NP4 Theory Unit 1 Exam

Nose Fractures: assessment

Nose Fractures: may result in loss of tissue integrity when it interferes w/ gas exchange; when bone or cartilage is not displaced & no complications are present, tx may not be needed. Displacement of bone or cartilage can cause airway obstruction or cosmetic deformity & can be source of infection. -Document any nasal problem; deviation, malaligned nasal bridge, change in nasal breathing, crepitus, bruising, & pain. -Blood or CSF may drain from nares; result of simple nasal fracture, rare but serious injury (ex. skull fracture). CSF contains glucose, test w/ dipstick; or yellow "halo" appears as a ring at the dried edge of the fluid.

PE Care Coordination & Transition Management

PE Care Coordination & Transition Management: D/C when hypoxemia & hemodynamic instability have resolved & adequate anticoagulation has been achieved. Anticoagulation tx usually continues after D/C (wks, mo, yrs); Teach Bleeding Precautions; activities to reduce VTE risk & PE recurrence, complications, & need for follow-ups. --Enoxaparin & newer anticoag.(dabigatran, rivaroxaban, and apixaban) do not require labs. -Home Care: some D/C home w/ min. risk for recurrence & no permanent physiologic changes; others have heart or lung damage that requires home & lifestyle changes. May need RT tx in home. --Extensive lung damage; may have activity intolerance from reduced gas exchange & become fatigued easily. Living arrangements may need to be modified; 1 floor living & avoid stairs. Depending on the degree of impairment, may require ADL assistance. -Home Care; Assessment of Pts Recovering from PE: -Assess respiratory status: observe RR & depth of ventilation. Auscultate lungs. Examine nail beds & mucous membranes for evidence of reduced gas exchange. Take a pulseOx reading. Ask if chest pain or SOB is experienced in any position. Ask about the presence of sputum & its color & character. -Assess CV status: take VS, including apical pulse, pulse pressure; assess for presence or absence of orthostatic hypotension & quality & rhythm of peripheral pulses. Note presence or absence of peripheral edema. Examine neck vein filling in the recumbent & sitting positions. -Assess lower extremities for DVT: examine lower legs & compare w/ each other for general edema & calf swelling, surface temp., red streaks or cordlike [palpable] structure. -Assess for evidence of bleeding: examine mouth & gums for oozing or frank bleeding. Examine all skin areas, esp. old puncture sites & wounds, for bleeding, bruising, or petechiae. -Assess cognition & MS: check LOC & orientation. -Assess understanding & adherence to management; s/s to report to the PHCP. Drug tx plan (correct timing & dose, AE). Bleeding Precautions. Prevention of VTE.

RN Management of MV

RN Management of MV: remember why they're using ventilator→ management efforts also focus on correcting causes of the RF. -Address the physical & psychological concerns; MV→ anxiety. Explain the ventilator purpose & acknowledge feelings; encourage to express concerns. Act as the coach to help & support. -MV in ICUs often experience delirium, or "ICU psychosis"; need frequent, repeated explanations & reassurance. -Always assess patient first, ventilator second. Ventilator alarm sounds→ examine pt for breathing, color, & O2sat before assessing ventilator. -Vital to understand why MV is needed; some problems requiring ventilation [ex. excessive secretions, sepsis, & trauma], require different tx to successfully wean from MV. -Chronic health problems (ex. COPD, Lt-sided HF, anemia, malnutrition) may slow weaning & require close monitoring & tx. -Action Alert: RN priorities w/ MV are monitoring & evaluating responses, managing ventilator system safely, & preventing complications. -Monitoring pt response: monitor, evaluate, & document response to ventilator; assess VS & breath sounds Q30-60m at first. Monitor respiratory parameters (ex. capnography, pulseOx) & check ABGs. -RN spends most time w/ pt & is most likely 1st ID changes in VS or ABGs, fatigue, or distress. Condition does not respond to current tx→ promptly coordinate w/ respiratory HCP & RT. --Be a resource for psychological needs; anxiety→ reduce tolerance for MV; skilled & sensitive RN care promotes emotional well-being & synchrony w/ the ventilator. Pt cannot speak→ communication can be frustrating & produce anxiety. May panic bc they believe voice is lost; reassure that the ETT prevents speech only temporarily. --Plan & teach communication methods to meet needs; keep belongings w/in reach; encourage visits from family & friends. Observation of facial expressions in noncommunicative may indicate pain, esp. during suctioning. --Visits from family, friends, & pets & keeping a call light w/in reach are ways of them a sense of control over the environment; urge them to participate in self-care.

Best Practice for Patient Safety & Quality Care: Tracheostomy Care

-After Assessing Need, perform care according to agency policy, usually Q8hrs & PRN. -Best Practice for Patient Safety & Quality Care: Tracheostomy Care --Assemble the necessary equipment & maintain Std. Precautions. --Suction the tracheostomy tube if necessary. --Remove old dressings & excess secretions. Set up a sterile field. --Remove & clean the inner cannula. Use 1/2-strength peroxide (if ordered) to clean the cannula & sterile NS to rinse it. If the inner cannula is disposable, remove it & replace w/ new one. --Clean the stoma site & then the tracheostomy plate with 1/2-strength peroxide followed by sterile NS. Ensure that none of the solutions enters the tracheostomy. --Change tracheostomy ties if they are soiled. Secure new ties in place before removing soiled ones to prevent accidental decannulation. If a knot is needed, tie a square knot that is visible on the side of the neck. Only 1 finger should be able to be placed between the tie tape & the neck. --Document the type & amount of secretions & the general condition of the stoma & surrounding skin integrity. Document their response to the procedure.

Head & Heck Cancer: Post-op care & Management

-Managing Pain: manage pain, while still allowing them to be able to participate in care. IV Morphine via PCA pump for the first 1-2 days post-op. Progress→ liquid opioids via feeding tube. PO drugs for pain & discomfort are started only after they can tolerate PO intake. -Maintaining Nutrition: malnutrition risk; feeding tube is placed during OP for nutrition support while healing; remain for 7-10 days. Removed when able to swallow safely. Aspiration cannot occur after a total laryngectomy; airway is completely separated from the esophagus. -Promoting Communication: voice quality & speech are altered; enormous effects on social interactions, continued employment, & quality of life. RN + SLP, work w/ patient & family toward developing an acceptable communication method during the inpatient period. --Mechanical devices: called electrolarynges; may be used for communication. Most are battery-powered & placed against the side of the neck or cheek. Air inside the mouth & throat is vibrated; they move their lips & tongue as usual. Quality of speech is robotlike. -Preventing Aspiration: OP changes URT & alt. swallowing mechanisms increase risk aspiration. Aspiration→ pneumonia, wt loss, & prolonged hospitalization. --NGT feeding increases risk; keeps the LES partially open. Most who need EN have a PEG tube placed; not an NGT. --TT may fix the larynx in place, resulting in difficulty swallowing. Inflated cuff can balloon backward into the esophagus & interfere w/ food passage. When cognitively intact, may adapt to eating normal food when the TT is small & cuff is not inflated. -Supporting Self-Esteem: pt w/ head & neck cancer usually has a change in self-concept & self-image resulting from stoma or artificial airway, speech changes, & change in eating method. May feel socially isolated from change in voice & facial appearance. Loose-fitting, high-collar shirts or sweaters, scarves, & jewelry can cover the laryngectomy stoma, tracheostomy tube, & other changes. Cosmetics may aid in covering any facial or neck disfigurement.

Noninvasive Positive-Pressure Ventilation (NPPV): 3 Common Modes

-Noninvasive Positive-Pressure Ventilation (NPPV): type of noninvasive ventilation (NIV); uses positive pressure to keep alveoli open & improve gas exchange w/o the dangers of intubation. Can deliver O2 or RA; nasal mask, nasal pillows, or full-face mask system allows mechanical delivery. -3 common modes: 1.) CPAP; delivers a set PAP throughout each cycle of inhalation & exhalation. Opens collapsed alveoli; benefits patient's w/ post-op atelectasis, cardiac-induced pulmonary edema, & COPD. Not helpful for respiratory failure following extubation. 2.) vL-limited or flow-limited; delivers a set tidal vL w/ the inspiratory effort & won't give anything more than that; in-between the effect of CPAP & BiPAP. 3.) Pressure-limited; includes pressure support, pressure control, & bi-level PAP (BiPAP), which cycles different pressures at inspiration & expiration. BiPAP: cycling machine delivers a set inspiratory PAP each time the patient begins to inspire; when they begin to exhale, the machine delivers a lower set end-expiratory pressure; 2 pressures improve tidal vL, reduce RR, & relieve dyspnea. -CPAP & BiPAP are both commonly used after extubation to prevent respiratory failure & need for reintubation. -Used to manage dyspnea, hypercarbia, & acute exacerbations of COPD, cardiogenic pulmonary edema, & acute asthma attacks. -NPPV prevents the complications associated w/ intubation (ex. VAP: ventilator-associated pneumonia; VAEs: ventilator-associated events); still has risks & complications. -Masks must fit tightly to form a proper seal; can lead to loss of tissue integrity w/ skin breakdown over the nose or face. Full face masks cause fewer skin problems than nasal-oral masks. -Leaks can cause uncomfortable pressure around the eyes, & gastric insufflation can lead to vomiting & aspiration. -NPPV is recommended only for use in alert patients who have the ability to protect their airway, although a NGT may still be required for safety. -NPPV is used commonly for sleep apnea; holds open the upper airways. Those using CPAP or BiPAP at home often bring their home equipment to the hospital; feel more comfortable using their own equipment. -RN: patients using NPPV tx is increasing in every setting; RN must be knowledgeable about the equipment, technique, & potential complications. RT support can help safely manage a patient receiving NPPV.

Interventions for ARF:

-O2-tx: appropriate for any patient w/ acute hypoxemia; used in ARF to keep the PaO2 >60mmHg while tx the cause. If O2 tx does not maintain acceptable PaO2 levels [indicating adequate gas exchange], MV (invasive or noninvasive) may be needed. -Drugs: order is based on the cause→ whats the source, what will support it. --Bronchodilators given systemically, [via nebulizer, or MDI]; dilate the bronchioles & decrease inflammation to promote gas exchange. Txs ventilatory issues. --Corticosteroids: may be used, but benefit has not been demonstrated conclusively. --Analgesics: needed if pain present. If they require MV, may need neuromuscular blockade drugs for optimal ventilator effect. -Other management strategies depend on the underlying condition(s) that predisposed them to ARF development; may include diuretics or antibiotics. -Position of comfort: RN will help them find a position of comfort that allows easier breathing (ex. usually a more upright position). -Decrease anxiety occurring w/ dyspnea; help w/ relaxation, diversion, & guided imagery. -Start energy-conserving measures; ex. minimal self-care & no unnecessary procedures. Encourage DB & other breathing exercises.

PE Severity & Management Options (tbl 29.1)

-RN management of PE; rapid categorization of PE severity & prompt management are required. PE Severity & Management Options (tbl 29.1): -Massive PE; Mortality as high as 65%: --S/S: severe hypotension (SB <90 for >15min); cardiac arrest, cardiopulmonary collapse; severe bradycardia; shock; severe dyspnea, respiratory distress. --Tx: CPR; Inotropic and/or vasopressor support, fluids; Fibrinolytic tx; Tissue plasminogen activator (tPA); Alteplase; Unfractionated heparin initial tx. -Submassive PE: --S/S: normotension; RV dysfunction on echocardiography; RV dilation on echocardiography or CT; Rt bundle branch block; ST elevation or depression; T-wave inversion; Elevated BNP or troponin. --Tx: is controversial; some agents not approved for this group; must weigh benefits of thrombolytic tx against risk for bleeding; fibrinolytics may be preferred if patient appears to be decompensating or if there is RV dysfunction (hypokinesis) or elevation in BNP or troponin; LMWH (preferred agent); Fondaparinux; Unfractionated heparin. -Low-risk PE; Mortality ranges from 1-8%: --S/S: normotension; no RV dysfunction; no elevation in BNP or troponin. --Tx: fibrinolytics not warranted because of risk for bleeding; LMWH; Direct thrombin inhibitor; Inpatient hospitalization not usually required.

Ventilator Controls & Settings: Tidal vL, Rate, FiO2, IPAP, PEEP, Flow Rate, & Other

-Tidal vL (VT): vL of air received w/ each breath; measured on inspiration or expiration; average prescribed VT 6-8 mL/kg, based on IBW & accurate measure of Ht. -Rate (breaths/min): # ventilator breaths delivered per min; usually 10-14 breaths/min. Pt condition & ventilator mode can be factors if above or below this range. -Fio2: O2 level delivered to pt; FiO2 is based on ABGs & pt condition; 21-100% O2. -Peak airway (inspiratory) pressure: pressure used by the ventilator to deliver a set tidal vL at a given lung compliance; appears on the display. It's the highest pressure reached during inspiration. PIP trends reflect changes in lung resistance & ventilator resistance. --Increased PIP= increased airway resistance in pt or ventilator tubing (bronchospasm or pinched tubing, patient biting the ET tube), increased secretions, pulmonary edema, or decreased pulmonary compliance (lungs or chest wall is "stiffer" & harder to inflate). --Upper pressure limit is set to prevent barotrauma; limit is reached→ high-pressure alarm, & remaining vL is not given. -PEEP: + pressure exerted during expiration; improves oxygenation by enhancing gas exchange & preventing atelectasis. MV often have a set PEEP of 5-6 cm H2O to prevent alveolar collapse & improve arterial oxygenation; may be increased to 15 cm H2O+ when PaO2 remains low despite increasing FiO2. --Need for increased PEEP= severe gas exchange problem; important to lower FiO2 delivered whenever possible, prolonged use of high FiO2 can damage lungs from toxic effects of O2. Effect should be increase in PaO2 so FiO2 can be decreased. -Flow rate: how fast each breath is delivered; usually 40-60L/min. Agitated or restless, widely fluctuating inspiratory pressure reading, or other s/s air hunger→ flow may be too low. Increasing flow should be tried before using chemical restraints. -Other settings: used depending on ventilation mode & pt condition; ex. waveform, plateau, pressure-vL loop, trigger sensitivity, & alarm settings.

Tracheotomy Post-op care & Assessing for Complications (Tube Obstruction, Dislodgment, & Decannulation)

-Tracheotomy Post-op care: Immediate needs are airway maintenance & respiratory assessment; focus on ensuring a patent airway; then confirm the presence of bilateral breath sounds. Perform a respiratory assessment at least Q1hr; assess for complications. -Tube obstruction: result of secretions or by cuff displacement. -Indicators: difficulty breathing; noisy respirations; difficulty inserting a suction catheter; thick, dry secretions; and high peak pressures (if a mechanical ventilator is used). --Assess the patient at least Q1hr for tube patency. Prevent obstruction by helping the patient cough & DB, providing inner cannula care, humidifying O2, & suctioning. If tube obstruction results from cuff prolapse over the end of the tube, the respiratory HCP repositions or replaces the tube. -Tube dislodgment & accidental decannulation: can occur when the tube is not secure. Prevent by securing the tube in place to reduce movement & traction or accidental pulling. --Tube dislodgment in the first 72hrs post-op is an emergency because the tracheostomy tract has not matured & replacement is difficult; tube may end up in the SubQ tissue instead of in the trachea ("false passage"). The patient will not be able to be ventilated. --Obese or those w/ short, large necks may be particularly difficult to recannulate if the tube is dislodged. --Critical Rescue: For safety, ensure that a TT of the same type (including an obturator) & size (or 1 size smaller) is at the bedside at all times, along w/ a tracheostomy insertion tray. Monitor the patient for tube placement. When tube is dislodged on an immature tracheostomy, respond by ventilating the patient using a manual resuscitation bag & facemask while another RN calls the RRT, as well as the surgical service that placed the tracheostomy. If a stay suture technique was used during the tracheostomy procedure, gentle tension on the sutures can reopen the trachea. --If decannulation occurs after 72hrs, extend the patient's neck & open the tissues of the stoma w/ a curved Kelly clamp to secure the airway. W/ the obturator inserted into the tracheostomy tube, quickly & gently replace the tube & remove the obturator. Check for airflow through the tube & for bilateral breath sounds. --If you cannot secure the airway, notify a more experienced RN, RT, or respiratory HCP for assistance. Ventilate with a bag-valve-mask. If the patient is in distress, call the RRT for help. To reduce tube dislodgment problems, many institutions have a "difficult airway" cart for high-risk patients.

Transtracheal Oxygen Delivery

-Transtracheal Oxygen Delivery: (TTO) LT method of delivering O2 directly into the lungs; small, flexible catheter is passed into the trachea through a small incision, under local anesthesia. Hooked to portable O2. Smaller & less severe tx, than a TT. -Used for anatomical issues of the airway that need to be bypassed; concern= risk of infection, its a direct line to airway & your bypassing your filtering system (nose; cillia). -Reduces loss of tissue integrity from nasal prongs & is less visible. -TTO team provides education, purpose of TTO, & care of the catheter. -Different flow rates are prescribed for rest & activity; rate also is prescribed for the NC, which is used when the TTO catheter is being cleaned.

