. The nurse assessment reveals absent breath sounds in the left lung field. A left-sided pneumothorax is suspected and is further validated when assessment of the trachea reveals:
a shift to the right. With a pneumothorax, the trachea shifts to the opposite side of the problem; with atelectasis, the trachea shifts to the same side as the problem. Subcutaneous emphysema is more commonly related to a pneumomediastinum and is not specifically related to the trachea but to air trapped in the mediastinum and general neck area.
What finding means that the ET tube is in the esophagus and not the trachea?
abdominal distention
What are the primary goals of mechanical ventilation?
adequate oxygenation / ventilation; reduced WOB, synchrony of vent/patient, avoidance of high peak pressures
The nurse suctions the client's ET tube when the client:
adventitious sounds over the trachea or bronchi confirm the presence of secretions that can be removed by suctioning, visible secretions in the ET tube, respiratory distress, suspected aspiration, increase in peak airway pressures, and changes in oxygen status
What will insufficient peak flow rates create?
air hunger
What is a complication with extubation that s/s should be assessed for?
airway obstruction
What is the major advantage to AC pressure control ventilation?
allows limitation of peak inspiratory pressures
What should always be present in the room on vented patients?
ambu bag
What needs to be bedside in preparation for intubation?
ambu bag, syringe (10cc) for cuff, meds
What are the major disadvantages for pressure support ventilation?
apnea alarm is the only backup, variable patient tolerance
When does weaning from the vent begin?
as soon as O2 levels start to normalize
What RR is the initial setting for a vent and what is monitored to determine accuracy?
between 12-16; ABGs
What are some physical assessment signs that the intubation in correct?
bilateral chest rise and fall
What is the major disadvantage to AC control ventilation?
may lead to inappropriate hyperventilation
The correct procedure for selecting an oropharyngeal airway is to:
measure the airway from the corner of the patient's mouth to the angle of the jaw.
What are some examples of obstructions related to high peak pressure alarms on the vent?
mucous plug, biting, ET tube blockage, bronchospasm
What type of pressure facilitates natural respiration?
negative (sucking in of air)
The most accurate and reliable control of FiO2 can be achieved through the use of a(n)
nonrebreathing circuit (closed).
How often is a patient woken up from sedation in order to assess the patient's ability to breath on their own (if pt condition permits)?
once a day
What is the major advantage to pressure support ventilation?
patient comfort, improved patient ventilator interaction
the maximum flow delivered by the vent during inspiration
peak flow rate
The finding of normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest in a newly intubated patient is probably caused by a
right mainstem intubation.
What should be considered when facing poor oxygenation, inadequate ventilation, or high peak pressures due to intolerance of vent settings?
sedation, analgesia, neuromuscular blockage
What can be caused by a NG tube in long term use that makes an OG tube a better option?
sinusitis that can lead to sepsis
What are used to prevent the patient from pulling out their own ET tube?
soft wrist restraints
a trial done with respiratory therapy to assess readiness for extubation
spontaneous breathing trial
What should be done if a patient gets hypoxic during intubation?
stop and bag the patient
a rigid tube that goes into the ET tube for easier placement
stylet
What are some examples of neurochemical blockers that are used during intubation?
succylcholine; ketamine
What should be kept available when intubating a patient that may have a full stomach?
suction
A patient was admitted to the critical care unit after a left pneumonectomy. The patient is receiving 40% oxygen via a simple facemask. The morning chest radiography study reveals right lower lobe pneumonia. After eating breakfast, the patient suddenly vomits and aspirates. The first action that should be taken after the patient's aspiration event is
suctioning his airway.
