Exam II

respiratory variation preload

*Right atrial pressure variation- assess responssiveness: change of RAP greater than 1 mm Hg with insipirations + *Change less 1= nonresponder to strok volume (SV IV) RAP-1 mmHG change=fluid volume deficit; <1mmHG change=non-responder Systolic Pressure>10mmhg change=fluid volume deficit -preload responsive needs fluid resuscitation (very specific criteria must be met to use this method-CMV and not ARDS wall compliance) Arterial Pressure >10% difference between systolic and diastolic inspiration vs expiration=fluid volume deficit -ability to respond to fluid resuscitation -mechanical ventilaiton needed and sedated -no more than 10 mL.kg tidal volume Stroke Volume Variation-takes significant parameters to accomplish as well as newer technologies that are not common place -transducer and pulse contour device -only mechanical ventilation pt tidal V 8 constant rate

thermodilution CO

- connector on PAC volume 5-10 mL, room temp 0.9 NS. -fluid to Right ventricle normal: smooth curve rapid upstroke and slow return baseline -not accurate in pt with low CO -assess PAC before or measure PAOP -assess patency proximal port -do not infuse vasoactive drugs -0-30 degrees HOB -10 F remp, inject rapid 4 sec at end expiration (reduce intrathoracic pressure) -obtain 3 CO) values 10% of each other

overdamped system

-Clots, air bubbles CARE -flush, or aspirate, disconnecting the patient if needed -change to noncompliant tubbing -loose connections (ensure secure) -kinks int he tubing system (straighten tubbing) -Flush system (pressure bag 300 mmHg)

underdamped system

-Excessive tubbing length >48 in (remove extensions) -Small bore tubing (replace with larger) -can be due to pt anatomy and diagnosis -add damping device to reduce artifact

RAP/CVP nursing implications

-Low pressure= hypovolemia -High= reduce right vent ability to eject blood- hypervolemia (aggressive IV), severe vasoconstriction, and mechanical ventilation, pulmonary HTN, and HF Zero/balance Waveform analysis Respiratory variation and PEEP Patient position Head of bed between 0 and 60 degrees Correlate values with assessment Monitor for complications

Cisatracurium (Nimbex)

-Peripheral Nerve Stimulator, neuromusc. blockade TOF testing- in ulnar and facial nerves -4 low energy impulses 4 twitches incomplete no twitches complete GOAL 2/4 Sedation Care of immobile, paralyzed patient ØMechanical ventilation and airway management ØEye lubrication ØDVT prophylaxis ØRepositioning and range of motion ØOral care ØUrinary catheter ØRoutine vital signs and assessments nonverbal pain and anxiety

readiness to wean

-Underlying cause for mechanical ventilation resolved -Hemodynamic stability; adequate cardiac output -Adequate respiratory muscle strength, insp -Neuro, cadiac assessment -Adequate oxygenation without a high FiO2 and/or high -PEEP -Absence of factors that impair weaning (infection, anemia, fever, sleep dep, pain, abd distention, mental readiness, minimal need sedatives) -Mental readiness -Minimal need for medicines that cause respiratory depression, minimal secretions, normal sounds, chest x ray RSBI Rapid Shallow Breathing Index BWAP Burn Weaning Assessment Porgram METHODS ØSynchronized intermittent mechanical ventilation ØPressure support- reduction PS stable 2 hrs ØT-piece trials- humidified o2 via piece ØCPAP- when requires PEEP, ØWeaning trial or spontaneous breathing trial (SBT) -pressure support, high extubation rates 30-120 min direct assessment breathing, pt all WOB STOP PROCESS Respiratory Respiratory rate > 35 or < 8 breaths/min Low spontaneous VT < 5 mL/kg Labored respirations Use of accessory muscles Abnormal breathing pattern Low oxygen saturation < 90% Cardiovascular HR or BP changes > 20% from baseline Dysrhythmias (e.g., PVCs) ST-segment elevation Blood pressure changes more than 20% from baseline Diaphoresis Neurologic Decreased level of consciousness Anxiety/agitation Subjective discomfort

hemodynamic monitoring

-Using MAP, CO, CVP, PQOP, urine output, pH and lactate -Newer: SvO2, ScvOw, waveform PARAMETERS:

RAP/CVP (right atrial pressure)(Central venous pressure) monitoring

-estimate central venous blood volume and preload right heart function -assess fluid resucitation compared to SI. If both low (hypovolemia) -equal pressures because no valves 1—catheter in right atrium Proximal port of pulmonary artery catheter 2—catheter in superior or inferior vena cava •Normal value •2 to 6 mm Hg •Recorded end exhalation as a mean value, end of diastole, ECG, and resp. tracing SHORTER CATHS- subclavian and internal jugular veins LONGER- upper extremities or femoral vein Triple lumen INSERTION- trendelburg position to promote venous fillinf in upper body and prevent air embolism (not in resp distress or ICP) -If CONTRA- Apply blanket roll between shoulder blades -local anesthesic, aseptic cleaning, syringe puncture backflow, after obtain RADIOGRAPH (right atrium)