Types of ARF

-Ventilatory failure: a problem in O2 intake (air movement or ventilation) & BF (perfusion)→ V/Q mismatch in which BF (perfusion) is normal but air movement (ventilation) is inadequate. -Defined by: PaCO2 level >45mmHg + acidosis (pH <7.35) in patients who have otherwise healthy lungs. --Chest pressure does not change enough to permit air movement in/out→ too little O2 reaches the alveoli, & CO2 is retained. --Inadequate O2 intake or excessive CO2 retention→ areas of no air movement & perfusion is wasted→ poor gas exchange & hypoxemia. -Oxygenation (gas exchange) failure: chest pressure changes are normal; air moves w/o difficulty but does not oxygenate the pulmonary blood sufficiently. --V/Q mismatch in which air movement & O2 intake (ventilation) are normal but lung BF (perfusion) is decreased. --Caused by: many lung disorders; include impaired diffusion of O2 at the alveolar level, Rt-to-Lt shunting in the pulmonary vessels, V/Q mismatch, RA w/ a low O2 level, & abnormal Hgb that fails to bind O2. -Combined V/O failure: involves hypoventilation (poor respiratory movements). -Impaired gas exchange at the alveolar-capillary membrane→ poor O2 diffusion into arterial blood & CO2 retention; w/ possible poor lung perfusion. -Lung perfusion is not adequate= V/Q mismatch; both ventilation & perfusion are inadequate. Leads to a more profound hypoxemia than either VF or OF alone. -Combination of VF+OF occurs in pts w/ abnormal lungs; ex. any form of chronic bronchitis, emphysema, or CF, or having an asthma attack. Bronchioles & alveoli are diseased→ OF; breathing work increases until the respiratory muscles cannot function effectively→ VF→ ARF. -ARF can occur in pts w/ cardiac failure along w/ VF; made worse because the cardiac system cannot adapt to the hypoxia by increasing CO.

ALI Leading to ARDS; Preventing ARDS

ALI Leading to ARDS; Preventing ARDS: -ALI→ ARDS has many causes; sepsis is the most common. Some causes result in direct injury to lung tissue; others do not directly involve the lungs. --Direct lung injury; ex. gastric acid aspiration, pneumonia, near-drowning, or inhaling toxic fumes. Surfactant production is impaired & remaining surfactant is diluted; leads to atelectasis, decreased lung compliance, & shunting (movement of blood in the lungs w/o gas exchange & oxygenation). --Indirect injury; ex. sepsis, pancreatitis, trauma, & other conditions, result in inflammatory mediators→ lungs→ damage ("cytokine storm"). -All causes result in systemic inflammatory response that produce a cytokine storm that maintain inflammation: Thick, swollen tissue + Lung fluid increases= Reduces gas exchange & oxygenation. -Health Promotion & Maintenance: ID those at high risk; Monitor pts on tube feedings to prevent aspiration & pts w/ impaired swallowing & gag reflex; Infection control guidelines (ex. handwashing, invasive catheter & wound care, & Contact Precautions, teach UAPs). Monitor pts tx for health problems associated w/ ARDS. Swallowing problems or a poor gag reflex→ use a suction toothbrush for oral care.

ARDS: patho

ARDS is ARF w/ these features: Hypoxemia that persists even when 100% O2 is given (refractory hypoxemia= cardinal feature); Decreased pulmonary compliance; Dyspnea; Non-cardiac associated bilateral pulmonary edema; Dense pulmonary infiltrates on x-ray (ground-glass appearance). --AKA: adult respiratory distress syndrome, "stiff lungs," shock lung, & acute respiratory dysfunction syndrome. --ARDS often occurs after acute lung injury (ALI) in people w/ no pulmonary disease as a result of other conditions; ex. sepsis, burns, pancreatitis, trauma, & transfusion. -Causes of ALI in ARDS; trigger is a systemic inflammatory response→ activates pro-inflammatory cytokines→ maintain continuing inflammation in the alveoli & pulmonary vasculature; response= "cytokine storm". If prolonged→ thick, swollen tissues→ hinder gas exchange & promote scar tissue; why ARDS s/s similar regardless of cause. --Alveolar-capillary membrane= main site of lung injury; normally is permeable only to small molecules; injured during sepsis, PE, shock, aspiration, severe COVID inflammation, or INH injury. Injury to AC membrane→ more permeable to large molecules→ allows debris, proteins, & fluid into the alveoli. --Lung tissue normally remains relatively dry; ARDS= lung fluid increases & contains more proteins. ARDS + COVID-19= results in thick exudate→ inhibits gas exchange. -Other changes in alveoli & bronchioles. Type II pneumocytes produce surfactant; increases lung compliance (elasticity & recoil of lung tissue) & prevents alveolar collapse. --Surfactant activity is reduced in ARDS; type II pneumocytes are damaged & surfactant is diluted by excess lung fluids→ unstable alveoli that tend to collapse→ collapsed or fluid-filled alveoli cannot exchange gases. --Edema then forms around terminal airways→ compressed, closed, & can be destroyed→ lung vL & compliance are further reduced. --Fluid continues leaking in more lung areas→ fluid, protein, & BCs collect in the alveoli & spaces between→ lymph channels are compressed, & more fluid collects. --Poorly inflated alveoli receive blood but cannot oxygenate it, increasing the shunt→ hypoxemia & V/Q mismatch. -Transfusion-related acute lung injury (TRALI): sudden onset (w/in 6hrs of transfusion) of hypoxemic lung disease w/ infiltrates on x-ray w/o cardiac problems. Activation of inflammatory response; cause= recent plasma transfusion-containing blood products; ex. PRBCs, platelets, & FFP.

ARF Assessment

ARF S/S: rt the systemic effects of hypoxia, hypercapnia, & acidosis. Patient is ALWAYS hypoxemic. --Assess for dyspnea (work of breathing; subjective)= hallmark of RF; evaluate how breathless they become performing common tasks, pt might not be aware of changes. Rapid developing= more intense. Slowly progressive= may 1st be noticed as DOE or when lying down; may have orthopnea [breathe easier when upright]. W/ chronic respiratory problems, a minor increase in dyspnea may represent severe gas exchange problems. --Assess for change in RR or pattern, & lung sounds. PulseOx may show decreased O2sat, but EtCO2 or PEtCO2 monitoring may be more valuable for monitoring ARF pt. PulseOx may show adequate O2sat, but bc of increased EtCO2 they may be close to RF. --Review ABG values to accurately ID the degree of hypoxia & hypercarbia. PaO2 <60 mmHg. PaCO2 >45 mmHg w/ pH<7.35 & SaO2 <90%. --Other s/s of hypoxic RF: restlessness, irritability or agitation, confusion, & tachycardia. --S/S hypercapnic failure: decreased LOC, headache, drowsiness, lethargy, & seizures. --S/S acidosis: decreased LOC, drowsiness, confusion, hypotension, bradycardia, & weak peripheral pulses.

Abnormal Breath Sounds, Adventitious, & Voice Sounds

Abnormal Breath Sounds, Adventitious, & Voice Sounds: -Abnormal breath sounds: Bronchial breath sounds heard at the lung edges are abnormal; bronchial sounds are transmitted to an area of increased density, ex. atelectasis, tumor, or pneumonia. Bronchovesicular breath sounds in an abnormal location, may indicate normal aging or an abnormality such as consolidation & chronic airway disease. -Adventitious sounds: are additional breath sounds along with normal sounds; indicate pathologic changes in the lung. Ex. crackle, wheeze, rhonchus, & pleural friction rub; vary in pitch, intensity, & duration; can occur in any phase of the respiratory cycle. Document exactly what you auscultate. -Voice sounds: vocal resonance; through the normally air-filled lung are muffled & unclear because sound vibrations travel poorly through air; become louder & more distinct when the sound travels through a solid tissue or liquid. -Increased vocal resonance: caused by pneumonia, atelectasis, pleural effusion, tumor, or abscess.

Acute Respiratory Failure: patho

Acute Respiratory Failure: Inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the pt. -Normal Patho= Ventilation (air movement=V) & Perfusion (BF=Q) match→ adequate pulmonary gas exchange. -ARF= mismatch between ventilation & perfusion (lung or lung area)→ reduction in gas exchange→ RF may result. ARF can be 1.) ventilatory failure; 2.) oxygenation (gas exchange) failure; or 3.) combination of both. -Classified by abnormal blood gas values; critical values are: --Hypoxemic, oxygenation failure: PaO2 <60mmHg ...or.... --Hypercapnia, ventilatory failure: PaCO2 >45mmHg occurring w/ acidemia (pH <7.35) ...and... --Arterial O2sat (SaO2) <90% in both cases; whatever the underlying problem, ARF pt is always hypoxemic (low arterial blood O2 levels). -Ventilatory failure: problem in O2 intake (air movement or ventilation) & BF (perfusion)→ V/Q mismatch in which BF (perfusion) is normal but air movement (ventilation) is inadequate.

Best Practice For Patient Safety & Quality Care: Suctioning the Artificial Airway

Best Practice For Patient Safety & Quality Care: Suctioning the Artificial Airway -Assess the need for suctioning. -Wash hands. Don protective eyewear. Maintain Std. Precautions. -Explain to the patient that sensations such as SOB & coughing are to be expected but that any discomfort will be very brief. -Check the suction source. Occlude the suction source, & adjust the pressure dial to between 80-120mmHg to prevent hypoxemia & trauma to the mucosa. -Set up a sterile field. -Preoxygenate the patient with 100% oxygen for 30sec-3min (>3 hyperinflations) to prevent hypoxemia. Synchronize hyperinflations w/ inhalation. -Quickly insert the suction catheter until resistance is met. Do not apply suction during insertion. -Routine instillation of NS is not supported. Gas exchange is impaired due to hypoxia & there is an increased infection risk. -Withdraw the catheter 0.4-0.8in (1-2cm), & begin to apply suction. Apply continuous suction & use a twirling motion of the catheter during withdrawal to avoid impairing tissue integrity. Never suction >10-15sec. -Hyperoxygenate for 1-5min or until the patient's baseline HR & O2sat are w/in normal limits. -Repeat PRN for up to 3 total suction passes. -Document secretion characteristics & patient responses.

Assessment of ARDS

Assessment of ARDS: -Physical S/S: Assess the breathing of all those at increased ARDS risk; ID if increased work of breathing is present, as indicated by Hyperpnea, noisy respiration, cyanosis, pallor, retraction intercostally or substernally; VS. --Document sweating, respiratory effort, & any change in MS. --Abnormal lung sounds are not heard on auscultation because the edema occurs first in the interstitial spaces & not in the airways. Assess VS at least Q1hr for hypotension, tachycardia, & dysrhythmias. -Dx Assessment: -Lowered PaO2: ARDS Dx is established by a lowered PaO2 value (decreased gas exchange & oxygenation), done w/ ABGs. Bc a widening alveolar O2 gradient develops w/ increased shunting of blood, the pt has a progressive need for higher levels of O2. -Widening alveolar oxygen gradient= increased FiO2 does not lead to increased PaO2 levels. -P/F (<200 mmHg): another ARDS characteristic is a P/F ratio (PaO2/FiO2) of <200mmHg; develop refractory hypoxemia & often needs intubation & MV. -Sputum cultures: via bronchoscopy & transtracheal aspiration are used to ID if lung infection also is present. -CXR: may show diffuse haziness or a "whited-out" (ground-glass) appearance of the lung. -ECG: rules out cardiac problems & usually shows no specific changes.

Auscultation of the Lungs & Normal Breath Sounds

Auscultation of the Lungs & Normal Breath Sounds: -Auscultation: w/ stethoscope for normal breath sounds, abnormal (adventitious) sounds, & voice sounds; info about the flow of air through the trachea & lungs; helps ID fluid, mucus, or obstruction in the respiratory system. -Begin w/ them sitting in an upright position; stethoscope pressed firmly against the chest wall (clothing can muffle sounds); patient breathes slowly & deeply through an open mouth (nose breathing causes turbulent sounds that are transmitted to the lungs). -Proceed from apex to base, side-to side through the ICS; avoid listening over bony structures. -Listen to a full respiratory cycle, noting the quality & intensity of the breath sounds. -Normal breath sounds: produced as air vibrates while moving through the passages (larynx to alveoli); ID by location, intensity, pitch, & duration w/in the respiratory cycle (ex. early or late inspiration & expiration). -Types: "bronchial" or "tubular"; harsh hollow sounds heard over the trachea and mainstem bronchi. --"Bronchovesicular"; heard over the branching bronchi. --"Vesicular"; soft rustling sounds heard in lung tissue over small bronchioles. --Describe these sounds as normal, increased, diminished, or absent.

Best Practice for Patient Safety & Quality Care: Oxygen Therapy

Best Practice for Patient Safety & Quality Care: Oxygen Therapy -Check the prescription for the type of delivery system & L/min or % of O2 to be applied. -Use humidification if O2 is being delivered at >4 L/min. -Be sure the equipment is functioning properly. -Check the skin around the patient's ears, back of the neck, & face Q4-8hrs for pressure points, irritation, & impaired tissue integrity. -Provide mouth care Q8hrs & PRN; assess nasal & oral membranes for cracks, dryness, or impaired tissue integrity. -Pad the elastic band & change its position often to prevent skin breakdown. -Clean the cannula or mask by rinsing w/ clear, warm H20 Q4-8hrs or PRN. Clean skin under the tubing, straps, & mask Q4-8hrs or PRN. -Lubricate the patient's nostrils, face, & lips w/ nonpetroleum cream to relieve the drying effects of O2. -Position the tubing so it does not pull on the patient's face, nose, or artificial airway. -Ensure that there is no smoking & that no other sources of sparks or flames (ex. candles or matches) are used in the immediate area. -Assess & document the patient's response to O2 tx. -Avoid hypoxia or hyperoxia. -Ensure that the patient has an adequate O2 source during any periods of transport. -Collaborate w/ the RT for optimum management.

Best Practice for Pt Safety & Quality Care: Care of Pt Receiving MV

Best Practice for Pt Safety & Quality Care: Care of Pt Receiving MV -Assess respiratory status & gas exchange at least Q4h for the first 24hrs & then PRN: VS Q4h + O2sat & lung auscultation (assess Q1h or more often for ICU). Be alert for the possibility of unintended extubation or self-extubation. If the pt requires sedation or restraints, follow institution guidelines for pt safety. Assess color around the lips & nail beds, & observe for bilateral chest expansion. Assess placement of the ETT. Evaluate ABGs as available. -Maintain HOB >30 degrees when supine to decrease risk for aspiration & VAP. -Review ventilator settings at least Q8h, + alarm settings, w/ RT. -Review pt info on the ventilator display to confirm they are receiving the prescribed set tidal vL & that peak pressures are not elevated (→ obstruction or decreased lung compliance). -Empty ventilator tubings when moisture collects. -Ensure cuff is adequately inflated to ensure tidal vL. Concern for overinflation→ have RT check cuff pressure. -Assess need for suctioning Q2hrs & suction only PRN (must pre-oxygenate before suctioning). -Assess mouth around ETT for pressure injuries. -Perform mouth care at least Q12hrs using std. ventilator bundles. -Perform tracheostomy care at least Q8hrs, changing ETT holder or tape PRN, & moving the oral ETT to the opposite side of the mouth daily [prevent ulcers]. -Assess ventilated pts for GI distress (diarrhea, constipation, tarry stools). -Turn at least Q2hrs & get them out of bed as prescribed to prevent immobility complications. -Monitor progress on current ventilator settings & promptly relay concerns to the respiratory HCP or RT. -Monitor for AEs of MV: infection, barotrauma, reduced CO. -Position to facilitate ventilation-perfusion (V/Q) matching ("good lung down"), as appropriate. -Monitor effects of ventilator changes on gas exchange,** pts subjective responses, & readiness to wean. -Provide communication method. Request consultation w/ SLP for assistance, if necessary. -Admin muscle-paralyzing agents, sedatives, & narcotic analgesics, as prescribed, using lowest possible dose to achieve comfort w/o oversedation. -Include pt & family whenever possible (esp. suctioning & tracheostomy care).

Bronchial & Oral Hygiene for TT

Bronchial & Oral Hygiene for TT: has a lot to do w/ their mobility. --Turn/reposition Q1-2h, support out-of-bed activities, encourage early ambulation [key]. If they are able to turn, remind them; if unable, then it's the RNs responsibility. Facilitates the side-to-side movement of secretions. --Getting up & ambulating→ DB→ coughing→ mobilizes secretions. --Coughing & DB, chest percussion, vibration, & postural drainage promote pulmonary cure. --RN will teach about coughing, DB, & IS; learning how to use body mechanics to remove secretions, decreases infection risk, time in hospital, ABs are more effective, & overall feel better. --Avoid glycerin swabs or mouthwash containing alcohol for oral care; alcohol can be drying & O2-tx is too; becomes a potential source of infection. --Ensure that anything introduced to the mucosa is effective in mobilizing secretions & reducing infection risk. Assess for ulcers, bacterial/fungal growth, infection.

Cancer of the nose & sinuses: causes, s/s, Dx, tx

Cancer of the nose & sinuses: -Tumors of the nasal cavities & sinuses result from loss of cellular regulation. Malignant tumors are rare; more common among adults w/ chronic exposure to wood dusts, textile dusts, leather dusts, flour, nickel & chromium dust, mustard gas, & radium; these w/ cigarette smoking increases the risk -Sinus Cancer: slow onset & s/s resemble sinusitis; s/s persistent nasal obstruction, drainage, bloody discharge, & persistent pain after tx of sinusitis; lymph node enlargement often occurs on the side w/ tumor mass. -Dx: tumor location is ID w/ x-ray, CT, or MRI; biopsy is performed to confirm Dx. -Tx: surgical removal of all or part of the tumor is the main tx for nasopharyngeal cancers & often combined w/ radiation tx. Chemotherapy may be used in conjunction w/ surgery & radiation for some tumors. -Post-op problems: change in body image or speech & changes in taste & smell. -RN: provide general post-op care; maintaining a patent airway, monitoring for hemorrhage, providing wound care, assessing nutrition status, & performing tracheostomy care [PRN]. Perform careful mouth & sinus cavity care w/ NS irrigations using an electronic irrigation system (ex. Water-Pik, Sonicare) or syringe. Assess for pain & infection.