Low CO/CI

-inadequate ventricular filling, HR too slow or fast -strok volume reduction: -decreased preload: hemorrhage, hypovolemia, vasodilation, fluid shift -Increased afterload: vasoconstriction, increased viscocity -Decreased contractility: MI, ischemia, HF, cardiomyopathy, cardiogenic shock, cardiac tamponade

lung volumes and capacities

-measured with spirometer to determine the function -these decline with aging Tidal Volume (VT) NO MEM ØNormal breath volume; 500 mL or 5 to 7 mL/kg INSIRATORY RESERVE VOLUME IRV- max gas that can be inspired at the end of a normal breath EXPIRATORY RESERVE VOLUME ERV- mac gas expired at the end normal breath RESIDUAL VOLUME RV- amount of air remaining in lungs after max expiration Functional Residual Capacity (FRC) ØVolume of gas remaining in the lungs at normal resting expiration ØAverage: 2300 mL Vital Capacity (VC) ØMaximum volume of gas forcefully expired after maximum inspiration Average: 4600 mL INSPIRATORY CAPACITY IC- max gas can be inspired at normal resting expiration, distends lung to max TOTAL LUNG CAPACITY TLC- gas in lungs at end of max inspiration

passive leg raising

-preload responsive indicated by increase in SV before IV fluids. -measuring the hemodynamic effects of leg elevation up to 45 degrees. -starting from a semi recumbent position, as it allows for a larger increase in cardiac preload because it induces the shift of venous blood not only from the legs, but also from the abdominal compartment.- -within the first minute of leg elevation -use doppler and pulse contour -used in spontaneously breathing and mechanical vent pts IF PRELOAD RESPONSE MORE THAN 10 % AND FLUID BOLUS IS INDICATED

mechanical ventilation indications

-unable maintain ABG, Acute resp failure Hypoxemia ØPaO2 ≤ 60 mm Hg on FiO2 > 0.5 Hypercapnea ØPCO2 ≥ 50 mm Hg with pH ≤ 7.25 Progressive deterioration ØIncreasing RR ØDecreasing VT ØIncrease in WOB, use accessory muscle

Noninvasive positive-pressure ventilation (NPPV)

-without ETT or tracheostomy Delivery of positive-pressure ventilation (PPV) ØVia face mask, nasal pillow ØTight seal ØIntact respiratory drive Reduces complications associated with MV, less sedation, VAP, and vocal cord injury Useful in many patients- prevent intubation ØCOPD ØHeart failure, cardiogenic edema ØPalliative care, early hypoxemic, resp failure immunocomp, sleep apnea, asthma, obesity, etc -can be pressure (more tolerated) or volume -ensure right size mask -montor skin, place wound care dressing on skin'-eye drops, monitor mouth drying, humidification -gastric decompression if needed -monitor RR, EVT, and PIP CONTRA- apnea, CV instability (hypo/HTN), secretions,, high aspiration risk, trauma

accuracy hemodynamic monitoring

1. Positioning the patient. HOB 30 degrees (prevent pneumonia, comfort) 2. Level air fluid interface= PHELBOSTATIC AXIS: (0 stopcock transducer at level of atria for accuracy) -Fourth intercostal space, midaxillary line -Approximate level of right atrium -mark with permanent marker -assess skin integrity -regularly monitoring for false results 3. Zero transducer Negate atmospheric pressure Zeroing stopcock is leveled at phlebostatic axis and "zeroed"- open stopcock of transducer to air (closed tot he pt) 0 mmHg -at the beginning of the shit, reposition, and significant hemo changes. 4. Assess Dynamic response testing Square wave test- record pressure waveform whil activating fast flush valve for 1 sec. If square + - Perform before cath insertion, at least once a shift after drawing blood from line, and any time system is opened. CRUCIAL *Overdamped- no oscillations, upstroke slurred or small undershoot not produced (false low systolic, false high diastolic) COMP -Thrombosis, Hematoma -bleeding -pneumo/hemothorax -cardiac dysrrhythmia -Pericardial tamponade -infection- CLABSI hand washing, strict sterile, barrier precautions, chlorhexidine skin antisepsis, optimal catheter site, daily review. -minimize opening, sutureless securement device, baths chlorhexidine, changing tubing no more freq than 72-96 hrs, aseptic treatment, ports, and aseptic meds. -Subclavian vein- pneumothorax and nerve damage -Internal Jugular site- low comp rate high infection -ensure alarms turned on

gas exchange

1.Ventilation = movement of O2 in and CO2 out of alveoli 2.Diffusion of O2 and CO2 at pulmonary capillary 3.Oxygenated blood perfused or transported to the tissues 4.Diffusion of O2 and CO2 occurs at cellular level ØTransport of CO2 to the right side of the heart ØDiffusion based on concentration gradients UPPER AIRWAY- Nasal caivty and pharynx LOWE AIRWAY- larynx (cords), trachea, bronchi (conduct to lungs) , broncheoli, alveoli (expand) LUNGS- left 2 lobes, right, 3 lobes pleura- lubricates, pneumothorax leads to collapse

invasive hemodynamic equipment

1•INVASIVE CATHETER, such as an arterial line, pulmonary artery catheter, or right atrial/central venous catheter, is needed. -Femoral vein cath- high risk infection, remove ASAP 2•NONCOMPLIANT PRESSURE TUBBING, when connected to the invasive catheter, allows for accurate transfer of data/pressure changes to the transducer and monitoring system. -no longer than 36-48 in min. additional stopcocks 3•TRANSDUCER translates pressure changes into waveforms.- must be 0 •3 WAY STOPCOCKS, when attached to the transducer, allow for the process of zero referencing and balancing to occur. 4•FLUSH SYSTEM, normally made up of 0.9% normal saline, ensures patency of the invasive catheter. -in pressure bag inflated 300 mmHg ensure flow 2-5 ml/hr -heparin flush risks of thrombocytopenia (risk/benefit) 5•BEDSIDE MONITOR provides a visual display of the invasive catheter pressures. -interpreted by clinician