Capnometry & capnography; PETCO2

Capnometry & capnography: noninvasive methods that measure the amount of CO2 present in exhaled air, it's an indirect measurement of arterial CO2 levels. Measure the partial pressure of end-tidal CO2 levels (PETCO 2; ETCO 2) in intubated & spontaneously breathing patients. --Provide info about CO2 production, pulmonary perfusion, alveolar ventilation, respiratory patterns, ventilator effectiveness, & possible rebreathing of exhaled air. -Capnometry: exhaled air sample is tested w/ a sensor that changes the CO2 level into a color or # for analysis. -Capnography: CO2 level is graphed as a specific waveform along w/ a #. More sensitive indicator of gas exchange adequacy than pulseOx; useful in early detection of respiratory depression. -Normal PETCO2: 20-40 mm Hg; alterations reflect changes in breathing effectiveness & gas exchange. Changes occur before hypoxia, can be detected using pulseOx because CO2 moves out of the body more easily than O2 moves into it. PulseOx & PETCO2 for patients at risk for respiratory problems can provide info to direct early intervention. -Increased PeTCO2: conditions that reflect inadequate gas exchange or an increase in cellular metabolism; increase production of CO2. --Ex. Gas exchange- hypoventilation, partial airway obstruction, & rebreathing exhaled air. Metabolism- fever, acidosis, & heavy exercise. -Decreased PETCO2: conditions w/ poor pulmonary ventilation. --Ex. pulmonary embolism, apnea, total airway obstruction, & malposition of an ET tube. --Ex. hyperventilation not based on O2 need, CO2 is blown off faster than it is generated in the tissues. --Ex. CP arrest decreases PETCO2; PETCO 2 may be used to determine the effectiveness of CPR & whether there is a spontaneous return of circulation.

Care Issues for the Patient w/ a Tracheostomy: Ensuring Air Warming & Humidification

Care Issues for the Patient w/ a Tracheostomy: -Ensuring Air Warming & Humidification: TT bypasses the nose & mouth; humidify & warm the inspired air. --Inadequate humidification & warming= tracheal damage. --Inadequate humidity= thick, dried secretions occlude airways & increase the risk for infection. -Prevent Complications: humidify the air as ordered; assess for a fine mist emerging from the tracheostomy collar or T-piece during ventilation. -Increase humidity: warming device can be attached to the H2O source w/ a temp. probe in the tubing circuit; monitor circuit temp. Q1hr by feeling the tubing & checking probe reading. Ensure adequate hydration; helps liquefy secretions. Increasing rate of the flowmeter increases the amount of delivered humidity. -Action Alert: Keep the temp. of the air entering a tracheostomy between 98.6-100.4°F (37-38°C); never exceed 104°F (40°C).

Care Issues for the Patient w/ a Tracheostomy: Preventing Tissue Injury

Care Issues for the Patient w/ a Tracheostomy: -Preventing Tissue Injury: loss of tissue integrity can occur where the inflated cuff presses against the tracheal mucosa; considered a "never event" pressure injury. --Mucosal ischemia: pressure exerted by the cuff on the mucosa exceeds the capillary perfusion pressure; to reduce tracheal damage, keep the cuff pressure 14-20mmHg or 20-30cm H2O (<25 cm H2O). -Cuffs use a high vL of air while keeping low pressure on the tracheal mucosa. -RN: inflate the cuff to form a seal between the trachea & cuff using the least amount of pressure. If the cuff cannot be inflated to seal well enough, a larger-diameter tube may be needed; pressure cuff inflator can be used to inflate the cuff to a specified pressure or to check the cuff pressure. --Check pressure at least 1x/shift w/ a pressure cuff inflator or the minimal leak technique. -Other factors that contribute to the risk for damage; ex. malnourished, dehydrated, hypoxic, older, or receiving corticosteroids; tube friction & movement damage the mucosa & lead to tracheal stenosis. --RN: Reduce local airway damage by maintaining proper cuff pressures, stabilizing the tube, suctioning only PRN, & preventing malnutrition, dehydration, & hypoxia.

Characteristics of Adventitious Breath Sounds (table 24.5)

Characteristics of Adventitious Breath Sounds (table 24.5): -Fine crackles; Fine rales: Popping, discontinuous sounds caused by air moving into previously deflated airways; sounds like hair being rolled between fingers near the ear. High-pitched rales: "Velcro" sounds late in inspiration usually associated with restrictive disorders. --Ex. Asbestosis, Atelectasis, Interstitial fibrosis, Bronchitis, Pneumonia, Chronic pulmonary diseases. -Coarse crackles; Low-pitched crackles: Lower-pitched, coarse, rattling sounds caused by fluid or secretions in large airways; likely to change with coughing or suctioning. --Ex. Bronchitis, Pneumonia, Tumors, Pulmonary edema. -Wheeze: Squeaky, musical, continuous sounds associated with air rushing through narrowed airways; may be heard w/o a stethoscope. Arise from the small airways; usually do not clear with coughing. --Ex. Inflammation, Bronchospasm (bronchial asthma), Edema, Secretions, Pulmonary vessel engorgement (cardiac "asthma"). -Rhonchus (rhonchi): Lower-pitched, coarse, continuous snoring sounds; arise from the large airways. --Ex. Thick, tenacious secretions, Sputum production, Obstruction by foreign body, Tumors. -Pleural friction rub: Loud, rough, grating, scratching sounds caused by the inflamed surfaces of the pleura rubbing together; often associated with pain on deep inspirations. Heard in lateral lung fields. --Ex. Pleurisy, TB, Pulmonary infarction, Pneumonia, Lung cancer.

Characteristics of Normal Breath Sounds (table 24.4)

Characteristics of Normal Breath Sounds (table 24.4): -Bronchial (tubular, tracheal): High pitch; Loud aptitude; Inspiration < expiration; Harsh, hollow, tubular, blowing quality; Normal location- Trachea and larynx. -Bronchovesicular: Moderate pitch; Moderate amplitude; Inspiration = expiration; Mixed quality; Normal location- Over major bronchi where fewer alveoli are located; posterior, between scapulae (especially on right); anterior, around upper sternum in first and second intercostal spaces. -Vesicular: Low pitch; Soft amplitude; Inspiration > expiration; Rustling quality, like the sound of the wind in the trees; Normal location- Over peripheral lung fields where air flows through smaller bronchioles and alveoli.

Characteristics of the 5 Percussion Notes (table 24.3):

Characteristics of the 5 Percussion Notes (table 24.3): -Resonance: Low pitch; Moderate to loud intensity; Hollow quality; Long duration; Resonance is characteristic of normal lung tissue. -Hyper-resonance: Higher than resonance pitch; Very loud intensity; Booming quality; Longer than resonance duration; Hyper-resonance indicates the presence of trapped air, so it is commonly heard over an emphysematous or asthmatic lung & occasionally over a pneumothorax. -Flatness: High pitch; Soft intensity; Extreme dullness quality; Short duration; An ex. location is the sternum. Flatness percussed over the lung fields may indicate a massive pleural effusion. -Dullness: Medium pitch; Medium intensity; Thud-like quality; Medium duration; Ex. locations are over the liver & kidneys. Dullness can be percussed over an atelectatic lung or a consolidated lung. -Tympany: High pitch; Loud intensity; Musical, drum-like quality; Short duration; Ex. are the cheek filled w/ air & the ABD distended with air. Over the lung, a tympanic note usually indicates a large pneumothorax.

Checking Cuff Pressure

Checking Cuff Pressure: -Check pressure at least 1x/shift w/ a pressure cuff inflator or the minimal leak technique. -Inflator: keep the pressure at 14-20mmHg or 20-30cmH2O. --Rarely, the cuff pressure is increased to maintain ventilator vLs when peak pressures are >50mmHg (65cmH2O) & PEEP is >10mmHg (14cmH2O). --High PEEP values can deflate the cuff over time, & more air may need to be added to maintain a proper seal. --Manufacturers have guidelines for the specific vLs for each cuff size; most are adequately inflated w/ <10 mL air. -Minimal leak technique: to ensure adequate cuff pressure and reduce the risk for pressure injury, a pressure cuff inflator is not used. --After completing tracheostomy care & suctioning the airway above the cuff, attach a 10-mL Luer-Lok syringe to the valve in the pilot balloon. --Place a stethoscope on the side of the patient's neck near the tracheostomy tube & slowly deflate the cuff w/ the syringe while listening for a loud, gurgling air rush as the seal is broken & air bypasses the tracheostomy tube on inhalation. --Then, while reinjecting the air in the syringe, continue to listen for air passing the cuff. When air is no longer heard passing the cuff, the airway is sealed. --At this point, remove 1 mL of air from the cuff; ensures that the airway is sealed sufficiently to allow adequate ventilation & that the tube fit is kept just loose enough to prevent tracheal injury.

Comparison of High-Flow Oxygen Delivery Systems (table 25.2)

Comparison of High-Flow Oxygen Delivery Systems (table 25.2): -High-Flow Delivery Systems: Venturi mask, aerosol mask, face tent, high-flow nasal cannula (HFNC), tracheostomy collar, & T-piece; devices deliver an accurate O2 level when properly fitted, w/ O2 concentrations of 24-100% at 8-15 L/min. -24%-50% FiO 2 with flow rates as recommended by the manufacturer, usually 4-10 L/min; provides high humidity --Perform constant surveillance to ensure an accurate flow rate for the specific FiO2. --Keep the orifice for the Venturi adapter open & uncovered because the adapter does not function when the orifice is covered & O2 delivery varies. --Provide a mask that fits snugly & tubing that is free of kinks because these conditions can reduce Fio2. --Assess for dry mucous membranes to ensure comfort. --Change to a NC during mealtime to ensure continued O2 tx while eating. -24%-100% FiO 2 with flow rates of at least 10 L/min; provides high humidity --Assess that aerosol mist escapes from the vents of the delivery system during inspiration & expiration to ensure humidification is adequate. --Empty condensation from the tubing because preventing condensation buildup promotes an adequate flow rate, ensures a continued prescribed FiO2, & helps prevent infection. --Change the aerosol H20 container PRN to ensure adequate humidification. -24%-100% FiO 2 with flow rates of at least 10 L/min; provides high humidity --Empty condensation from the tubing to prevent it from interfering w/ flow rate delivery of FiO2 or draining into the tracheostomy. --Keep the exhalation port open & uncovered to prevent patient suffocation. --Position the T-piece so it does not pull on the tracheostomy or ET tube, which can cause pain & loss of tissue integrity. --Make sure the humidifier creates enough mist; mist should be seen during inspiration & expiration to demonstrate an adequate flow rate.

Comparison of Low-Flow Oxygen Delivery Systems (table 25.1)

Comparison of Low-Flow Oxygen Delivery Systems (table 25.1): -Low-Flow O2 Delivery Systems: easy to use; fairly comfortable. Amount of O2 delivered varies, based on breathing pattern; O2 is diluted w/ RA, which lowers the amount actually inspired. -24%-40% FiO 2 at 1-6 L/min ≈ 24% at 1 L/min; ≈ 28% at 2 L/min; ≈ 32% at 3 L/min; ≈ 36% at 4 L/min; ≈ 40% at 5 L/min; ≈ 44% at 6 L/min --Ensure that prongs are in the nares properly to prevent hypoxemia & skin breakdown w/ loss of tissue integrity. --Apply H20-soluble jelly to nares PRN to reduce mucosal irritation from the drying effect of O2 tx. --Assess the patency of the nostrils to detect conditions that prevent effective O2 delivery such as congestion or a deviated septum. --Assess the patient for changes in RR & depth because these changes reflect how well O2 is being delivered. -40%-60% FiO 2 at 5-8 L/min; flow rate must be set at least at 5 L/min to flush mask of carbon dioxide ≈ 40% at 5 L/min; ≈ 45%-50% at 6 L/min; ≈ 55%-60% at 8 L/min --Be sure that mask fits securely over nose & mouth because a poorly fitting mask reduces the FiO2 delivered. --Assess skin & provide skin care to the area covered by the mask because pressure & moisture under it can cause loss of tissue integrity. --Monitor the patient closely for risk for aspiration because the mask limits the patient's ability to clear the mouth, esp. if vomiting occurs. --Provide emotional support to the patient who feels claustrophobic to decrease anxiety & increase acceptance of the device. --Suggest to the respiratory HCP to switch the patient from a mask to the NC during eating to promote gas exchange while eating. -60%-75% at 6-11 L/min, a liter flow rate high enough to maintain reservoir bag two-thirds full during inspiration and expiration --Make sure that the reservoir does not twist or kink, which results in a deflated bag that can decrease the amount of O2 delivered & increases rebreathing of exhaled air. --Adjust the flow rate to keep the reservoir bag inflated to meet the patient's O2 needs. -80%-95% FiO 2 at a liter flow high enough to maintain reservoir bag two-thirds full --Interventions as for partial rebreather mask; this patient requires close monitoring to ensure proper functioning of the device. --Make sure that valves & rubber flaps are patent, functional, & not stuck. --Valves must open during exhalation & close during inhalation to prevent dramatic decrease in FiO2, which could lead to suffocation. --Closely assess the patient on increased FiO2 via nonrebreather mask to determine whether the patient's O2 needs are adequately met or if intubation is needed.

Complications of Tracheostomy (table 25.3)

Complications of Tracheostomy (table 25.3): -Tracheomalacia: Constant pressure exerted by the cuff causes tracheal dilation and erosion of cartilage, leading to loss of tissue integrity. --Indications: increased amount of air is required in the cuff to maintain the seal. A larger tracheostomy tube is required to prevent an air leak at the stoma. Food particles are seen in tracheal secretions. The patient does not receive the set tidal vL on the ventilator. --Tx: no special management is needed unless bleeding occurs. --Prevent: use an uncuffed tube as soon as possible. Monitor cuff pressure & air vLs closely & detect changes. -Tracheal stenosis: narrowed tracheal lumen is caused by scar formation from irritation of tracheal mucosa & impaired tissue integrity by the cuff. --Indications: stenosis is usually seen after the cuff is deflated or the tracheostomy tube is removed. The patient has increased coughing, inability to expectorate secretions, or difficulty breathing or talking. --Tx: Tracheal dilation or surgical intervention is used. --Prevent: prevent pulling of and traction on the tracheostomy tube. Properly secure the tube in the midline position. Maintain proper cuff pressure. Minimize oronasal intubation time. -Tracheoesophageal fistula (TEF): excessive cuff pressure causes erosion of the posterior wall of the trachea & loss of tissue integrity; hole is created between the trachea & the anterior esophagus. Highest risk also has a NGT present. --Indications: similar to tracheomalacia; Food particles are seen in tracheal secretions. Increased air in cuff is needed to achieve a seal. The patient has increased coughing & choking while eating. The patient does not receive the set tidal vL on the ventilator. --Tx: manually administer O2 by mask to prevent hypoxemia. Use a small, soft feeding tube instead of a NGT for tube feedings; a gastrostomy or jejunostomy may be performed by a physician. Monitor the patient with a nasogastric tube closely; assess for TEF and aspiration. --Prevent: maintain cuff pressure. Monitor the amount of air needed for inflation & detect changes. Progress to a deflated cuff or cuffless tube as soon as possible. -Trachea—innominate artery fistula: a poorly positioned tube causes its distal tip to push against the lateral wall of the tracheostomy. Continued pressure causes necrosis & erosion of the innominate artery. This is a medical emergency! --Indications: tracheostomy tube pulsates in synchrony with the heartbeat. There is heavy bleeding from the stoma. This is a life-threatening complication. --Tx: remove the tracheostomy tube immediately. Apply direct pressure to the innominate artery at the stoma site. Prepare the patient for immediate surgical repair. --Prevent: correct the tube size, length, & midline position. Prevent pulling or tugging on the tracheostomy tube. Immediately notify the surgeon of the pulsating tube.

Dx OSA

Dx OSA: not Dx w/ any 1 blood test or imaging method. -1st: Questionnaire about perceived sleep quality & extent of daytime sleepiness. Ex. Stop-bang both S/O questions; Snoring hx, Tired during day, Observed stop breathing while asleep, High BP, BMI >35 kg/m2, Age >50yrs, Neck circumference >40cm, & Male gender. -2nd: Results suggest OSA; may then undergo a less intrusive "at-home" sleep study. In own bed w/ electronic monitoring of RR, HR, chest movement, eye movements, & other muscle activity. -3rd: Results indicate sleep apnea, referred for a more definitive overnight sleep study; polysomnography. Directly observed during a full sleep time while wearing monitoring equipment to evaluate depth of sleep, type of sleep, respiratory effort, O2sat, CO2 exhalation, cardiac abnormalities, & muscle movement. Ex. EEG, ECG, pulseOx, & EMG. --Shows severity of OSA; if current tx is working; what tx they may need= complete clinical picture.

ET Intubation

ET Intubation: Know how to contact intubation personnel in an emergency; explain procedure to the pt clearly. --Ensure each intubation attempt lasts no >30s [preferably <15s]; after 30s, provide O2 via mask & manual resuscitation bag to prevent hypoxia & cardiac arrest; suction PRN. --BLS measures, like obtaining patent airway & delivering 100% O2 by a manual resuscitation bag w/ a facemask, are crucial to survival until help arrives. --Critical Rescue: monitor pts at risk for airway obstruction & impaired ventilation. ID need for emergency intubation & ventilation→ bring code ("crash") cart, airway equipment box, & suction equipment (often on cart) to bedside. Maintain a patent airway w/ positioning (head-tilt, chin-lift) & insertion of an OPA or NPA until intubated. Delivering manual breaths w/ a BVM may be required. --During intubation, RN coordinates the rescue response & continuously monitors for VS changes, s/s hypoxia or hypoxemia, dysrhythmias, & aspiration. --HCP; tube placement, verification &, tube stabilization; RN, RT, or anesthesia provider stabilizes ETT at the mouth or nose; tube is marked where it touches the incisor tooth or naris. After completion, verify & document the presence of bilateral & equal breath sounds & tube level. --Cuff at distal end is inflated after placement, creates a seal between trachea & tube; ensures delivery of set tidal vL for MV. Inflated w/minimal-leak technique; when inflated to an adequate sealing vL, a minimal amount of air can pass around it to the vocal cords, nose, or mouth; they cannot talk when cuff is inflated. --Pilot balloon w/ 1-way valve permits air insertion into cuff & prevents air from escaping. Balloon is a guide for ID if air is in cuff; it does not show how much or how little is present; it does not indicate how much pressure is exerted on trachea from cuff balloon.