Balancing o2 delivery and demand

ASSESSMENT: CO, hgb, and SaO2 -obtain blood sample and ABG analysis -for critical pt: trauma, ARDS, sepsis, complex cardiac •Obtained via monitoring catheters •SvO2—mixed venous oxygen saturation via specialized PAC -measured in PA •ScvO2—central venous oxygen saturation via specialized central line -measure in central venous system, superior vena •Normal values •SvO2—60%-75% = adequate balance between supply and demand •ScvO2—65%-85% = adequate balance between supply and demand •High values = tissues not able to use oxygen •Low values = oxygen demand exceeds delivery LOW SvO2 >60- Decreased o2 delivery: hypoxia, hemorrhage, hypovolemia, anemia, shock, restrictive ventilation Increase consumption: strenous activity, fever, pain, anxiety, seizure High SvO2 >75- increase o2 delivery: hyperox decrease o2 consumption: Hypothermia, anesthesia, hypothyroidism, blockade, sepsis >80- errorr, wedged PAC, clot, recalobration needed.

Work of breathing

Amount of EFFORT required to maintain ventilation Respiratory pattern changes automatically WOB increases, more energy needed WOB high, leads to muscle fatigue and eventually respiratory failure, more o2, and glucose -accessory muscle higherWOB

ventilatory medications

Analgesics: morphine Sedatives: benzodiazepines, neuroleptics, and propofol Neuromuscular blocking agents (NMBAs): paralytic agents -interrupt as least once, weaning assess, reorient -insufficient sedation- dyssynchrony -oversedation/ prolonged- longer intubation

Abnormal breathing patterns

CHEYNE STOKES- CNS disorders, and congestive HF -Deep shallow resp, apnea 20 sec WORRY! BIOT'S- cluster breaths vary in depth and varying apnea -brainstem injury KUSSUMAUL- deep, regular, and rapid >20 -DKA, metabolic acidosis APNEUSTIC- gasping inspirations short ineffective expirations pons lesions

GI system ventilatory

Complications ØStress ulcers ØGI bleeding Interventions ØStress ulcer prophylaxis Provide nutritional support, eneteral feeding ASAP monitor blood in stools HOB 30-45 reduce aspiration risk

nonpharmacological ventilation

Create a healing environment ØFocus the plan of care on patient and family ØReduce noise levels ØReduce light stimulation ØProvide reassurance ØAdequate rest with near-normal sleep-wake cycles ØOrientation measures (time, place) Complementary and alternative measures ØTherapeutic touch ØGuided imagery/relaxation ØSpirituality/prayer

High frequency oscillatory ventilation (HFOV)

Delivers low tidal volume at very fast rate (300-420 bpm) Used in patients with noncompliant lungs (such as ARDS) who remain hypoxemic despite conventional and advanced ventilation Close monitoring essential Sedation and paralysis may be indicated COMP- implement bundle to prevent -HOB elevation, sedative, spontanous breathing trials, and thromboembolism probhylaxis, stress ulcer proph

Extubation

Determine need for secretion management Assess -good cough and require duction no more 2 hrs -ASK PT SPEAK, ASSESS VS, and quiet ØStridor ØHoarseness ØChange in vital signs ØLow oxygen saturation NPPV may prevent need for reintubation -TRACH- cuff leak test CLT, high risk stridor postextubation (large ETT)

PAC nursing implications

Discuss the role of the nurse during preinsertion. •Provide education. •Obtain informed consent. •Set up equipment: guidewire, introducer, catheter, sheath, pressure tubing, transducer, and monitor. •Flush lumens.to prevent infection. •Monitor pressures in each chamber and record values. •Assess for complications: Dysrhythmias Pneumothorax or hemothorax •Measure and record catheter length once it has been placed in proper position. •Assure zero reference. •Proper patient positioning •Measure pulmonary artery pressure •Normal values •PA systolic: 15 to 25 mm Hg •PA diastolic: 8 to 15 mm Hg •Obtain chest x-ray. Should not be left inflated no more than 5 seconds -ensure deflated NO MORE THAN 1.5 ML INFLATION record how much is needed.

Compliance

Distensibility or stretch Determined by elasticity, "recoil" less elastic= stiff lungs, ARDS, pulmonary edema, obesity, emphysema, create negative pressure to inflate stiff lungs Types ASSESSMENTS ØStatic—measured under condition of no airflow (2 seconds inspiratory hold) RESTING 50-170 ml ØDynamic—measured while gases flowing EXPIRATION 50-80 mL -POOR OF THIS REQUIRES MORE VENTILATORY PRESSURE LEADING TO RISK OF VOLUTRAUMA

MV complications

ETT Out of Position ØRight mainstem bronchus- unequal chest expansion, sounds ØDislodged- anxious pt, transportation -if manipulating assess bilateral chest excursion, ausculate, cm check, or manually vent. Unplanned Extubation 1. using tongue 2. leaning forward, removal, due to agitation, inadequate sedarion, high LOC, restraints. ØNurse must protect airway to prevent unplanned extubation ØSecuring the tube is important Damage to Oral and Nasal Mucosa ØSkin breakdown from tape and commercial devices, education, analgesia sedation, restricts -damage larynx due to movement, prevent flexion and extension neck -pressure not exceed 25-30

VAP (ventilator associated pneumonia)