Emergency care of PE Hypoxemia

Emergency care of PE Hypoxemia: -Managing hypoxemia: sudden onset of dyspnea & chest pain, or other s/s of respiratory impairment, immediately initiate the RRT. Apply O2, reassure the patient, & elevate the HOB. Prep for blood gas analysis while continuing to monitor & assess for other changes. -Management of PE: --Apply O2 by NC or mask. Reassure pt that the correct measures are being taken. Place patient in high-Fowler position. --Apply telemetry monitoring equipment. Obtain venous access. Assess oxygenation continuously with pulseOx. --Assess respiratory status at least Q30min by: Listening to lung sounds; Measuring the rate, rhythm, and ease of respirations; Checking skin color and capillary refill; Checking position of trachea. --Assess cardiac status by: Comparing BP in right and left arms; Checking pulse quality; Checking cardiac monitor for dysrhythmias; Checking for distention of neck veins. --Ensure that prescribed chest imaging & lab tests are obtained immediately (may include CBC w/ differential, platelet count, PT, PTT, D-dimer level, ABGs). --Examine the chest for presence of petechiae. Give prescribed anticoagulants. Assess for bleeding. Handle patient gently. Institute Bleeding Precautions.

Epistaxis: causes, S/S, Anterior & Posterior interventions

Epistaxis: AKA Nosebleed; common problem, result of the many capillaries w/in the nose. -Causes: loss of tissue integrity from trauma to nasal mucosa, HTN, blood dyscrasia (leukemia), inflammation, tumor, decreased humidity, nose blowing, nose picking, chronic cocaine use, & medical tx (NG suctioning). Older adults tend to bleed from posterior nose. S/S often occur after sneezing or blowing nose. -Anterior Bleeds: document amount & color of blood, take VS; ask about #, duration, & causes of episodes. --Emergency Care for Anterior: Maintain Std. Precaution. Position upright & leaning forward to prevent aspiration. Reassure & attempt to keep them quiet to reduce anxiety & BP. Apply direct lateral pressure to nose for 10min & apply ice or cool compresses to the nose & face. If nasal packing is necessary, loosely pack both nares w/ gauze or nasal tampons. To prevent rebleeding, instruct to not blow nose for 24hrs after bleeding stops. Instruct to seek medical assistance if measures are ineffective or if bleeding occurs frequently. --Nasal plug= contains an agent to promote clotting & expands on contact w/ blood to compress mucosal BVs. --Medical tx: if it does not respond to these txs. Affected capillaries cauterized w/ silver nitrate or electrocautery, & nose packed. -Posterior epistaxis is an emergency; cannot be easily reached & may lose lots of blood quickly. --Packing is usual tx; possible cauterization. Assess for respiratory distress, tolerance of devices. --Placement is uncomfortable; airway may be obstructed w/ reduced gas exchange if the pack slips; tubes or packing is usually removed after 1-3 days. --Posterior packing, epistaxis catheters (nasal pressure tubes), or gel tampons are placed through the nose w/in the posterior nasal region; placement is uncomfortable; airway may be obstructed w/ reduced gas exchange if the pack slips; tubes or packing is usually removed after 1-3 days. --After its removed, teach Home tx for comfort & safety; petroleum jelly to nares for comfort, NS nasal sprays after healing for moisture & prevent rebleeding; avoid vigorous nose blowing, aspirin or NSAIDs, & strenuous activities for >1mo. --Humidity, O2, bedrest, & ABs may be prescribed; Opioids for pain; assess at least Q1hr for gag & cough reflexes; use pulseOx to monitor for hypoxemia. --Other tx: if it does not respond to packing or tubes; cauterizing or ligating the BVs, or embolization of the bleeding artery w/ interventional radiology. --Embolization complications= facial pain, loss of tissue integrity w/ necrosis of skin or nasal mucosa, facial nerve paralysis, & blindness.

High-Flow Delivery Systems: Venturi Mask & T-Piece

High-Flow Delivery Systems: -Venturi Mask: for precise O2 delivery; [ex. Ventimasks] deliver the most accurate O2 concentration w/o intubation; work by pulling in a proportional amount of RA for each liter flow of O2. --Adaptor located between bottom of mask and O2 sources. Adapters w/ holes of different sizes allow specific amounts of air to mix w/ the O2, resulting in more precise delivery. --Each adapter requires a different flow rate. Another type has 1 adapter w/ a dial that is used to select the amount of O2 desired. -T-Piece: Delivers desired FIO2 to clients w/ tracheostomy, laryngectomy, ET tube. Aerosol should appear on exhalation side. --Tracheostomy collar is used to deliver high humidity & the desired O2 to the patient w/ a tracheostomy; special adapter (T-piece) is used to deliver any FiO2 to the patient with a tracheostomy, laryngectomy, or ET tube. --RN: Adjust the flow rate so the aerosol appears on the exhalation side [short side] of the T-piece.

Patient & Family Education; prep for Self-Management: Home Laryngectomy Care

Patient & Family Education; prep for Self-Management: Home Laryngectomy Care -Avoid swimming; use care when showering or shaving. Lean slightly forward & cover stoma when coughing or sneezing. -Wear a stoma guard or loose clothing to cover it. Clean stoma w/ mild soap & H2O. -Lubricate stoma w/ non-oil-based ointment PRN. Increase humidity by using NS in the stoma as instructed, bedside humidifier, pans of H2O, & houseplants. -Obtain & wear a Medical Alert bracelet & emergency care card for life-threatening situations; explains how to provide an ER airway or resuscitation to person w/ stoma.

Facial Trauma: s/s, priorities

Facial Trauma: effects respiratory status & airway; changes size, shape, & anatomy of URT; priority action is airway assessment. It's described by the specific bones (ex. mandibular, maxillary, orbital, nasal fractures) & side involved; rich facial blood supply results in extensive bleeding & bruising w/ loss of tissue integrity. -Mandibular (lower jaw) fractures; most common. -Le Fort I is a nasoethmoid complex fracture. Le Fort II is a maxillary & nasoethmoid complex fracture. Le Fort III combines I & II plus an orbital-zygoma fracture, called craniofacial disjunction bc the midface has no connection to the skull. -S/S airway obstruction: stridor, SOB, dyspnea, anxiety, restlessness, hypoxia, decreased O2sat, cyanosis, & loss of consciousness. Anticipate need for ER intubation, tracheotomy, or cricothyroidotomy. -After establishing the airway, assess trauma site for bleeding & obvious fractures; assess for soft-tissue edema, facial asymmetry, pain, or CSF leakage[= skull fracture]. Assess vision & eye movement; orbital & maxillary fractures can entrap the eye nerves & muscles. Check behind ears (mastoid area) for "battle sign,"; associated w/ skull fracture & brain trauma. Facial trauma can occur w/ spinal trauma & skull fractures; obtain cranial CT, facial series, & cervical spine x-rays.

Hazards & Complications of O2 Tx: Absorptive Atelectasis, Infection

Hazards & Complications of O2 Tx: -Absorptive Atelectasis: High O2 delivery= diluted nitrogen; O2 diffuses from alveoli into blood & the alveoli collapse. --S/S crackles & decreased breath sounds on auscultation. --Nitrogen makes up 79% of RA, it maintains patent airways & alveoli (prevents collapse). --Action Alert: Monitor the patient receiving high levels of O2 closely to recognize indications of absorptive atelectasis (new onset of crackles & decreased breath sounds) Q1-2hrs when O2 tx is started & PRN thereafter. -Infection: humidifier or nebulizer may be a source of bacteria & fungus, increasing the risk for infection. --Cannulas & masks can also harbor organisms. --Change equipment per agency policy; Q24hrs for humidification systems to Q7days or whenever necessary for cannulas & masks.

Hazards & Complications of O2 Tx: Combustion

Hazards & Complications of O2 Tx: Combustion: O2 enhances combustion; fire burns better in its presence; it doesn't burn or explode. -Open fires, even small ones (candle) are NOT allowed in the same room; post an "O2 in Use" sign on the door, smoking is prohibited in the patients room when O2 is in use. -Electrical equipment must be grounded (have 3 prongs) & plugged into grounded outlets to prevent fires from electrical arching sparks. -Frayed cords are NOT used; can spark & ignite a flame. -Flammable solutions (high alcohol or oil) are NOT used. Alcohol hand rubs are okay. -Surgical fires in the OR (rare) occur when an ignition source (cautery or lasers) are used in presence of a fuel source & an oxidizer (O2 or nitrous oxide). Improved by limiting the O2-rich atmosphere (w/o causing hypoxia) & minimizing exposure to flammable pharm agents (large vL liquid alcohol skin prep).

Hazards & Complications of O2 Tx: Drying of the Mucus Membranes

Hazards & Complications of O2 Tx: Drying of the Mucous Membranes: for O2 flow rate >4L/min, humidify the delivery system to prevent tissue injury and & of tissue integrity; ensure O2 bubbles through the H20 in the humidifier. -O2 can be humidified via a large-vL jet nebulizer in mist form (aerosol); heated nebulizer further increases the humidity & is used for O2 delivery through an artificial airway. -Upper airway passages warm & humidify the air during breathing; these passages are bypassed w/ an artificial airway (ex. ET tube). -RN: to deliver humidified O2, the nebulizer or humidifier must have a sufficient amount of sterile H2O w/ adequate flow rate. -Condensation that forms in the tubing can be a source of infection; remove it as it collects by disconnecting the tubing & removing the H2O; minimize the time disconnected, patient is not getting O2. -Some nebulizers & humidifiers have a H20 trap hanging from the tubing, so you can drain w/o disconnecting. -Check the H2O level & change the humidifier PRN, esp. if H20 is cloudy or has particles. -Action Alert: Assess the tubing system used for O2 delivery to recognize buildup of condensation; respond by draining. To prevent bacterial contamination of the system & prevent infection, never drain the fluid from the tubing or water trap back into the humidifier or nebulizer.

Hazards & Complications of O2 Tx: O2 toxicity

Hazards & Complications of O2 Tx: O2 Toxicity: rt the concentration delivered, tx duration, & degree of lung disease. Continuous O2 tx >50% for >24-48hrs, can injure lung & reduce tissue integrity. -Excessive tissue O2 levels increase the concentration of reactive O2 species (ROS: O2 free radical; damaging substances) which can combine w/ cellular elements & induce oxidative stress, causing cell damage & cell death. -Lung injury from O2 toxicity: causes & indications same as ARDS. --S/S start w/ dyspnea, nonproductive cough, chest pain beneath the sternum, GI upset, & crackles on auscultation. --As exposure to high levels of O2 continues, problems become more severe, w/ decreased vital capacity, decreased compliance, & hypoxemia. --Continued prolonged exposure leads to atelectasis, pulmonary edema [hemoptysis], hemorrhage, & hyaline membrane formation. --Surviving O2 toxicity depends on correcting the underlying disease process & decreasing the O2 amount delivered. -RN: toxic effects difficult to manage; prevention is key. Lowest level of O2 needed to maintain gas exchange & prevent toxicity is ordered. Monitor ABGs & notify the HCP when PaO2 is >90mmHg. Monitor the ordered O2 level & length of tx to ID patients at risk. --Use of noninvasive positive airway pressure techniques w/ O2 or use of MV may reduce the amount of O2 needed. --As soon as their condition allows, the ordered O2 amount is decreased.

Head & Heck Cancer: Post-op care

Head & Heck Cancer; Post-op care: surgery often lasts 8hrs+; immediately after OP in the ICU; monitor airway patency, VS, hemodynamic status, & comfort level. -Take VS & monitor for hemorrhage & other complications of anesthesia & surgery Q1hr for first 24hrs & then per policy until stable. -Complications: airway obstruction, hemorrhage, wound breakdown, & tumor recurrence; first priorities after head & neck surgery are airway maintenance & ensuring gas exchange. -Maintaining the Airway & Gas Exchange: immediately post-op, may need MV. Weaning, usually use a trach. collar (over artificial airway or open stoma) w/ O2 & humidity to help move secretions. Secretions may be blood-tinged for 1-2 days; use Std. Precautions, & report increased bleeding to the surgeon. -Laryngectomy tube: used for total laryngectomy patients & when need to prevent scar tissue shrinkage of the skin-tracheal border. Like TT care, except pt can change tube daily or PRN. -Laryngectomy button: similar to a laryngectomy tube; provide alt. communication techniques; they cannot speak. -Managing the Wound: stoma care after a total laryngectomy is a combination of wound & airway care. Inspect stoma & clean suture line w/ sterile NS (or prescribed solution) to prevent secretions crusting & obstructing airway. Suture line care Q1-2hrs for the first few days, then Q4hrs. Stoma & trachea mucosa should be bright pink & shiny, w/o crusts. --Tissue "flaps": may close the wound & improve appearance; skin, SQ tissue, & sometimes muscle, taken from other areas & used for reconstruction after head & neck resection. First 24hrs post-op are critical; evaluate grafts & flaps Q1hr for the first 72hrs. Monitor cap refill, color, drainage, & Doppler activity of the areas major BVs. Report changes to surgeon immediately; surgical tx may be needed. Position so that the flaps are not dependent. --Critical Rescue: assess Q1hr for the 1st several days after head & neck surgery to ID a carotid artery leak. Suspect a leak→ initiate RRT & do not touch the area; additional pressure could cause an immediate rupture. Carotid artery actually ruptures [bc drying or infection]→ immediately place constant pressure over the site & secure the airway. Maintain direct manual, continuous pressure on the carotid artery & immediately transport to surgery for carotid resection. Do not leave the patient; carotid artery rupture has a high risk for stroke & death.

Head & Neck Cancer:

Head & Neck Cancer: usually squamous cell carcinomas; slow-growing tumors are curable when Dx & tx early. Px for adv. disease at Dx depends on tumors extent & location. Un-tx, these cancers are often fatal w/in 2yrs of Dx. -Begins with mucosa that is chronically irritated, becoming tougher and thicker. Eventually genes controlling cell growth are damaged, allowing excessive growth of these abnormal & malignant cells. -Risk Factors: tobacco & alcohol [major], esp. in combination; also voice abuse, chronic laryngitis, exposure to chemicals or dusts, poor oral hygiene, LT GERD, & oral infection w/ HPV. -S/S: initial lesions 1st appear as white, patchy lesions (leukoplakia) or red, velvety patches (erythroplakia). First spreads (metastasizes) into local lymph nodes, muscle, & bone. Later spread is systemic to distant sites (lungs or liver). -Assess Hx: tobacco [pack-yrs] & alcohol use [drinks/day; yrs], acute or chronic laryngitis or pharyngitis, oral sores, swallowing difficulty, & lumps in the neck. Oral exposure to HPV & other risk factors. -Laryngeal cancer: painless hoarseness [change in voice quality] may occur due to tumor size & inability of the vocal cords to come together for normal speech; all adults w/ hx of hoarseness, mouth sores, or a lump in the neck for 3-4wks should be evaluated for laryngeal cancer.

High-Flow Delivery Systems: HFNC

High-Flow Delivery Systems: -High-Flow Nasal Cannula: [ex. Vapotherm] 30-60L/min. Widely used for better O2 & temp. control w/ humidification; combination of heat & humidity minimizes damage to mucous membranes, improves oxygenation, & is often better tolerated than other high-flow systems. -May be less loss of tissue integrity because there is no tight-fitting mask to cause skin breakdown. -Possible better secretion clearance & lower incidence of respiratory infections; low level of PAP achieved, which recruits alveoli & increases end-expiratory lung vL. -FiO2 & flow rates can be adjusted independently & may achieve an actual FiO2 close to the predicted FiO2. -Shown promise as an alternative w/o some of the limitations of NPPV (CPAP, BiPAP); improves ability to clear secretions & communicate. -RN: Use pulseOx to adjust the HFNC to their response.

Indications for MV & Intubation

Indications for MV & Intubation: MV is for severe problems of gas exchange, pt is supported until the underlying problem improves or resolves; usually MV is a temporary life-support technique. May be lifelong for severe restrictive lung disease or chronic progressive neuromuscular disease that reduces ventilation. -Often used for hypoxemia & progressive alveolar hypoventilation w/ respiratory acidosis. -Hypoxemia is usually caused by pulmonary shunting of blood when other O2 delivery methods do not provide a sufficiently high FiO2. -Used when ventilatory support is needed temporarily post-op, those who expend too much energy w/ breathing & barely maintain adequate gas exchange, or when general anesthesia or heavy sedation is given. -ETT: a long polyvinyl chloride tube, passed through the mouth or nose & into the trachea; tube tip rests about 2cm above the carina; anesthesiologist, RN anesthetist, or RT usually performs the intubation. --Oral: fast & easy way to establish an airway; often an emergency procedure. --Nasal: for oral surgeries & when oral intubation is not possible; avoided w/ midface trauma or possible basilar skull fracture & is not used if they have bleeding problem.

Indications for Suctioning a TT

Indications for Suctioning a TT: -Suctioning maintains a patent airway & promotes gas exchange by removing secretions when the patient cannot cough adequately. -S/S of need for suctioning: audible or noisy secretions; crackles or wheezes heard on auscultation; restlessness, increased HR or respiratory rates; or mucus in the artificial airway; patient request; increase in the ventilator peak airway pressure. -Routine unnecessary suctioning is not performed w/o indications to prevent mucosal damage, bleeding, or bronchospasm. -Action Alert: airway suction, unlike NG suction, is performed only on an intermittent basis & not continuously. However, during an actual suctioning episode, suction is applied continuously during catheter withdrawal to prevent dropping of secretions from the catheter back into the airway.