Elevate head of bed 30 to 45 degrees -Interrupot sedation once daily readiness wean Prevent drainage of condensate back to patient Hand hygiene ETT with subglottic suction capability Aspirate secretions from above ETT Oral hygiene program- 0.12 chlorhezidine antiseptic Noninvasive ventilation as possible -DVT , peptic ulcer prophylaxis

noninvasive ventilation assessment

End-tidal CO2 (ETCO2) assess level CO2 alveoli at end of exhalation, close to ETT or trach tube, cannula for pts without artificial airway on nares. ØMust compare with ABGs and use for trending ØValues tend to be 2 to 5 mm Hg less than PaCO2 (30-40) If not means not perfused lungs (pulmonary embolism, due to dead space) Calorimetric CO2 detector ØDisposable devices -after intubation to differentiate tracheal from esophageal intubation, color changes

respiratory buffer system

Excretes excess CO2 from system when metabolic disorder occurs Immediate action- faster compensation

Mechanical ventilation data

Exhaled tidal volume (EVT) amount of gas in exhale ØShould not be more than 50 mL different from set VT q. 4 hrs, assess vent received Peak inspiratory pressure (PIP) maximim pressure during inspiration. ØShould be less than 40 mm Hg- inury -q.4 hrs report >40 Total respiratory rate- breaths by the ventilator set rate ØCount total rate, which accounts for set rate and patient effort MODES-how breaths are delivered The VT delivered by the ventilator is constant, monitor for elevated PIP.

Ventilator settings

FiO2 Oxygen- Fraction of inspired oxygen based on pt needs based on ABG pulse ox.60-100 TIDAL VOLUME(VT) volume with each breath Ø6 to 8 mL/kg (ideal weight) ØAdjusted according to peak and plateau pressures -avoid excessive pressure PIP INSPIRATORY RATE- flow of gas in lungs RESPIRATORY RATE Ø14-20 breaths initially INSPIRATORY-EXPIRATORY RATE normal 1:2 INVERSE RATIO- for noncompliant lungs Positive end-expiratory pressure (PEEP) additional positive during exp, increase o2 Ø5-20 cm H2O open alveoli ØIncreases FRC to improve oxygenation -SHOULD BE 0 ON EXPIRATION ØCan cause reduced cardiac output if high and impedes venous return AUTOPEEP Spontaneous development of PEEP Caused by gas trapping in alveoli ØInsufficient expiratory time ØIncomplete exhalation CAUSED BY: •Rapid RR •Airflow obstruction •Inverse I:E ventilation Assess by 2-sec pause (hold) maneuver Auto-PEEP = Total PEEP - Set PEEP SENSITIVITY amount of patient effort ØGoal is to avoid, too high sensitivity= patient-ventilator dyssynchrony ("fighting the ventilator")

Allen Test Procedure

For Arterial Pressure monitoring prior insertion -Ask pt to tight fist with wrist in neutral position -occlude radial artery pressure with thumb 19 seconds -ask to open fist while pressing -ulnar circulation is adequate IF BLANCHING RESOLVES WITHIN 5 SECONDS -Inadequate= more than 10 seconds MODIFIED- occlude both radial and ulnar for 10 seconds, release pressure of ulnar only,

Arterial Blood Gases

GOLD STANDARD Adequacy of oxygenation and ventilation Acid-base status -From arterial puncture or line Interpret in conjunction with: ØClinical history ØPhysical assessment

22-26

HCO3 Metabolic, kidneys low- acidosis DKA, RENAL, D, high- alkalosis ANTIACIDS, VOMITING, NG SUCTION, LOW P, DIURETICS

High CO/CI

HR elevation: increased activity, anemia, metabolic demands, adrenal disorder, fever, anxiety -stroke volume increases: *Increased preload: fluid resuscitation, alteration in ventricular compliance *Decreased afterload: vasodilation in sepsis, decreased viscosity anemia, increased contractility, hypermetabolic states, medication therapy.

respiratory assessment

HX- good baseline, even if not resp disease. Tobacco pack per year history Occupational history Sputum production Shortness of breath, dyspnea, cough, anorexia, weight loss, and chest pain Oral and inhalant respiratory medicines OTC drugs Allergies: medication and environmental Last chest x-ray and tuberculosis screen

right ventilation sounds, none in left

How do you tell if the ET tube is in the right mainstem bronchus? What do you do if you suspect the ET tube is in the esophagus?

cardiovascular system ventilatory

Hypotension Decreased cardiac output, especially with PEEP RISK- hypovolemia pts, and poor cardiac reserve -hemodynamic monitoring inotropic agents may be needed

Invasive hemodynamic monitoring

INDICATIONS- more detailed *Arterial line- hemodynamic instability, assess vasoactive meds, freq. ABG, with stroke volume device *Central Venous Catheter- measure right filling, fluid status, guide resuscitation, ScvO2, assess transv pace *Pulmonary Artery Cath- left heart PAOP, identify cause hemo instability, assess pulmonary artery pressures, SvO2, measure CO ØArterial pressure monitoring ØPulmonary artery pressure monitoring ØRight atrial pressure monitoring

Respiratory physical examination

INSPECTION ØHead, neck, fingers, and chest (clubbing, cyanosis, obstruction, JVD, pursed lip, barrel chest) ØAccessory muscles, sternal retractions, nasal flaring, asymmetrical chest movements, open-mouth breathing, and gasping breaths Respiratory rate 10-20 FULL MINUTE ØTachypnea: rate > 20, low PaO2, anemia, pain, anxiety ØBradypnea: rate < 10, depressant, alkalosis, fatigue INSP-EXP 1:2 ØAssess rate and depth and altered patterns (eupnea normal) PALPATION ØChest wall excursion ØTracheal deviation- TENSION PNEUMO ØChest wall tenderness- trauma, inflammation, fracture ØSubcutaneous crepitus- air beneath SQ, emphysema, rice, barotrauma, fractures. ØTactile fremitus PERCUSSION- hemo/pneumothorax, consolidation -tap 2 times middle finger Resonance: normal lung sound Dullness: denser than normal tissue Flatness: air is absent, lung collapse Hyperresonance: increased amount of air (emphysema) Tympany: air-filled area, pneumothorax AUSCULTATION q 4 hrs, with diaphragm, sitting position Assess breath sounds, presence of adventitious lung sounds, voice sounds Quiet environment Systematic approach •Always compare side by side. •Always listen posterior as well as anterior.

arterial pressure monitoring

INVASIVE technique to monitor arterial blood pressure -indicated for patients who are hemodynamically GOLD unstable (hypo/HTN) , are in need of frequent lab work, and are being managed with vasoactive agents. -•Prior to the insertion of an invasive arterial catheter, assessment of the perfusion to involved limb must occur. *Sites: Radial artery- accessible collateral perf. ulnar Allen's test prior to insertion to verify collateral circulation in the extremity Issues related to predictability of Allen's test Brachial artery Femoral artery CANNULATION-using Doppler US NORMAL WAVEFORM- sharp upstroke, peak represents sytolic= reflects left vent. function= reflext resistance <140 systolic pressure normal DOWNSTROKE- small notch dicrotic, aortic valve closure at beginning of diastole= distribution of blood flow.

tracheostomy

Indications ØLong-term mechanical ventilation ØFrequent suctioning ØProtecting the airway ØBypass an airway obstruction ØReduce WOB Performed in the operating room or bedside (percutaneous) -reduces WOB because is shorter than ETT less resistance, greater comfort, decreased sedatives and antipsychotics, less restraint, lower unplanned extubation -can swallow if gag reflex, easy oral hygiene, speaking valve -decide after 10 days CONTRA- neck injury, obesity, coagulopathy -document values q. 15 min. CUFFED V UNCUFFED- cuff prevent ventilation, uncuffed for long term SINGLE V 2BLECANNULA- double has inner, it is removable for cleaning FENESTRATED- hole in outer cannula, it assists weaning, allows communication. inner reinsert an cuff reinflated for eating, suctioning, mechanical vent, or bag valve -assess effort SPEAKING VALVE-only for capable spontaneous vent., deflate cuff monitor SpO2, VS, WOB

RAP/CVP complications

Infection CLABIS Pneumothorax or hemothorax Carotid puncture, during insertion Heart perforation- right ventricle or atrium Dysrhythmias- obtain chest radiograph

ETT communication

Lack of vocal expression- reassurance Ineffective communication Major stressors ØFear ØFrustration ØIsolation ØAnger ØHelplessness ØAnxiety ØSleeplessness -Head nods, mouthing words, gestures, and writing , but they are often inhibited by wrist restraints. -charts, communication boards and computer---generated voice devices could improve communication -reassure loss of voice is temporary, will come back once extubated.

positive pressure ventilation

MECHANICAL Movement of gases into lungs through positive pressure Opposite of normal respirations •"Pushes" gases into the lungs. UNCOMFORTABLE

PAC parameters

Measurement capabilities PA systolic: 15-25mm Hg peak pressure in right ventricle PA diastolic: 8-15 mm Hg resistance pulmonary vasc. PAOP/PCWP/PAWP: 8-12 mm HG ballon inflated LVEDP left vent. function -measure at expiration, ECG and resp waveform Inflated balloon flows into wedge position in pulmonary capillary, measuring pressure PAOP increased= overload aggressive IS, renal dysf. low= dehydration hypovolemia, diuretic, hemorrhage Cardiac Output/Index (4-8 L/min; 2.5-4.2 l/min/m2 Thermodilution CO Proximal injectate port •Pulmonary artery pressures reflect the function of the left ventricle. •To reduce the risk of pulmonary artery rupture, pulmonary artery diastolic pressure can be substituted if measurements are similar to pulmonary artery occlusive pressures. •When performing a pulmonary artery occlusive pressure or "wedge" pressure, the nurse should document the amount of air necessary to wedge the balloon. Should not be left inflated no more than 5 seconds

bicarbonate buffer system

Most common, metabolic by the kidneys Activated as H+ ions increase Increased H+ ions combined with HCO3 to form carbonic acid (H2CO3) Carbonic acid breaks down into H2O and CO2

alarms

Never shut alarms off; silence only Manually ventilate if uncertain of problem bag valve, ensure available ASSESS High peak pressure- kinks Low pressure; low PEEP/CPAP- leaks Low exhaled tidal volume- disconnection Low minute ventilation High exhaled tidal volume- water excess High minute ventilation Apnea ACTION IF DISTRESS, disconnect from vent and manually ventilate while RT assesses

Propofol (Diprivan)

Nonbenzo, sedation and anxiolytic, anesthesia SIDE EFFECTD hypotension, resp. depression, fever, sepsis, hyperlipidemia IMPLICATIONS intubated and mechanical ventilation -monitor Bp and hemodynamics -change infusion set q 12 hrs -monitor lipid levels

breath sounds

Normal ØBronchial- upper tracheal. larynx ØBronchovesicular- middle, large central ØVesicular- down, small airways Adventitious sounds ØCrackles- bubles (atelectasis, fluid, mucus,edema) ØRhonchi- low pitch coarse rattle (mucus, inflammed) ØWheezes- whistles (bronchospasms, asthma) ØPleural friction rub-(squeak) lung lining, infection ØStridor- closed beyond wheeze, crowing (obstruction) -shallow resp may mimic decreased breath sounds, ask to breathe.