Interventions for ARDS

Interventions for ARDS: -Often needs intubation & MV w/ PEEP or CPAP; best practice involves "open lung" & lung protective ventilation strategies. --Low tidal vLs (6 mL/kg) are shown to prevent lung injury. PEEP is started at 5cm H2O & increased to keep O2sat adequate; PEEP levels may need to be high. --Pressure-controlled is preferred over vL-controlled ventilation; promotes nonfunctional alveoli to participate in gas exchange. --SE of PEEP is tension pneumothorax; assess lung sounds Q1hr & suction PRN to maintain a patent airway. -Airway pressure release ventilation (APRV) & high-frequency oscillatory ventilation (HFOV) are alt. modes of MV; improve gas exchange w/ oxygenation & ventilation in moderate-to-severe ARDS. Airway pressure w/ APRV & HFOV is significantly higher than conventional MV. Sedation & paralysis may be needed for adequate ventilation & to reduce tissue O2 needs [esp. HFOV]; sedation & paralysis are not required w/ APRV but may be needed to prevent patient disruption of MV; method can allow for spontaneous breathing between mandatory breaths. -Positioning may be important in promoting gas exchange; exact position is controversial. Some do better in the prone position, esp. if it is started early in the disease course. Manually turning Q2hrs has shown to improve perfusion; often is not performed as frequently as needed. --Early progressive mobility also shown benefit in reducing ventilator needs, days on ventilator, & mortality. -Severe ARDS; extracorporeal membrane oxygenation (ECMO) w/ heart-lung bypass equipment has been a successful life-support technique, when traditional tx have failed. -ABs tx infections when organisms are ID; other drugs manage any underlying cause. No tx reverse the pathologic lung changes. -Conservative fluid tx: infusing smaller amounts of IV fluid & using diuretics to maintain fluid balance; liberal fluid tx often results in an increasingly positive fluid balance & more edema. Critically ill & at ARDS risk as a result of trauma, fluid management that involves slight hypotension is thought to help prevent ARDS. -Malnutrition risk; further reduces respiratory muscle function & immune response; must include RDN. EN or PN is started ASAP.

Interventions for Facial Trauma

Interventions for Facial Trauma: -Tx 1st focus on: establishing an airway, controlling hemorrhage, & assessing for the extent of injury. --Time is critical in stabilizing head & neck trauma; early ID & tx by special services to optimize recovery. --Stabilizing fractured jaw allows teeth to heal in proper alignment & involves fixed occlusion (wiring jaws together w/ the mouth closed); remains in 6-10wks. Tx delay, tooth infection, or poor oral care may cause jaw bone infection; may require surgical removal of dead tissue, IV AB tx, & longer time w/ jaws in a fixed position. --Extensive jaw fractures may require open reduction w/ internal fixation (ORIF); compression plates & reconstruction plates w/ screws may used. Plates usually permanent. Depending on metal used, could interfere w/ MRI. --Inner maxillary fixation (IMF): bones are realigned & then wired in place w/ the bite closed. --Post-op: teach about oral care w/ irrigating device; Water-Pik or Sonicare. W/ IMF, teach self-management w/ wires in place; dental liquid diet. If they vomit, watch for aspiration. Teach how to cut wires if vomiting occurs to maintain gas exchange; if wires cut, instruct to return to surgeon for rewiring ASAP. Nutrition is important & difficult w/ fractures due to oral fixation; collaborate w/ RDN for teaching & support. -Action Alert: instruct to keep wire cutters w/ them at all times to prevent aspiration if vomiting occurs.

Interventions for O2-tx & Choosing a Delivery System

Interventions for O2-tx: -Recognize: O2 is combustable, flammable; no open flames. -Check: [always!] prescription -Use: humidification to prevent skin breakdown (if 4L/min+). O2 is drying→ breakdown -Check: pressure points on skin -Provide: mouth care, lubricate nostrils, face lips (non-petroleum (flamable); h2O based lubricant) -Clean: cannula & mask; throughout the day, wipe it out (soap + H2O); if it falls on the ground get a new one; coughing up mucus so needs to be cleaned (no alcohol wipes; flammable). -Collaborate: w/ RT -Choice of Delivery System Depends on: Required concentration (ordered by HCP; or on tx driven protocol; O2 concentration achieved w/ the system (different system= different amounts of O2); importance of accuracy & control of O2 concentration; comfort (some can't tolerate mask; breakdown behind ears→ use foam pads); use of humidity (depends on rate); patient mobility (if mobile; how can we support this w/ carrying O2).

Laboratory Profile: Respiratory Assessment; ABGs

Laboratory Profile: Respiratory Assessment -Arterial Blood Gases: assesses gas exchange & perfusion as oxygenation (partial pressure of arterial O2; PaO2), alveolar ventilation (partial pressure of arterial CO2; PaCO2), & acid-base balance. Blood gas studies provide info for monitoring tx results, adjusting O2 tx, & evaluating the patient's responses. --PaO2: 80-100 mm Hg; Older adults: values may be lower ---Elevations indicate possible excessive O2 administration. ---Decreased indicate possible COPD, asthma, chronic bronchitis, cancer of the bronchi & lungs, cystic fibrosis, respiratory distress syndrome, anemias, atelectasis, or any other cause of hypoxia. --PaCO2: 35-45 mm Hg ---Elevations indicate possible COPD, asthma, pneumonia, anesthesia effects, or use of opioids (respiratory acidosis). ---Decreased indicate hyperventilation/respiratory alkalosis. --pH: Up to 60 yr: 7.35-7.45; 60-90 yr: 7.31-7.42; >90 yr: 7.26-7.43 ---Elevations indicate metabolic or respiratory alkalosis. ---Decreased indicate metabolic or respiratory acidosis. --HCO3: 21-28 mEq/L ---Elevations indicate possible respiratory acidosis as compensation for a primary metabolic alkalosis. ---Decreased indicate possible respiratory alkalosis as compensation for a primary metabolic acidosis. --SpO2: 95%-100%; Older adults: values may be slightly lower ---Decreased levels indicate possible impaired ability of Hgb to release O2 to tissues.

Laboratory Profile: Respiratory Assessment; CBCs

Laboratory Profile: Respiratory Assessment -Complete Blood Count: -RBC count provides data about O2 transport. Hgb [w/in RBCs], transports O2 to the tissues. A deficiency of Hgb could cause hypoxemia. --RBCs: Females 4.2-5.4 × 106/mcL; Males 4.7-6.1 × 106/mcL --Hemoglobin, total: Females 12-16 g/dL; Males 14-18 g/dL --Hematocrit: Females 37%-47%; Males 42%-52% --Elevated levels (polycythemia) are often related to the excessive production of erythropoietin in response to a chronic hypoxic state (ex. COPD) & from living at a high altitude. --Decreased levels indicate possible anemia, hemorrhage, or hemolysis. -WBC count (leukocyte count): Total 5,000-10,000/mm3 --Elevations indicate possible acute infections or inflammations. --Decreased may indicate an overwhelming infection, autoimmune disorder, or immunosuppressant Tx.

Laboratory Profile: Respiratory Assessment; Differential WBC

Laboratory Profile: Respiratory Assessment -Differential WBC (Leukocyte) Count: --Neutrophils: 2500-8000/mm3, or 55%-70% of total, or 5-6.2 × 109/L ---Elevations indicate possible acute bacterial infection (pneumonia), COPD, or inflammatory conditions (smoking). ---Decreased indicate possible viral disease (influenza). --Eosinophils: 50-500/mm3, or 1%-4% of total, or 0.0-0.3 × 109/L ---Elevations indicate possible COPD, asthma, or allergies. ---Decreased indicate pyogenic infections. --Basophils: 15-50/mm3, or 0.5%-1% of total, or 0.02-0.05 × 109/L ---Elevations indicate possible inflammation; ex. chronic sinusitis, hypersensitivity rx. ---Decreased may be seen in an acute infection. --Lymphocytes: 1000-4000/mm3, or 20%-40% of total, or 1.0-4.0 × 109/L ---Elevations indicate possible viral infection, pertussis, & infectious mononucleosis. ---Decreased may be seen during corticosteroid tx. --Monocytes: 100-700/mm3, or 2%-8% of total, or 0.1-0.7 × 109/L ---Elevations: see Lymphocytes; also may indicate active TB. ---Decreased: see Lymphocytes.

Laryngeal trauma: assessment, interventions

Laryngeal trauma & damage: occur w/ a crushing or direct-blow injury, fracture, or prolonged ET intubation w/ loss of tissue integrity. -S/S: difficulty breathing, inability to produce sound (aphonia), hoarseness, & SQ emphysema. Bleeding from airway (hemoptysis) may occur, depending on location of trauma. -Dx: direct visual exam of the larynx by laryngoscopy or fiberoptic laryngoscopy to ID extent of injury. -Management: assess effectiveness of gas exchange & monitor VS (& respiratory status, pulseOx) Q15-30min. Maintaining a patent airway is a priority; apply O2 & humidification to maintain adequate O2sat. --Critical Rescue: assess for s/s of respiratory difficulty= tachypnea, nasal flaring, anxiety, sternal retraction, SOB, restlessness, decreased O2sat, decreased LOC, stridor. S/S present→ stay w/ pt & instruct other trauma team members or RRT to prep for an ER intubation or tracheotomy. --Surgical tx: may be needed for mucous membrane lacerations, cartilage exposure, & cord paralysis. Laryngeal repair is performed ASAP to prevent laryngeal stenosis & to cover any exposed cartilage. Artificial airway may be needed temporarily.

Laryngectomy; Care Coordination & Transition Management

Laryngectomy; Care Coordination & Transition Management: No complications→ usually D/C home or extended-care facility w/in 2wks. At D/C, pt or family should be able to perform tracheostomy or stoma care & participate in nutrition, wound care, & communication methods. -HC Resources; Often need referrals to support groups or community health agency familiar w/ care of patients recovering from head & neck cancer; encourage smoking cessation. -Extensive home care prep needed after a laryngectomy for cancer; convalescence period is long, & airway management is complicated. -Patient w/ severe respiratory problems, home changes to allow for 1-floor living may be needed. -Increased humidity is needed; humidifier add-on to a forced-air furnace, or a room humidifier or vaporizer. Stress that meticulous cleaning of these items is needed to prevent spread of mold or other infection sources. -Home care RN is an important resource; RN assesses the patient & home for problems in self-care, complications, adjustment, & adherence to the regimen. -Self-Management Education: Teach care for the stoma, tracheostomy, or laryngectomy tube, depending on OP type. -Stoma care teaching, focused on protection, needed from the anatomic changes resulting from OP. Instruct to use a shower shield over the tube or stoma when bathing to prevent water from entering the airway. Suggest they wear a protective cover or stoma guard to protect it during the day. -Communication involves having them continue the selected communication method that began in the hospital. -Psychosocial Prep: Permanent stoma, trach tube, NG or PEG tube, & wounds cause an altered body image. Stress importance of returning to normal lifestyle; most can resume many usual activities w/in 4-6wks post-op. -Total laryngectomy cannot produce sounds during laughing & crying. Mucus secretions may appear unexpectedly when emotions arise, coughing or sneezing occurs. Mucus can be embarrassing, & they need to be prepared to cover stoma w/ a handkerchief or gauze. Undergone composite resections→ difficulty w/ speech & swallowing; may need to deal w/ tracheostomy & feeding tubes in public places.

Low-Flow Delivery Systems: Nasal Cannula & Simple Facemask

Low-Flow Delivery Systems: -Nasal cannula: prongs, 1-6L/min; O2 concentration of 24% [1L/min] to 44% [6L/min]. Flow rate >6 L/min does not increase gas exchange because anatomical dead space is full. Adding +1L/min increases FiO2 by 4%. -Often used for chronic lung disease or when needing LT O2-tx. -Place the nasal prongs in the nostrils, w/ the openings facing the patient, following the natural anatomic curve of the nares. -"Dead Space": places in the airways where air flows but the structures are too thick for gas exchange. -High flow rates also increase mucosal irritation & injury to tissue integrity. -Simple Facemask: Delivers O2 up to 40-60% for ST therapy or in an emergency. Minimum of 5 L/min needed to prevent rebreathing exhaled air. -Ensure appropriate fit to maintain inspired O2 levels. Care for the skin under the mask & strap to prevent breakdown.

Low-Flow Delivery Systems: Partial Rebreather & Nonrebreather

Low-Flow Delivery Systems: -Partial rebreather: Provides 60-75% with flow rate of 6-11 L/min. Has a reservoir bag but no flaps. -W/ each breath, the patient rebreathes 1/3 of the exhaled tidal vL, which is still high in O2 & increases the FiO2. -Ensure that the bag remains slightly inflated at the end of inspiration; can call RT for assistance. -Non-rebreather: Delivers highest O2 level (of the low-flow systems); can deliver FiO2 >90%, depending on their breathing pattern. Used when respiratory status is unstable & may require intubation. -Ensure valves are patent & functional. Has a 1-way valve between the mask & reservoir & usually has 2 flaps over the exhalation ports; valve allows them to draw all needed O2 from the reservoir bag, & the flaps prevent RA from entering through the exhalation ports (would dilute the O2 concentration). -During exhalation, air leaves through exhalation ports while the 1-way valve prevents exhaled air from re-entering the reservoir bag. -RN: Rate kept high (10-15 L/min) to keep the bag inflated during inhalation. Assess for this safety feature at least hourly. -Critical Rescue: Check to ensure that the valve & flaps on a nonrebreather mask are intact & functional during each breath. If the flaps or valve should fail, the patient would inhale RA & exhaled CO2 w/ each breath, which decreases O2 delivery. Ensure that the reservoir does not fully deflate so that the full vL of gas is available w/ each breath.

MV Indications, Goal, Ventilator Types, Modes of Ventilation

MV: support & maintain gas exchange. RN, pivotal role in care coordination & problem prevention. --Goal: improve gas exchange & decrease work for effective breathing; support until lung function is adequate or until acute episode passed. Does not cure lungs→ it supports until they can breath independently. Normal gas exchange w/ oxygenation, ventilation, & respiratory muscle strength is achieved→ can discontinue MV. -Positive Pressure: most common; usually ETT or tracheostomy is needed. During inspiration→ pressure generated→ drives gas flow to push air→ lungs & expand chest. NIPPV: use mask or nasal prongs to deliver gas flow. -Negative Pressure: air pressure is lower in 1 place in comparison to another; ex. iron lung→ create subatmospheric pressure [P<room air] around the chest→ lowers pleural & alveolar pressure→ facilitates air flow into lungs. -Assist-control (AC) ventilation: full support mode; ventilator takes over the work of breathing. Tidal vL & ventilatory rate are preset; called mandatory breaths. If pt does not trigger spontaneous breaths→ AC establishes a ventilatory pattern. --Disadvantage: continues to deliver preset tidal vL even when spontaneous breathing rate increases→ hyperventilation & respiratory alkalosis. Investigate & correct causes of hyperventilation, ex. pain, anxiety, or acid-base imbalances. -Synchronized intermittent mandatory ventilation (SIMV): similar to AC→ tidal vL & ventilatory rate are preset; used in pressure- or vL-regulated mode. If they do not breathe→ ventilatory pattern is established by SIMV. Unlike AC, it allows spontaneous breathing at their own rate & tidal vL between ventilator breaths. Used as main ventilatory mode or weaning mode. -Pressure support ventilation: for spontaneously breathing pts; no tidal vL set. Delivers the pts own breath w/ assistance from a set airway pressure & PEEP; used as a step in weaning process. -CPAP & BiPAP: noninvasive pressure support modes of ventilation (NIPPV); for spontaneously breathing pts; require a nasal mask or facemask. Both used for OSA, but BiPAP also for COPD, HF, respiratory muscle fatigue, or impending RF to avoid more invasive ventilation methods. --Normal CPAP levels= 5-15cm H2O. --Normal BiPAP levels= IPAP 10-20cm H2O; EPAP 4-8cm H2O.

Maintaining Communication W/ TT

Maintaining Communication W/ TT: -Allows speaking: cuffless tube, fenestrated tube, & fenestrated tube is capped or covered. -Until natural speech is feasible, teach them & the family about other communication means. --Ex. writing tablet, board w/ pictures & letters, communication flash cards, hand signals, computer tablets, & smartphones; promote communication & decrease frustration. Phrase questions for "yes" or "no" answers to ease response. Mark the central call light system to indicate that they cannot speak. For any patient with a communication problem, including a speech-language pathologist promotes better outcomes. -1-way valve that fits over the tube & replaces need for finger occlusion; device to facilitate speech for trach. patients. --Allows them to breathe in through the tracheostomy tube. --Valve closes on exhalation, so air is forced through the vocal cords, allowing speech. --To assist in speech, they must not be connected to a ventilator, must have the cuff deflated, & must be able to breathe around the tube. --Some valves have a port for supplemental O2 w/o impairing the ability to speak. -NPSG: inability to talk is a stressor for the patient; helping communication is an important RN action & is required by TJC NPSG. When the patient can tolerate cuff deflation, they place a finger over the tracheostomy tube on exhalation, forcing air up through the larynx & mouth for speech.

Major Risk Factors for PE

Major Risk Factors for PE: -Prolonged immobilization; Central venous catheters; Surgery; Pregnancy; Obesity; Adv. age; General & genetic conditions that increase blood clotting; Hx of TE. Smoking, estrogen tx, HF, stroke, cancer (esp. lung or prostate), & trauma also increase risk for VTE & PE. Traveling for long periods of time increases risk. -Lifestyle Changes: Smoking cessation, esp. women using HRT (increases clotting); tobacco & nicotine narrow BVs & increase clot risk. Reducing wt; Be more physically active. --If traveling: Drink plenty of water; Change positions often; Avoid crossing legs; Get up from sitting for 5min/hr; Refrain from massaging & compressing leg muscles. --SCDs: compress cap system; compress→ shunt→ increase return. Take off Q8h. -Health Promotion & Prevention: prevention of conditions, esp. venous stasis, that lead to VTE & PE; major RN concern. -Active/passive ROM; Ambulate ASAP post-op; Compression stockings & VTE protocol; Instruct pt to not cross legs; Change pt position Q2h; Teach pts to refrain from clothing items that restrict [decrease] circulation to an extremity.