compensation

Normalize pH -kidneys compensate for resp abnormalities -lungs compensate for metabolism Partial: pH abnormal Complete: pH normal range

noninvasive o2 assessment

OXYGENATION Pulse oximetry (SpO2) noninvasive measure ØValue of 90% = PaO2 60 mm Hg Ensure accurate readings ØLimit movement, warm perfused, avoid inflated cuff ØAvoid edematous areas ØEffect of sunlight, fluorescent light, nail polish, artificial nails, and dyes Periodic ABGs to compare value with SaO2

resistance

Opposition to gas flow in the airways -this decreases when narrow and lengthened airway (bronchoconstriction, mocus, or edema) this may result in reduced lung volume and inadequate ventilation ØAirway length ØAirway diameter •Small tube •Spasms •Mucus ØFlow rate of gases Increased breathing effort

volutrauma

Overdistension of alveoli, lung tissue injury results of stress Damages the lung similar to early ARDS Keep PIP < 40 cm H2O, edema •Excess volume can create damage similar to that of ARDS. •Important to monitor PIP and plateau pressure.

35-45

PaCO2 Respiratory low- alkalosis HYPERVENTILATION high-acidosis RETENTION CO2 -hypoventilation- CO2 retained acidosis -hyperventilation, CO2 excreted alkalosis

oxygenation

PaO2─partial pressure of oxygen dissolved in arterial blood ØNormal value 80 to 100 mm Hg ØDecreases in elderly ØValue < 60 mm Hg treated ØValue < 40 mm Hg is life threatening SaO2─amount of oxygen bound to hemoglobin ØNormal value 92% to 99% Frequently measured via pulse oximetry (SpO2) Hypoxemia: decreased oxygenation of arterial blood PaO2 <60 S/S- pallor, cool, dry, cyanoses, diaphoresis, dyspnea, tachypnea, accessory muscles, tachycardia, dysrrhythmias, chest pain, HTN-hypo, anxiety, restlessness, confusion, fatigue, agitation, coma Hypoxia: decreased oxygenation at tissue level

Pressure Support Ventilation (PSV) (CPAP)

Patient's spontaneous effort is assisted by preset amount of positive pressure -Must have reliable resp. drive and VT -pt performs all WOB, provides pressure at end of expiration, prevent alveolar collapse -similar top PEEP but this one is EXPIRATORY assist Ø6 to 12 cm H2O Decreases WOB with spontaneous breaths Also useful in weaning -can be via nasal or face mask -comfort, provides muscle conditioning, weaning

airway management

Positioning-head tilt/ chin lift, jaw thrust airway open Devices ØOral airway- prevents tongue from blocking, for decreased LOC, or prevent from bitting ETT CONTRA- conscious pt, gag reflex -assess lips and tongue for sigsn or pressure ulceration and suction -suction before intubation ØNasopharyngeal airway- consious pt, comfortable, difficult to place, COMP- nose bleeds, ulceration, sinusitis, otitis media risk ØEndotracheal intubation ORAL- quick, preferred, less kink, discomfort, dif. mouth care, impair swallow, increase secretions NASO-greater comfort, better care, communication, difficult to place, infection, increased WOB small diameter, bleed

Volume assist/ control ventilation (VAC)

Preset number of breaths at preset VT Patient may trigger additional breaths VT does not vary CONSTANT Ventilator performs most of the WOB, ventilate regardless of effort Useful in normal respiratory drive but weak or unable to exert WOB -REQUIRES NEGATIVE INSPIRATION Risk of hyperventilation and respiratory alkalosis (tachypnea treatment) -pt rely on ventilator -monitor PIPI, if increased evaluate resistance or compliance -monitor comfort, ABG and VS

barotrauma

Pressure trauma injury to lungs due to mechanical ventilation. Alveoli overdistended high VT, PEEP, + pressure vent FACTORS-ARDS, pneumonia can cause emohysema leaking alveoli Examples ØPneumothorax ØTension pneumothorax LIFE THREAT air enters pleural space, collapse, tachycardia, hypotension TREAT- chest tube, remove ventilation and bag valve Detect ØHigh PAP, mean airway pressure ØDecreased breath sounds ØTracheal shift ØSubcutaneous crepitus ØHypoxemia •Trauma can occur secondary to mechanical ventilation. •Types include barotrauma and volutrauma. •Can be life-threatening-Tension pneumothorax is a medical emergency that must be identified and treated quickly.

Endotracheal suctioning

Prevent hypoxemia, airway trauma, infection, and ICP with head injury, stimulates cough reflex, and promotes removal 80-120 mmHg sterile, rinse cath Suction as indicated by assessment ØVisible secretions ØCoughing, o2 desaturation, VS ØRhonchi, crackles ØHigh PIP on ventilator ØVentilator alarm -when patency is questioned. Conventional Procedures- assess breath sounds before 1-3 only 10-15 seconds, rest periods ØHyperoxygenate throughout procedure 100% 30 sec before, during, and afterwith bag valve -if not, hyperinflation 3-5 times breaths before Avoid normal saline instillation (tachycardia, ICP, bronchospasm) -adequate hydration and humidification CLOSED- suction cath enclosed in plastic sheath attached to airway, maintain o2, reduces hypoxemia, maintains PEEP positive end expiratory pressure, for unstable pt, TB

Pantoprazole (Protonix)

Reduce ulcers PPI S.E Constipation, dizziness, lightheadedness, severe allergic reactions IMPLICATIONS- monitor for presence of blood in vomit or stool, unintentional weight loss, difficulty swallowing abdominal pain or persistent vomiting

regulation of breathing

Respiration stimulated by elevated CO2 Not true for COPD ØStimulus is hypoxia ØRationale for low oxygen in patients with COPD , low oxygen level (hypoxia) stimulates breathing. INSPIRATION- diaphragm lowers and flattens, muscle contraction, negative pressure EXPIRATION- massive muscle relax and lungs recoil, positive pressure.

psychosocial ventilatory complications

Stress Anxiety Dyssynchrony- if ventilator not set correctly Noise Altered sleep-wake patterns Dependence Sleep awake problems

oxygen toxicity

The degree of injury is related to the duration of exposure and to the FiO2, not to the PaO2. Signs ØTracheobronchitis- irritation ARDS Øthe FiO2 of 1.0 may be tolerated for 24 hours ØAtelectasis -nitrogen to prevent collapse alveoli PEEP can be adjusted, target PaO2 70-100 -SpO2 90-92 FiO2 0.60 or less

B

The nurse assesses a patient with an ETT and mechanical ventilation whose high peak pressure alarm is sounding. What is the cause of this alarm? A.Anxiety B.Biting or kinking of ETT C.Disconnected ventilator circuit D.Patient not initiating any breaths

arterial pressure complications

Thrombosis- if continuous flush solution is not maintained Clot if flush not used appropriately Embolism- small clot formation around tip of the catheter or from air entering. Air entering system/clot dislodgment Hemorrhage- sudden Loose connections/catheter dislodgment -MAINTAIN ALARMS! individualized to pt's parameters Infection- not routine replacement unless infection is suspected

Nitroprusside (Nipride)

Vasodilation, reduce CO S/E- HA, tinnitus, dizzy, diaphoreisis, apprehension, low bp, tachycardia, palpitations, hy[pxemia, N/V, abd pain IMP- Monitor toxicity LOC, seizures. check serum thiocyanate if more 72 hrs

pressure ventilation

Ventilator set to allow airflow until preset inspiratory pressure is reached VT is variable, depends on lung compliance and resistance ADVANTAGE PIP can be better controlled DISADVANTAGE Risk of hypoventilation and respiratory acidosis *Includes CPAP- expiratory support pressure support (PSV)- expiratory support pressure A/C-set RR, breath augmented CMV, no set BT 15-25 cm inverse-ratio ventilation- longer inspiration airway pressure release (APRV)-

volume ventilation

Vt for every breath ADVANTAGE- set VT regardless of compliance or resistance MONITOR FOR ELEVATED PIP!!! Types 1ØVolume assist/control (V-A/C) 2ØSynchronized intermittent mandatory ventilation (SIMV)

long-term ventilation is anticipated (SCI, burns)

When is a tracheostomy done early in the course of airway management?

C

Which is an advantage of nasotracheal intubation? A.Easier to remove secretions from tube B.Less likely to kink C.More comfortable for the patient D.Reduces risk of sinusitis

C

Which patient would probably not be a candidate for NPPV? A.COPD with acute pneumonia B.Heart failure exacerbation in need of diuretics C.Drug overdose with shallow respirations D.Asthma exacerbation in need of bronchodilators and steroids

RAP/CVP waveform

a- atrial contraction follows P wave c- closure of tricuspid valve follows R wave v- right atrial filling and right ventricular systole follows T wave -Identify at end of expiration. -locate c wave, average the a z point- locating end of the QRS complex and using as reference point

cardiac index

better assessment; based on body size = CO ÷ body surface area Normal 2.5-4.2L/min/m2 Calculated on the computer after entering patient's height and weight

7.35-7.45

pH low- acidosis high- alkalosis

pulse contour CO

provides CCO, stroke volume (SV), SVV, and SVR data -through an existing arterial line. -provide more accurate measurements for clients on mechanical ventilation due to the respiratory variations CONTRA- inaccurate in PVD, and aortic insufficiency, intraaortic balloon -Assess SV after fluid given if no response report •noninvasive alternative to invasive methods such as the PA catheter. These systems have been reported to be better predictors of fluid responsiveness in mechanically ventilated patients.

endotracheal intubation (ETT)

through the mouth or nose, distal cuff balloon inflated for sealing trachea. ØOrotracheal route preferred to reduce infections Used to: ØMaintain an airway ØRemove secretions, continous suctioning, decrease VAP, suction not exceeding -20 ØPrevent aspiration ØProvide mechanical ventilation NARES- vasconstrictor, semi fowler, high or supine, 28 cm-26 cm ORO Right size tube- remove dentures, position, suction, airway, IV, education Ø7.5 to 8.0 mm female; 8.0 to 9.0 mm male Check balloon on tube for leak Stylet- metal Lubricate tube- water soluble Laryngoscope and blade Sniffing position- visualize epiglottis, towel under head 4'' Premedicate prn Topical anesthetic/ paralytic medication Ventilate patient Suction oropharynx Intubate within 30 sec Inflate balloon Verify placement Auscultate epigastric area Auscultate bilateral breath sounds, and expansion ETCO2 detector- CO2 Esophageal detector device Chest x-ray—3 to 4 cm above carina Secure tube when placement is verified Record cm at the lip line for reference SECURE- harness device or tape

oxygen administration

treat or prevent hypoxemia -the amount administered described as FiO2 (fraction of inspired oxygen) Low <35% (NC, simple, partia re, nonre) Mod 35-60% High >60 (air, venturi, high NC) Humidification ØFlow rates > 4 L/min ØMechanical ventilation- prevent mucous membrane from drying -monitor secretions, hydration -do not empty concentration in airway Fraction of delivered oxygen (FiO2) ØRoom air 21% or 0.21 FiO2 Nasal cannula = 0.24-0.44 FiO2, 6L 24-44% High-flow cannula = 0.60-0.90 FiO2 15-40 L Simple face mask = 0.30-0.60 FiO2, 5-12L Face masks w/ reservoirs ØPartial rebreather = 0.35-0.60 FiO2 ØNonrebreather = 0.60-0.80 FiO2 -assess for skin breakdown and hygiene

ventilator care bundle

ØHead of bed 30 degrees ØAwaken daily and assess readiness to wean ØStress ulcer prophylaxis ØDVT prophylaxis Oral care (chlorhexidine in some bundles)