Management of ARDS: 3 phases

Management of ARDS: general management focuses on the 3 phases of ARDS; phase timing varies by patient. -Exudative phase: includes early changes of dyspnea & tachypnea; results from the alveoli becoming fluid filled, pulmonary shunting, & atelectasis. --Early txs focus on support & providing O2 (via mask or NC). -Fibrosing alveolitis phase: increased lung injury leads to pulmonary HTN & fibrosis; body attempts to repair damage, & increasing lung involvement reduces gas exchange & oxygenation; multiple organ dysfunction syndrome (MODS) can occur. --Tx focus on delivering adequate O2, preventing complications, & lung support. -Resolution phase: usually occurs after 14 days, injury resolution is possible; if not, they die or have chronic disease; fibrosis is possible. Survivors often have neuropsychologic deficits.

Management of OSA

Management of OSA: -Nonsurgical: reduce obstruction & improve depth & duration of restorative sleep patterns. Changes in sleeping position or weight loss may correct mild OSA & improve gas exchange; severe requires additional methods to prevent obstruction. -Position-fixing devices: prevent tongue subluxation & reduce obstruction. Some also help prevent tongue from slipping backward; devices are bulky & some cannot tolerate their presence; may increase risk for loss of tissue integrity of the oral mucosa. -CPAP: NPPV to hold open the upper airways; most commonly used form of OSA nonsurgical management. Small electric compressor & type of delivery device; ex. nasal-oral facemask, nasal mask, or nasal pillows (w/ or w/o cushioned or gel prongs). Need good fit to form a seal for successful tx. --Newer machines are quiet & humidify air; smaller mask better tolerated & help maintain tissue integrity. -Drug therapy: don't tx the cause; has not been successful. Sedatives may make it worse; stimulants for daytime wakefulness have many SEs & do not contribute to restorative sleep. -Surgical: reserved for anatomic causes & severe OSA that remains resistant to nonsurgical tx; considered if pt cannot tolerate CPAP or when it doesn't improve OSA. -RN Care: stress that adherence w/ tx is critical in reducing associated health problem risks. Providing accurate info & education is essential for success; SA clinics & practices provide in-depth educational materials & resources to help reduce anxiety & promote adherence. Teach maintenance of the compressor & mask/tubular system; use distilled H20; clean device daily.

Need for suctioning & tracheostomy care

Need for suctioning & tracheostomy care is determined by the secretions, specific disorder, coughing ability, need mechanical ventilation, & wound care. -Using a penlight, inspect the inner lumen of the tube to assess for secretions. -Secure tracheostomy tubes in place using either twill tape ties or commercial tube holders; these devices require changing when soiled or at least daily to keep clean, prevent infection, & assess tissue integrity under the ties. -It's best to use the assistance of a coworker to stabilize the tube & prevent decannulation when changing the ties or tube holders. -Emergent nature of a decannulation in the post-op period, some facilities have policies requiring a 2nd licensed person be present during suctioning or moving a patient w/in the first 72hrs. -Properly secured tie or holder allows space for only 1 finger to be placed between the tie or holder & the neck. -Tube movement causes irritation & coughing; may lead to decannulation, reducing gas exchange. -Include the patient in tracheostomy care as a step toward self-care. -Action Alert: prevent decannulation during tracheostomy care by keeping the old ties or holder on the tube while applying new ties or holder or by keeping a hand on the tube until it is securely stable. Best performed w/ the assistance of a coworker. Some hospitals require a 2nd licensed person during tracheostomy care for the first 72hrs after tracheostomy.

Nose Fractures: interventions

Nose Fractures: interventions -Simple closed reduction: moving bones by palpation to realign; using local or general anesthesia w/in first 24hrs after injury. After 24hrs, more difficult to reduce because of edema & scar formation; reduction may be delayed for several days until edema is gone. Management focuses on pain relief & cold compresses to decrease swelling. -Rhinoplasty: surgical nose reconstruction; repair a fractured nose, or change shape for function or appearance; reduction & surgery may be needed for severe fractures or when not healing properly. --Return from OP w/ packing in nostrils; prevents bleeding & provides support for the reconstructed nose. W/ packing, they cannot breathe through nose; "moustache" dressing (or drip pad), often a folded 2 × 2 gauze pad, is usually under the nose. Change or teach them to change the drip pad as necessary. Splint or cast may cover nose for better alignment & protection. --Post-op: observe for edema & bleeding from loss of tissue integrity; w/ uncomplicated rhinoplasty usually D/C that day. --Action Alert: assessing how often the patient swallows after nasal surgery is a priority; repeated swallowing may indicate posterior nasal bleeding. Use a penlight to examine the throat for bleeding & notify the surgeon if bleeding is present. --Teach routine care; stay in semi-fowlers [prevent aspiration] & move slowly; suggest rest & use cool compresses [reduce swelling]; after gag reflex returned, urge to drink >2500 mL/day. Prevent bleeding; avoid forceful coughing or Valsalva, don't sniff upward or blow nose, & not sneeze w/ closed mouth for the first few days after packing removed. Avoid aspirin & NSAIDs. Use humidifiers; eat soft food. ABs may prevent infection. Bc of edema; final result may take 6-12mo.

O2 Therapy: Care Coordination & Transition Management

O2 Therapy: Care Coordination & Transition Management -Home Care Management: must be stable before home O2 is considered. Medicare= must have severe hypoxemia; PaO2 <55 or SpO2 <88% on RA & at rest. Criteria vary when hypoxemia is caused by nonpulmonary problems or when O2 need is only at night or w/ exercise. --Home Care Prep: home O2 tx is provided in 1 of 3 ways; compressed gas in a tank or a cylinder, liquid O2 in a reservoir, or an O2 concentrator. RN must review safety issues w/ patient & family. -Self-Management Education: home O2 tx is prescribed, begin a teaching plan; collaborate w/ the RT to teach about the equipment needed & the safety aspects of using & maintaining the equipment (ex. O2 source, delivery device, humidity). --During D/C planning & teaching, be sensitive to their emotional adjustment to oxygen therapy; encourage them to share feelings & concerns (social acceptance). Help realize that adherence is important for being able to participate in ADLs & other enjoyable events. --Compressed Gas: Teach them to check the gauge daily to assess the amount of O2 left in the tank. Tanks must always be in a stand or rack; tank that is accidentally knocked over could suddenly decompress & move around in an uncontrolled manner. --Action Alert: Assess their knowledge of O2 tx to recognize any deficiencies. Respond by providing safety info & stressing the importance of not smoking where O2 is in use. Teach that smoking materials, candles, gas burners, & fireplaces (open flames) are not to be used in the same room in which O2 is being used. -Health Care Resources: RN will work w/ the D/C planner to help the patient select a DME company to deliver O2 equipment & select a community health RN agency for follow-up care in the home. Re-evaluation of need occurs on a periodic basis.

O2-Hgb Dissociation Curve

O2-Hgb Dissociation Curve: -S-shaped curve: indicates it's harder for O2 to dissociate from Hgb in tissues that are well oxygenated & much easier in tissues that are "starving" for O2. O2 unloading from Hgb is based on the tissues need, not the amount of O2 already there. -50% Hgb have completely dissociated their O2 when blood perfuses tissues w/ an O2 tension (concentration) of 26 mmHg; "normal" point at which 50% of Hgb are no longer saturated w/ O2. -O2-Hgb dissociation curve shifts as tissue O2 needs change. P50= the partial pressure of O2 at which Hgb is 50% saturated; PO2= partial pressure of O2. -Right Shift: need for O2 is greater in tissues; Hgb will dissociate O2 faster, even when the tissue O2 tension levels are >26 mm Hg. Easier for O2 to unload to the tissues bc they need it to support higher metabolism; tissue protection mechanism, O2 goes to the tissue that needs it the most. -Causes: periods of increased tissue metabolism; increased tissue temperature, increased CO2, decreased pH (acidosis), chronic hypoxia, & increased levels of diphosphoglycerate (DPG: a by-product of glucose metabolism). -Ex. Patient w/ an MI has reduced BF to the area, heart muscle is metabolizing under hypoxic conditions (more tissue CO2 & acidosis). Hgb that reaches this tissue unloads O2 faster to prevent ischemia & cardiac mucle cell death. -Left Shift: tissues need less O2 bc they are metabolizing more slowly; tissue O2 tension level has to be even lower for Hgb to unload O2. Prevents wasting O2 delivery to tissues that are not using the O2 they already have. -Causes: decreased tissue temperature, decreased CO2 levels, decreased glucose breakdown products (ex. DPG), & higher pH (alkalosis). -Ex. Aging blood cells (banked blood) have lower levels of DPG; massive blood transfusions may cause a left shift, even when tissues could use more O2. -Ex. Patient w/ an MI thinks they are having indigestion & takes antacids (HCO3- based). Antacids increase the pH in the blood & tissues, shifting the curve to the left. The hypoxic cardiac muscle cells receive even less O2, & more of them die.

OSA: Patho, S/S, RN Assessment

OSA: type of breathing pattern disruption during sleep; lasts >10sec & occurs min. of 5x/hr; usually occurs w/ sleep time hypopnea= lower-than-normal RR & depth insufficient for effective gas exchange. -Patho: Reduced Gas Exchange [O2sat <80%]→ Increases CO2→ Decreases pH→ stimulates neural centers to breathe & pt awakens after 10+sec of apnea→ corrects obstruction & respiration resumes→ falls asleep & cycle resumes (often as Q5min)→ daytime sleepiness→ LT reduction in deep sleep→ reduced body restoration→ fatigue, irritability, depression. -S/S: chronic excessive daytime sleepiness, inability to concentrate, morning headache, & irritability. LT chronic→ increased risk HTN, stroke, cognitive deficits, wt gain, DM, pulmonary & CVD, metabolic issues. -Most common cause is UAO by the soft palate or tongue. Contributing factors; obesity, large uvula, short neck, smoking, enlarged tonsils or adenoids, & oropharyngeal edema. -Assess: Hx- Persistent daytime sleepiness, snoring, GERD; nightmares; awakened by snoring (ask family); use of sleep aids; evening alcohol consumption; awakened by heartburn (GERD s/s). Physical- appearance, ht/wt; retracted lower jaw, smaller chin, & shorter neck; tonsils, adenoids, pillars, soft palate are swollen or enlarged; HTN (BP x2 if un-Dx). Psyc- irritability & personality changes (ask family); depression, social disinterest, memory loss, can't concentrate.

PE Interventions: Control Bleeding & Minimize Anxiety

PE Interventions: -Controlling bleeding: drugs that disrupt clots or prevent formation→ impaired ability to start & continue the blood clotting cascade when injured, increasing risk of bleeding. --Priority RN actions: ensuring specific antidotes are present on the RN unit, protect from situations that could lead to bleeding, ensuring correct dosage & timing of drugs, assessing labs, & monitoring the bleeding amount that occurs. --Assess for bleeding at least Q2hrs; ex. oozing around puncture sites or the gums, bruises that cluster, petechiae, or purpura). Examine all stools, urine, drainage, & vomitus for gross blood, & test for occult. Measure any blood loss as accurately as possible. Assess the ABD for increasing distention or firmness; consider measuring ABD girth Q8hrs (internal bleeding→ increasing girth). --Monitor labs daily. Review CBC to ID the risk for impaired clotting & whether any blood loss has occurred. Severe blood loss→ PRBCs &/or FFP may be prescribed. Monitor the plt count; decreasing may indicate ongoing clotting or HIT caused by the formation of anti-heparin antibodies; plt transfusion may be indicated. -Minimizing anxiety: usually anxious, fearful, & in pain; result of the life-threatening nature of the problem & cerebral hypoxia. Tx: O2 tx (for Hypoxemia), communication, & drugs. --Communication is critical in allaying anxiety; acknowledge the anxiety & their perception of a life-threatening situation. Stay w/ them, speak calmly & clearly, providing assurances that appropriate measures are being taken. Explain the rationale & share info when giving drugs, changing position, taking VS, or assessing. Coordinate w/ pastoral care to provide spiritual comfort. --Drug tx w/ an anti-anxiety drug may be prescribed if it interferes w/ Dx testing, management, or adequate rest. Unless MV, sedating agents are avoided to reduce hypoventilation risk & risk for worsening delirium [w/ older patients]. Pharm tx is used for pain management; care is taken to avoid suppressing the respiratory response.

PE Interventions: Drugs for Clotting Problems

PE Interventions: Drugs for Clotting Problems -Normal PT: 11-12.5 sec; 85%-100% -Normal INR: 0.8-1.1x the control value -PTT for Anticoagulation tx: 0.8-1.1x the control value -Anticoagulants: tx begins immediately to prevent embolus enlargement & more clotting. Unfractionated heparin, LMWH, or fondaparinux is used unless it's massive or occurs w/ hemodynamic instability. -Review PTT (AKA aPTT)—before tx started & thereafter per policy. [Warfarin= INR.] Therapeutic PTT= 1.5-2.5x control value for PE. -Heparin tx usually continues for 5-10 days. Most are started on PO anticoagulant (ex. warfarin), on day 1 or 2 of heparin tx. -Tx w/ both heparin & warfarin overlap until the INR reaches 2.0-3.0 (therapeutic range). Heparin is usually infused for >5 days & continues for 24hrs after INR >2. Monitor the plt count & INR during this time. -LMWH (ex. dalteparin, enoxaparin) or a direct thrombin inhibitor (ex. apixaban, dabigatran, rivaroxaban) is often used instead of warfarin. PO anticoagulant use continues for 3-6wks; patients at continuing PE risk may take it indefinitely. -NPSG: Heparin comes in a variety of concentrations & amounts; contributes to drug errors. TJCs NPSGs; check prescribed dose carefully & ensure correct concentration is used to prevent OD or UD. --Assess for HIT: low plt (normal= 200,000-400,000). 50,000= life threatening bleeding risk, stop heparin, call HCP, need a plt infusion. -Fibrinolytic drugs (ex. alteplase), are used for tx of PE when specific criteria are met; ex. shock, hemodynamic collapse, or instability. Breaks up existing clot. High risk of bleeding; monitored in ICU. -Antidotes to anticoagulants & fibrinolytics should be readily available on the unit, from the pharmacy, or from the blood bank for patients undergoing these tx. Prevent Bleeding Complications! --Heparin antidote= protamine sulfate; Warfarin antidote= vitamin K1, available as an injectable drug, phytonadione. Fibrinolytic tx antidotes= clotting factors, FFP, & aminocaproic acid. (Alteplase= Aminocaproic acid).

Tracheotomy Post-op care & Assessing for Complications (Pneumothorax, SQ Emphysema, Bleeding, & Infection)

Post-Op Complications: -Pneumothorax: air in the chest cavity; can develop during the tracheotomy procedure if the chest cavity is entered. CXR after placement are used to assess for pneumothorax. -Subcutaneous emphysema: when there is an opening or tear in the trachea & air escapes into the fresh tissue planes of the neck. Air can progress throughout the chest & other tissues into the face. Inspect & palpate for air under the skin around the new tracheostomy. --Critical Rescue: Assess the skin around a new tracheostomy to ID subcutaneous emphysema. S/S puffy, feel a crackling sensation when pressing on this skin; respond by notifying the surgeon immediately. -Bleeding: small amounts from the tracheotomy incision is expected for the 1st few days, but constant oozing is abnormal. Wrap gauze around the tube & pack gently into the wound to apply pressure to the bleeding sites. Ensure that the tracheostomy cuff is properly inflated. --Bleeding can occur in the trachea or in the tissues surrounding the incision. If hemorrhage occurs, the site may need surgical exploration or ligation of BVs. -Infection: can occur at any time. In the hospital, use sterile technique to prevent infection during suctioning & tracheostomy care. Assess the stoma site at least Q8hrs for purulent drainage, redness, pain, swelling, or changes in tissue integrity. --Tracheostomy dressings may be used to keep the stoma clean & dry; resemble a 4×4 gauze pad with an area removed to fit around the tube. If tracheostomy dressings are not available, fold standard sterile 4×4s to fit around the tube. --Do not cut the dressing because small bits of gauze could then be aspirated through the tube. Change these dressings often because moist dressings provide a medium for bacterial growth; careful wound care prevents local infection.

Prevention of Pulmonary Embolism

Prevention of Pulmonary Embolism: -Start passive & active ROM exercises for the extremities of immobilized & post-op. -Ambulate ASAP post-op. Use pneumatic compression devices post-op as prescribed. -Evaluate for criteria indicating the need for anticoagulant tx. -Give prescribed prophylactic low-dose anticoagulant or antiplatelet drugs after specific OP procedures as soon as surgical bleeding risk has subsided. -Teach to avoid the use of tight garters, girdles, & constricting clothing. -Prevent pressure under the popliteal space (ex. do not place a pillow under the knee; instead, use an alternating pressure mattress). -Perform a comprehensive assessment of peripheral circulation Q8hrs. -Elevate the affected limb 20+ degrees above the heart to improve venous return, as appropriate. -Change position Q2hrs or ambulate as tolerated. -Refrain from massaging leg muscles. Instruct not to cross legs. -Teach about precautions. Encourage smoking cessation.

Providing Tracheostomy Care; Focused Assessment

Providing Tracheostomy Care: Assess; Secure tracheostomy tubes in place; Prevent accidental decannulation. Keeps the tube free of secretions, maintains a patent airway, & provides wound care; performed whether or not they can clear secretions. -Assess the patient before providing care. -Focused Assessment: the Patient w/ a Tracheostomy --Note the quality, pattern, & rate of breathing & compare w/ the baseline. Tachypnea can indicate hypoxia, & dyspnea can indicate secretions in the airway. --Assess for cyanosis, esp. around the lips, which could indicate hypoxia. Check the O2sat w/ pulseOx. --If O2 is prescribed, ensure that they're receiving the correct amount, w/ the correct equipment & humidification. --Assess the tracheostomy site for color, consistency, & amount of secretions in the tube or externally. --If the tracheostomy is sutured in place, assess for redness, swelling, or drainage from suture sites. --If the tracheostomy is secured w/ ties, assess the condition & security of the ties. Change if they are moist or dirty. --Assess the skin around the tracheostomy & neck for impaired tissue integrity, including behind the neck, from the ties or from excess secretions. --Assess behind the faceplate for the size of the space between the outer cannula & their tissue & whether any secretions have collected in this area. --If the tube is cuffed, check cuff pressure or collaborate with the RT to confirm cuff pressure. --Auscultate the lungs. --Ensure that a second (emergency) tracheostomy tube & obturator of the correct size are available.

Pulmonary Embolism Assessment

Pulmonary Embolism Assessment: -Physical; S/S: range from vague, nonspecific discomforts to hemodynamic collapse & death; important to remember that many w/ PE do not have "classic" s/s, often leads to it being overlooked. --W/ possible PE; assess for sudden SOB, dry or productive cough w/ hemoptysis, syncope, hypotension, & fainting; sharp, pleuritic inspiratory chest pain. -Classic S/S: Sudden onset of dyspnea; Sharp, stabbing chest pain (on inspiration); Apprehension, restlessness; Feeling of impending doom; Cough; Hemoptysis [if infarction present]; Diaphoresis; Increased RR; Crackles; Pleural friction rub; Tachycardia; S3 or S4; Fever, low grade; Petechiae over chest & axillae (usually only w/ fat embolism syndrome [FES]); Decreased SaO2. -Respiratory: mostly r/t decreased gas exchange; Dyspnea, tachypnea, tachycardia, pleuritic chest pain (stabbing on inspiration), dry cough [or productive], hemoptysis. Crackles, wheezes, or pleural friction rub; or normal. -Cardiac: r/t decreased tissue perfusion; Tachycardia, Distended neck veins, syncope, cyanosis, systemic hypotension [ bc pulmonary HTN & reduced forward BF], abnormal heart sounds [S3/S4], abnormal ECG [nonspecific & transient; T-wave & ST-segment changes may occur, as Lt or Rt axis deviations]. RV dysfunction & failure are extreme complications; may have cardiac arrest or frank shock. -Critical Rescue: monitor pts at risk to ID s/s of PE (ex. SOB, chest pain, &/or hypotension w/o an obvious cause). If s/s present, respond by initiating the RRT. If PE is strongly suspected, prompt categorization & management strategies are started before Dx studies have been completed. -Psychosocial: s/s of PE are abrupt→ Anxiety; Hypoxemia can trigger anxiety & sense of impending doom. Life threat + ICU admit→ anxiety & fear.

Pulmonary Embolism Dx & Analysis

Pulmonary Embolism Dx & Analysis: -Labs: ABGs; Hypoxia & pain→ Hyperventilation→ [Initial] Resp Alkalosis w/ decrease CO2. --PaO2/FiO2 ratio falls as a result of "shunting" of blood from the Rt to Lt side of heart w/o picking up O2 from the lungs. Shunting→ PaCO2 rises→ resp acidosis. [Later on] Tissue hypoxia→ lactic acid buildup→ metabolic acidosis. --Even if ABGs & pulseOx show hypoxemia; results alone are not sufficient for the Dx of PE. Pt w/ a small embolus may not be hypoxemic, & PE is not the only cause of hypoxemia. --Other labs performed when PE suspected; ex. General metabolic panel, troponin, beta natriuretic peptide (BNP), D-dimer D-dimer rises w/ fibrinolysis; value is normal or low, it can rule out PE; even if the value is high, other Dx testing is needed to ID PE. -Imaging: CT-PA or helical CT (or MRA) --Computed tomography pulmonary angiography (CTPA) or helical CT may be used for Dx; type of imaging has the added advantage of revealing other pulmonary abnormalities causing the s/s. --Magnetic resonance arteriography (MRA) is used in place of CTPA in some settings. --CXR may be used to Dx other conditions that mimic acute PE. --Doppler US may be used to document the presence of VTE. -Analysis: Analyze Cues & Prioritize Hypotheses -Hypoxemia (r/t deoxygenated blood passes; mismatch of lung perfusion & alveolar gas exchange w/ oxygenation) -Hypotension (r/t decreased circulation to LV) -Potential for excessive bleeding (r/t anticoagulation or fibrinolytic tx) -Anxiety (r/t hypoxemia & sense of life-threatening illness)

Pulmonary Embolism

Pulmonary Embolism: Collection of particulate matter→ enters venous circulation→ lodges in pulmonary vessels. -Any substance can cause embolism; blood clot is most common. Ex. Blood, fat, oil, air, tumor cells, cholesterol, amniotic fluid & fetal debris, foreign objects (ex. broken IV catheters), injected particles, & infected clots can enter a vein & cause PE. -Embolism: blood clot [thrombus] or other object that is carried in the bloodstream & lodges in another area. Large emboli in lung vessels→ obstruct pulmonary BF→ reduces gas exchange & O2→ pulmonary tissue hypoxia, decreased perfusion, & potential death. -Thrombus Patho: inappropriate blood clotting→ VTE (DVT) formed in leg or pelvis vein→ breaks off→ travels to rt-heart→ lodges in PA (or its branch)→ obstructing alveolar perfusion & outflow→ increased alveolar dead space & V/Q mismatch. Platelets collect on the embolus→ triggers release of substances→ BV constriction. Widespread pulmonary vessel constriction & pulmonary HTN impair gas exchange & tissue perfusion. Deoxygenated blood→ arterial circulation→ hypoxemia; but some w/ PE do not have hypoxemia. --Some have ongoing issues or residual problems after acute problems have resolved; continue to impair gas exchange & perfusion. --Common cause of preventable death bc s/s may be vague, & it may be mis-Dx→ high risk pts may not receive appropriate initial care.

Pulse Oximetry

Pulse Oximetry: shows Hgb saturation w/ O2; normally Hgb is almost 100%sat w/ O2 in superficial tissues. Uses a wave of infrared light & a sensor placed on the finger, toe, nose, earlobe, or forehead. -Normal: 95% to 100%; little lower in older patients & in those with dark skin. Recorded as SpO2 (peripheral arterial O2sat) or SaO2. Can detect desaturation before s/s occur (ex. dusky skin, pale mucosa, pale or blue nail beds). -Causes for low readings: patient movement, hypothermia, decreased peripheral blood flow, ambient light (sunlight, infrared lamps), decreased Hgb, edema, & fingernail polish. --Impaired peripheral BF- test O2sat on the forehead. -Spo2 <91%: in an adult w/o a chronic respiratory problem (esp. <86%) are an emergency & require immediate assessment & tx. -Spo2 <85%: body tissues have a difficulty becoming oxygenated. -Spo2 <70%: is usually life threatening; some cases <80% may be life threatening. Pulse oximetry is less accurate at lower values.

RN Care of ETT or TT

RN Care of ETT or TT: assess & care for ET or TT; maintain patent airway by suctioning when any of these conditions are present: Secretions; Increased peak airway (inspiratory) pressure(PIP); Rhonchi; Decreased breath sounds. -Proper care of the ET or TT also ensures a patent airway. Assess tube position at least Q2h, esp. when airway is attached to heavy ventilator tubing that may pull on it. --Position ventilator tubing so they can move w/o pulling on the ET or TT, possibly dislodging it. --Detect tube position changes; mark where tube touches teeth or nose. --Give oral care per policy; std. oral care performed at least Q12h→ shown to reduce VAP, exact solution remains controversial. -Special attention is needed when being transported while on MV. Monitor SpO2 during transport to assess adequacy of ventilation; assess lung sounds each time they're moved, transferred, or turned. Consider use of EtCO2 monitoring, if available. -Prevent ventilator associated events (VAEs): conditions that result in a sustained decreased oxygenation. --Specific indicators: >20% increase in the daily minimum FiO2 or an increase of >3 cm H2O in the daily minimum PEEP to maintain oxygenation. --Other complications affecting many body systems are rt + pressure from the ventilator.

RN Interventions for Various Causes of Ventilator Alarms (tbl 29.5): Major alarms indicate high pressure or low exhaled vL.

RN Interventions for Various Causes of Ventilator Alarms (tbl 29.5): Major alarms indicate high pressure or low exhaled vL. -High-Pressure Alarm (PIP reaches the set alarm limit [usually 10-20 mm Hg above their baseline PIP) --An increased amount of secretions or a mucus plug is in the airways. Suction PRN. --The patient coughs, gags, or bites on the oral ETT. Insert oral airway to prevent biting on the ET tube; provide adequate pain management and sedation as prescribed. --The patient is anxious or fights the ventilator. Provide emotional support to decrease anxiety; increase the flow rate; explain all procedures to the patient; provide sedation or paralyzing agent as prescribed. --Airway size decreases related to wheezing or bronchospasm. Auscultate breath sounds; collaborate with RT department to provide prescribed bronchodilators. --Pneumothorax occurs. Alert the pulmonary HCP or RRT about a new onset of decreased breath sounds or unequal chest excursion, which may be caused by pneumothorax; auscultate breath sounds. --The artificial airway is displaced; the ET tube may have slipped into the right mainstem bronchus. Assess the chest for unequal breath sounds & chest excursion; obtain a CXR as ordered to evaluate the position of the ET tube; after the proper position is verified, secure the tube in place. --Obstruction in tubing occurs because the patient is lying on the tubing or there is water or a kink in the tubing. Assess the system, beginning w/ the artificial airway & moving toward the ventilator. --There is increased PIP associated with deliverance of a sigh. Empty water from the ventilator tubing & remove any kinks; coordinate with RT or pulmonary HCP to adjust the pressure alarm. --Decreased compliance of the lungs is noted; a trend of gradually increasing PIP is noted over several hours or a day. Evaluate the reasons for the decreased compliance of the lungs; increased PIP occurs in ARDS, pneumonia, or any worsening of pulmonary disease. -Low-Exhaled vL (or Low-Pressure) Alarm (sounds when there is a disconnection or leak in the ventilator circuit or a leak in the patient's artificial airway cuff) --A leak in the ventilator circuit prevents breath from being delivered. Assess all connections & all ventilator tubing for disconnection. --The patient stops spontaneous breathing in the SIMV or CPAP mode or on pressure support ventilation. Evaluate their tolerance of the mode; evaluate for overmedication w/ sedation or pain drugs. --A cuff leak occurs in the ET or tracheostomy tube. Evaluate the patient for a cuff leak; cuff leak is suspected when they can talk (air escapes from the mouth) or when the pilot balloon on the artificial airway is flat.

RN Care for the ETT: Priority, Complications, Positioning

RN care for ETT: Assess placement, cuff leak, breath sounds, indications of adequate gas exchange & oxygenation, & chest wall movement regularly. --Maintain patient airway: PRIORITY action! --Critical Rescue: assess intubated to ID indications of decreased gas exchange (cyanosis, decreased O2sat, increased ETCO2, anxiety); indications present→ check DOPE: displaced tube, obstructed tube (often w/ secretions), pneumothorax, & equipment problems. ET tubes generally become displaced into the Rt mainstem bronchus→ absent breath sounds on Lt. -Monitor for complications: [ETT or NTT] during placement, while in place, during extubation, or after extubation (either early or late); common complications are tube obstruction, tube dislodgment, pneumothorax, tracheal tears, bleeding, & infection. --Trauma & other problems: face, eye, nasal & paranasal areas; oral, pharyngeal, bronchial, tracheal, & pulmonary areas; esophageal & gastric areas; CV, musculoskeletal, & neurologic systems. -Assess ET tube position: prevent pulling or tugging on tube to avoid tube dislodgment, & check pilot balloon for cuff inflation; common cause of unplanned extubation in adults is confusion & agitation. --Monitor cuff pressure; ensure it's 20-30cm H2O to stabilize w/o causing tracheal injury; suctioning, coughing, & speaking→ dislodgment; neck flexion, neck extension, & head rotation→ tube movement. --Pt position changes→ affect cuff pressures; may require more frequent monitoring. Tongue movement→ change tube's position. Other measures fail→ need order for soft wrist restraints & apply if pulling on tube. Restraints→ last resort to prevent accidental extubation. --NPSG: compliance w/ TJC-NPSGs→ reassess restraint need daily. Need continues→ get new prescription daily. Adequate sedation (chemical restraint) may be needed to decrease agitation or prevent extubation. Obtain permission for restraints from pt or family.

Respiratory assessment during MV

Respiratory assessment during MV: assess breathing pattern rt the ventilatory cycle→ ID if tolerating or fighting the ventilator. Patient asynchrony w/ MV has many causes & reduces gas exchange effectiveness. -Assess & record breath sounds, & confirm if equal bilaterally to ensure proper ETT placement. -ID need for suctioning by observing secretions for type, color, & amount; most common indicator= coarse crackles over the trachea. -Assess area around ETT or tracheostomy site at least Q4h for color, tenderness, skin irritation, & drainage; document findings. -Critical Rescue: always assess MV pt for indications of respiratory distress & poor gas exchange. S/S respiratory distress develop during MV→ immediately remove ventilator & provide ventilation w/ BVM device; allows quick ID of whether the problem is w/ the ventilator or pt. If no ventilator problem is ID, reconnect them to it & request RT assistance.

A&P of the Respiratory System

Respiratory system= upper airways, lungs, lower airways, & alveolar air sacs. -Gas exchange: O2 transport to the cells and CO2 transport away from cells through ventilation & diffusion. --Ventilation: major function of the respiratory system; the movement of atmospheric air (higher O2) into the lungs & removal of the CO2 produced during metabolism. --Respiratory diffusion: the movement of gases down their concentration gradients across the alveolar & capillary membranes. Room air O2 —> blood; Blood CO2 —> alveolar air—> exhaled. -Perfusion: "2nd diffusion"; occurs after ventilation & diffusion in the lungs; allows O2 to be made available to the cells. It's the arterial BF through the tissues (peripheral perfusion) & blood that is pumped by the heart (central perfusion). Adequate gas exchange must occur for tissue perfusion.

Suctioning Complications: Hypoxia, Loss of Tissue Integrity, Infection, Vagal Stimulation & Bronchospasm

Suctioning Complications: -Suctioning can cause hypoxia, injury to mucosal tissue integrity, trauma, infection, vagal stimulation, bronchospasm, & cardiac dysrhythmias. -Hypoxia causes: Ineffective oxygenation before, during, & after suctioning; Use of a catheter that is too large for the artificial airway; Prolonged suctioning time; Excessive suction pressure; Too frequent suctioning; Use of NS instillation w/ suctioning. --Prevent & Manage Hypoxia: Hyperoxygenate w/ 100% O2 via a manual bag-valve-mask attached to an O2 source. Instruct to take DBs 3-4x w/ the existing O2 system before suctioning. Monitor the HR or use a pulseOx while suctioning to assess tolerance of the procedure. --Assess hypoxia: increased HR & BP, O2 desaturation, cyanosis, restlessness, anxiety, dysrhythmias. --Hypoxia tx: stop suctioning; using the 100% O2 delivery system, reoxygenate until baseline O2sat level returns. O2sat <90% by pulseOx indicates hypoxemia. Use a correct-size catheter to reduce hypoxia risk & still remove secretions effectively; size should not be >1/2 the size of the tracheal lumen. Std. adult catheter size is 12-14 Fr. -Loss of tissue integrity by trauma results from frequent suctioning, prolonged suctioning, excessive suction pressure, & nonrotation of the catheter. --Prevent mucosa trauma: suctioning only PRN & lubricate the catheter w/ sterile H2O or NS before insertion. Apply only continuous suction during catheter withdrawal because the practice of intermittent suction during catheter withdrawal does not protect the mucosa and can lead to "dropping" of secretions in the airway. Use a twirling motion during withdrawal to prevent grabbing of the mucosa. Apply suction for only 10-15sec; longer can lead to alveolar collapse. Estimate this time frame by holding your own breath & counting to 10-15 while suctioning. -Infection: each catheter pass introduces bacteria into the trachea. --Prevention: in the hospital, use sterile technique for suctioning & for all equipment (ex. suction catheters, gloves, saline or water); suction the mouth or nose after suctioning the artificial airway. Clean technique can be used at home. --Action Alert: never use oral suction equipment for suctioning an artificial airway; this can introduce oral bacteria into the lungs & increase the risk for infection. -Vagal stimulation & bronchospasm are possible during suctioning. Vagal stimulation results in bradycardia, hypotension, heart block, ventricular tachycardia, or other dysrhythmias. --Tx: stop suctioning immediately & oxygenate the patient manually w/ 100% O2. Hypoxia caused by suctioning can stimulate a variety of cardiac dysrhythmias; if cardiac monitoring in place, check the monitor during suctioning. -Bronchospasm may occur when the catheter passes into the airway. --Tx: may need a bronchodilator to relieve bronchospasm & respiratory distress.

Surgical Interventions for PE; Managing Hypotension in PE

Surgical Interventions for PE: --Embolectomy: surgical or percutaneous removal of embolus; performed when fibrinolytic tx cannot be used w/ a massive or multiple large PE w/ shock or bleeding complications. --IVC filtration: w/ placement of a retrievable VC filter prevents further emboli from reaching the lungs in pts w/ ongoing PE risk. Used when filter placement is considered less risky than drug tx; ex. recurrent or major bleeding while receiving anticoagulants, septic PE, & undergoing pulmonary embolectomy. -Manage Hypotension: in addition to the txs for hypoxemia, IV fluid & drug tx are used to increase CO & maintain BP. --IV fluids: crystalloid solutions to restore plasma vL & prevent shock. Monitor ECG & PA & central venous/RA pressures; increased fluids can worsen pulmonary HTN→ Rt-HF. Monitor fluid adequacy; UO, turgor, & mucous membranes. --Drug therapy: vasopressors used when hypotension persists despite fluid resuscitation. Common ex. NE, epinephrine, or dopamine. Agents that increase myocardial contractility (+ inotropic agents; milrinone & dobutamine*)*, may be used. Vasodilators (ex. nitroprusside), may be used to decrease PA pressure if impeding cardiac contractility. Assess cardiac status hourly during tx w/ any of these drugs.

Swallowing after tracheostomy & laryngectomy; "Supraglottic" Swallowing

Swallowing after tracheostomy & laryngectomy; -Swallowing can be a problem w/ TT; can be normal if the CN's & anatomic structures are intact. --Normal swallow= larynx rises & moves forward to protect itself from the passing stream of food & saliva. --TT Swallow= TT may fix larynx in place, resulting in difficulty swallowing. Inflated TT cuff can balloon backward into esophagus & interfere w/ food passage. Wall between the posterior trachea & esophagus is very thin; allows this pushing action. When cognitively intact, may adapt to eating normal food when the TT is small & cuff is not inflated. -Partial vertical or supraglottic laryngectomy: must be observed for aspiration; critical to teach how to use alt. swallowing methods w/o aspirating. --"Supraglottic" Swallowing method: used after swallowing study has ID it is safe, esp. effective after a partial laryngectomy or base-of-tongue resection. It exaggerates the normal protective mechanisms of cessation of respiration during the swallow; double swallow helps clear food that may be pooling in the pharynx or throat. -Patient & Family Education; prep for Self-Management: Supraglottic Method of Swallowing -Sit upright, preferably out-of-bed, position. -Clear throat. Take a DB. Place ½-1 tsp of food in mouth. -Hold breath or "bear down" (Valsalva). Swallow 2x. -Release breath & clear throat. Swallow 2x again. Breathe normally.

Tracheostomy Care Coordination & Transition Management

Tracheostomy Care Coordination & Transition Management: Patient should be able to provide self-care -Teach: Tracheostomy tube care; Shower shield; Cover loosely with small cotton cloth during the day; Increase home humidity; Wear a medical alert bracelet; Follow-up. -At D/C: patient should be able to provide self-care; tracheostomy care, nutrition care, suctioning, & communication. Education begins before OP; most self-care is taught in the hospital. --Teach pt & cg how to care for the TT. Review airway care; cleaning & s/s of infection or loss of tissue integrity. Teach clean suction technique, & review the plan of care. --Instruct to use a shower shield over the trach tube when bathing to prevent water from entering the airway. --Teach to cover the airway loosely w/ a small cotton cloth to protect it during the day. Covering the opening filters the air entering the stoma, keeps humidity in the airway, & enhances appearance. Attractive coverings are available as cotton scarves, decorative collars, & jewelry. --Teach to increase humidity in the home. --Instruct to wear a medical alert bracelet that ID the inability to speak. --HC team assesses specific D/C needs & makes referrals to home care agencies & DME companies (suction equipment & trach supplies). --Follow-ups occur early after D/C; home care RN initiates & coordinates the services of RDN, RNs, SLP, & social workers, & ID community resources. -Patient-Centered Care; Older Adult Considerations: older patient w/ vision problems or difficulty w/ upper arm movement may have difficulty self-managing trach care & O2 tx. Teach to use magnifying lenses or glasses to ensure the proper setting on the O2 gauge. Assess ability to reach & manipulate the trach. If possible, work w/ a family member who can provide assistance during trach care.

Tracheostomy Tubes: Cuffed, Reusable Inner cannulas, Fenestrated Tubes, & Metal Tubes.

Tracheostomy Tubes: many types are available; selection is based on patient needs; many sizes & are made of plastic or metal; most are disposable. -TT may have a cuff & may have an inner cannula. -Cuffed tube: for patients receiving MV; the cuff is a small balloon surrounding the outside of the tracheostomy tube. Inflated to the proper size & pressure, it comes into contact w/ the trachea & seals it off so that all air movement occurs only w/in the TT. --Cuff is inflated through the use of a pilot balloon, which remains on the outside of the body where it can be accessed; pilot balloon is a small balloon w/ a valve on 1 end & a thin long tube on the other; the thin tube is connected to the cuff. --Inflate the cuff w/ an air-filled syringe, attached to the pilot balloon valve. Syringe is pressed, air 1st enters the pilot balloon & then moves through the thin tube to inflate the cuff. --Pilot balloon: function of inflating the cuff & can ID whether any air is in the cuff because it remains inflated when the cuff is inflated; does not indicate air vL or cuff pressure. -Tubes w/ reusable inner cannula; inspect, suction, and clean the inner cannula. First 24hrs post-op, perform cannula care PRN, perhaps hourly; after, care is determined by the patient's needs & agency policy. --Self-care: teach to remove the inner cannula & check for cleanliness. Instruct about suctioning & tracheostomy cleaning to prevent infection. --Breathing & swallowing move the tube, even a cuffed tube does not protect against aspiration; having a cuffed tube inflated may give a false sense of security that aspiration cannot occur. --Pilot balloon does not reflect whether the correct amount of air is present in the cuff. -Fenestrated tube: functions in many different ways. When the inner cannula is in place, the fenestration is closed, & this tube works like a double-lumen tube. --When the inner cannula is removed & the plug or stopper locked in place, air can pass through the fenestration, around the tube, & up through the natural airway so the patient can cough & speak. --RN: If the patient has trouble with these actions, he or she should be evaluated for proper tube placement, patency, size, & fenestration. Do not cap the tube until the problem is identified and corrected. --Action Alert: always deflate the cuff before capping the tube with the decannulation cap; otherwise the patient has no airway. Fenestrated tube may or may not have a cuff; w/ a cuff, some air flows through the natural airway when the patient is not being mechanically ventilated. -Metal tubes: when patient is scheduled for MRI, need to change to a plastic tube; metal tubes may be dislodged or heat up in the magnetic field during the scan.

Tracheostomy effect on swallowing; how to prevent aspiration

Tracheostomy effect on swallowing: TT sometimes tethers the larynx in place, making it unable to move effectively; result is difficulty in swallowing. When the cuff is inflated, it can balloon backward & interfere w/ food passage in the esophagus because the wall between the trachea & esophagus is thin. Keep the HOB elevated >30min after eating. -If balloon is inflated, can interfere w/ food passage through the esophagus. Consider liquids & soft foods; provide nutrition w/ less difficulty & discomfort. -Preventing Aspiration While Swallowing: -Avoid serving meals when they're fatigued. -Provide smaller & more frequent meals. -Provide adequate time; do not "hurry" them. -Closely supervise the self-feeding patient. Keep suctioning equipment close at hand & turned on. -Avoid H2O & "thin" liquids, & straws. Thicken all liquids, including H20. Thin liquids may be permitted after a swallowing evaluation by a speech-language pathologist. -Avoid foods that generate thin liquids during the chewing process (ex. fruit). -Position them in the most upright position possible. -When possible, completely (or at least partially) deflate the tube cuff during meals. -Suction after cuff deflation to clear the airway & allow comfort during the meal. -Feed each bite or encourage to take each bite slowly. -Encourage the patient to "dry swallow" after each bite ("double swallowing") to clear residue from the throat. -Avoid consecutive swallows of liquids. Provide controlled small vLs of liquids w/ a spoon. -Tell them to "tuck" the chin down & move the forehead forward while swallowing. -Allow them to indicate when they're ready for the next bite. -If coughing occurs, stop the feeding until they indicate that the airway is clear. -Assess RR, ease of swallowing, pulseOx, & HR during feeding.

Head & Heck Cancer: interventions

Tx focus of Head & Heck Cancer: remove or eradicate cancer while preserving as much function as possible. --Surgery, radiation, chemo, or biotherapy may be used alone or combined, depending on stage of disease; general health, nutrition status, age, & personal choice. -Tx laryngeal cancer: range from radiation tx (small specific area or tumor) to total laryngopharyngectomy w/ bilateral neck dissections followed by radiation, depending on extent & location of lesion. -RN Care: focuses on pre-op prep, optimal in-hospital care, D/C planning & teaching, & extensive OP rehab. -Radiation therapy: small cancers in specific locations; cure rate >40%. Radiation (esp. PBT); used alone or in combination w/ surgery & chemo, performed before or after surgery. --SE: most have hoarseness, sore throat, dysphagia, skin problems, impaired taste, & dry mouth for wks after radiation. Skin at the site becomes red, tender, & may peel during tx. --Instruct to avoid exposing to sun, heat, cold, & abrasive actions (shaving); wear protective clothing of soft cotton & wash area gently daily w/ mild soap; use skin care products (approved by radiation oncology dep.), reduces skin rx intensity. Salivary glands in irradiation path; causes xerostomia; effect is LT & may be permanent. Dental consultation is needed; cavity risk is increased by radiation & dry mouth. Moisturizing sprays, increased water intake, & humidification can ease discomfort. -Chemotherapy: used alone or w/ surgery or radiation. Chemo & radiation tx (chemoradiation); often used at the same time. Exact drugs used may vary, depending on cancer cell features, most chemo regimens for head & neck cancers include cisplatin (or another platinum-based drug) in combination w/ 5-FU. -Biotherapy: (targeted therapy) w/ an epidermal growth factor receptor inhibitor (EGFRI) like cetuximab; used when tumors over-express the receptor. It is a targeted therapy, but drug blocks epidermal growth factor receptors (EGFRs) in normal tissues & in the tumor. Results commonly in severe skin rx; difficult for the pt. Other biotherapies include some that are more specific for cancer caused by HPV types 16, 18, 31, and 33 (ex. nivolumab & pembrolizumab).

Upper Airway Obstruction: patho, s/s, Dx

Upper Airway Obstruction: interruption in airflow through nose, mouth, pharynx, or larynx. Can be life-threatening, when gas exchange impaired→ early ID is essential to prevent complications; respiratory arrest & death. -Tongue edema; surgery, trauma, angioedema as an allergic rx to drug. -Tongue occlusion; loss of gag reflex, loss of muscle tone, unconsciousness, coma. -Laryngeal edema from any cause; smoke or toxin INH, inflammation, allergic rx, anaphylaxis. Peritonsillar & pharyngeal abscess; Head & neck cancer; Thick secretions; Stroke & cerebral edema; Facial, tracheal, or laryngeal trauma or burns; Foreign-body aspiration. -Secretions: preventable cause that leads to asphyxiation; thickly crusted oral & nasopharyngeal secretions. Cause= poor oral hygiene w/ thickened & hardened oral secretions; can completely block the airway & lead to death. --Highest risk in alt. MS & LOC, dehydrated, can't communicate, can't cough effectively, or at risk for aspiration. -Proper RN care can eliminate this cause of airway obstruction. Assess oral care needs of pt w/ risk factors for thickly crusted secretions daily. Ensure UAPs understand importance & correct techniques for preventing. -Assess cause of partial or complete; partial= prompt care to prevent progression to complete. --Partial= general s/s; diaphoresis, tachycardia, anxiety, & elevated BP. Evaluate persistent or unexplained vague s/s. -Observe for hypoxia & hypercarbia; restlessness, increasing anxiety, sternal retractions, "seesawing" chest motion, ABD movements, or a feeling of impending doom from air hunger. -PulseOx or EtCO2 (or PEtCO2) for ongoing monitoring of gas exchange. -Assess for stridor, cyanosis, & LOC changes. -Dx: CXR or neck x-rays, laryngoscopic exam, & CT.

Upper Airway Obstruction: interventions

Upper Airway Obstruction: interventions -1st assess for the cause: Tongue falling back or excessive secretions. To manage; slightly extend head & neck, then insert a nasal or oral airway; suction to remove obstructing secretions. --If caused by a foreign body that cannot be removed by clearing the oral cavity manually, perform ABD thrusts. -Action Alert: ABD thrusts are performed on an unconscious pt instead of chest compressions only when obstruction is known, & have a palpable pulse. If no obstruction is seen unconscious person, chest compressions are started bc more unconscious adults have cardiac problems vs airway obstruction. -Emergency tx: may require cricothyroidotomy or tracheotomy to improve gas exchange; if object cannot be removed quickly. -ET intubation: when it's not caused by a foreign object; HCP inserts tube into trachea via nose (nasotracheal) or mouth (orotracheal). When pharyngeal or laryngeal edema formation is expected or likely; ETT is placed before swelling is severe enough to make insertion impossible. -Cricothyroidotomy: emergency tx performed by emergency personnel; used when it is the only way to secure an airway. Stab wound through the cricothyroid membrane between the thyroid cartilage & cricoid cartilage. Any hollow tube (prefer TT) can be placed through the opening to hold airway open until a tracheotomy can be performed. -Tracheotomy: surgical tx & performed in 5-10min (ER <2min); best done in OR under anesthesia; can be at the bedside. Local anesthesia is used when concerned the airway will be lost during anesthesia induction. Reserved if they cannot be easily intubated via ETT. --May require after >7 days of continuous ET intubation; when receiving MV for UAO or RF. Performed to prevent laryngeal injury & tissue integrity loss by the ETT.

Ventilator Controls & Settings: 3 components; vL-cycled, pressure cycled, flow cycled.

Ventilator Controls & Settings: settings generally based on 3 components: 1.) Inspiratory trigger is the initiation of ventilator breath from pt effort; or as a set, timed breath from the ventilator. 2.) Gas delivery achieved by setting the tidal vL= specific target vL of gas; or setting a target pressure that delivers a variable vL of gas. 3.) Breath termination the transition between I&E; inspiratory breath is terminated by a set vL, pressure, time, or flow. -vL-cycled: pushes air into lungs until preset vL is delivered; constant tidal vL is delivered, regardless of pressure needed to deliver tidal vL; set pressure limit prevents excessive pressure from being exerted on lungs. Advantage of this mode, constant tidal vL is delivered regardless of changes in lung or chest wall compliance or airway resistance. -Pressure-cycled: pushes air into the lungs until a preset airway pressure is reached; tidal vLs & inspiratory time vary. -Time-cycled: push air into lungs until a preset time has elapsed; tidal vL & pressure vary. -Flow-cycled: used w/ pressure support ventilation; it will terminate the breath when it reaches a preset flow rate (% of pts max. inspiratory flow).

Verifying Placement & Stabilizing the ETT

Verify tube placement: immediately after insertion, verify w/ ETCO2 levels & CXR; Assess breath sounds bilaterally (Lt side 1st), sounds over gastric area, symmetrical chest movement, air emerging from ETT. --Breath sounds & chest wall movement are absent on left side→ tube in Rt mainstem bronchus; respiratory HCP intubating them should be able to reposition the tube w/o repeating the entire procedure. --Tube is in stomach or esophagus→ ABD distended & EtCO2 monitoring indicate absence of CO2; reintubation is necessary & stomach must be decompressed w/ NGT after ETT is properly placed. --Monitor chest wall movement & breath sounds until placement is verified by CXR. --Tube shaft has a radiopaque line running the length; line shows on x-ray & is used to ID correct tube placement. Short horizontal lines (depth markings) are used to place the tube correctly at the naris or mouth (incisor tooth) & ID how far it's inserted. -Stabilizing: RN, RT, or anesthesia provider stabilizes ETT at the mouth or nose; tube is marked where it touches the incisor tooth or naris. 2 people working together use a head halter technique to secure it; an oral airway may be inserted or a bite block to prevent biting of the oral ET tube. 1st person stabilizes the tube at the correct position & prevents head movement; 2nd person applies the tube-holding device. After completion, verify & document presence of bilateral & equal breath sounds & tube level.

Warning Signs of Head and Neck Cancer; Dx Head & Nech Cancer

Warning Signs of Head and Neck Cancer (tbl 26.1): -Pain; Lump in the mouth, throat, or neck; Difficulty swallowing; Color changes in the mouth or tongue to red, white, gray, dark brown, or black -Oral lesion or sore that does not heal in 2 weeks; Persistent or unexplained oral bleeding; Numbness of the mouth, lips, or face -Change in the fit of dentures; Burning sensation when drinking citrus juices or hot liquids; Persistent, unilateral ear pain -Hoarseness or change in voice quality; Persistent or recurrent sore throat; SOB; Anorexia and weight loss -Dx Head & Neck Cancer: many types of imaging studies; ex. x-rays of the skull, sinuses, neck, & chest, are useful in Dx cancer spread & extent of tumor invasion. Studies common in Dx; CT w/ contrast, MRI, nuclear imaging, single-photon emission computed tomography (SPECT), and fluorodeoxyglucose positron emission tomography/CT (FDG-PET/CT) scans to locate metastatic sites. --PET: Positron emission tomography; uses radioisotopes to measure changes in metabolic processes. --Endoscopic exam w/ anesthesia; define the extent of the tumor. Biopsy tissues taken confirm Dx, tumor type, cell features, location, & stage.

Weaning from a TT

Weaning: Gradual decrease in tube size, to ultimate removal; Cuff deflated when pt can manage secretions & does not need assisted ventilation; Change from cuffed to uncuffed; Capping; Tracheostomy button. --Carefully monitor this process, esp. after each change. HCP or NP performs the steps in the process. --Cuff is deflated when they can manage secretions & do not need MV; this change allows them to breathe through the tube & upper airway. --Tube is changed to an uncuffed tube; if tolerated, the size is gradually decreased. --When a small fenestrated tube is placed, the tube is capped so all air passes through the upper airway & fenestrations, w/ none passing through the tube. --Assess to ensure adequate airflow around the tube when capped; tube may be removed after they tolerate >24hrs of capping. --Place a dry dressing over the stoma (gradually heals on its own). --Tracheostomy button: another device used for the transition from trach to natural breathing. It maintains stoma patency & assists spontaneous breathing. Ex. Kistner TT & Olympic trach. button; to function, the button must fit properly. --Disadvantage is the possibility of covert decannulation (ex. tube can dislodge from the trachea but remain in the neck tissues).