Noninvasive hemodynamic monitoring

Øblood pressure (NIBP) appropriate cuff size cuff too small= bp falsely elevated -arm at the level of the heart -not for severe hypotensive/HTN pts.or obese ØAssessment of jugular venous pressure- provides an estimate of intravascular volume -CVP elevated= JVD= overload -mid right atrium, srternal angle ØAssessment of serum lactate levels- end-organ perfusion -normal arterial(3-7 mg/dl) venous (5-20) -determine hypoperfusion in shock , establish resucitation -GOAL reduce 20% q 2 hrs -in conjuction with MAP, HR, UO, Hgb, SaO2, ScvO3

cardiac output

—volume of blood ejected from heart/min -assess heart ability to pump O2 to tissues(and CI) *assess continuous or via PAC = HR × Stroke volume (volume of blood ejected with each beat, preload, afterload and contractibility) 4 to 8 L/min -Slow/fast HR= low CO Ejection fraction—fraction of blood ejected with each beat Normal 60% to 70%

synchronized mandatory ventilation (SIMV)

•Delivers preset VT at preset frequency in synchrony with patient's SPONTANEOUS BREATHING •Between ventilator-delivered breaths, patient is able to breathe spontaneously VT VARIABLE •Patient receives preset FIO2 but self-regulates rate and volume of spontaneous breaths, participate WOB •Potential benefits •Improved patient-ventilator synchrony •Lower mean airway pressure •Prevention of muscle atrophy -can be used to wean, long MONITOR RR, and pt WOB if RR increases assess VT is 5 ml/kg -if rising fatigue atelectasis -assess PIP, comfort, VS, ABG

contractility

•Force of ventricular contraction •How well the heart is pumping •strength of myocardial fiber shortening during systole, the force of ventricular contraction that propels blood forward. •Optimizing preload influences by ensuring maximal stretch of myocardial fibers.

arterial pressure assessment

•Neuro Vascular Assessment 5 p •Assess every hour. •Includes: Pulse, Pallor, Capillary refill < 3 seconds, no Bleeding, no Hematoma. tEMPERATURE. Testing of sensation and movement. -Keep wrist in neutral position -when removed apply pressure 5 min -never administer medications HARMFUL COMP -document insertion date -change occlusive dressing- assess infection, dates -flush after use, clear blood, maintain 300 pressure, ensure the amount -ensure tightened connections in the tubing -free of kinks -minimize extensions -limit disconnecting or opening -ensure alarms on

systemic vascular resistance

•Peripheral vascular resistance •Diameter of blood vessels •Arterial BP = CO × SVR -norepinephrine increases HR and contractility causes vasoconstriction -Epinephrine- vasodilates (Decrease HR) -ANP & BNP- cause vasodilation and diuresis and inhibit sympathetic response or RAAS (decrease V) -RAAS- kidney in response to low bp vasoconstrictor (increase bp)retention of fluid

afterload

•Pressure or resistance against flow •Related to lumen size and viscosity •Systemic vascular resistance •Force overcome by the left ventricle upon contraction •Pulmonary vascular resistance •Force overcome by the right ventricle upon contraction •Example = opening door against wind

esophageal doppler

•Thin silicone probe placed in the distal esophagus •Evaluates descending aortic blood flow -LEFT VENTRICULAR performance -same as NG, some sedated, lubricated probe depth 35-40 cm until sound in monitor PV contractility70-120 -varies by age lower with more age -if low= ventricular dysfunction no fluids need. FTv-NORMAL- 330-360 ms <330 underfilled hypovolemia FT -minimally invasive, risk to the patient is significantly lower than those with invasive monitoring. CONTRA- esophaegeal stent, carcinoma, stricture, varices, pouch, surgery -aortic balloon pump, coartaction, coagulopathy

Arterial waveform

•Upstroke representing systolic pressure •#2 - Dicrotic notch representing aortic valve closure •#3 - End-diastolic pressure

preload

•Ventircular stretch before systole •Volume of blood in ventricle prior to contraction (LVEDV/LVEDP) •Frank-Starling law •Increased stretch = increased volume Stretch is within physiological limits •Example = balloon

dysphagia and aspiration ventilatory

•common after extubation -48 hrs or more intubated= risk disorded swallowing, aspiration, o2 desat, pneumonia •Assess swallowing prior to initiating oral feedings 3 oz water swallow test -consult speech therapist

cardiovascular system

•monitoring is to accurately assess the patient and provide therapies to optimize oxygen delivery and tissue perfusion. Heart rate Blood flow Oxygen delivery Tissue perfusion Pressure = flow × resistance Pressure—force exerted on the liquid mm Hg Flow: amount of fluid moved over time L/min or mL/min Resistance: opposition to flow (ease) compliance=low •A vessel with a small diameter has greater resistance than one with a larger diameter. (straw) Viscocity- friction

Pulmonary artery pressure (PAC) monitoring

•to measure pressures in the pulmonary artery and LEFT side of the heart. DIRECT MEASURE CO Introduced in 1970 -Swan-Ganz is a brand Reflects left ventricular function -long flexible multi-lumen, balloon-tipped catheter in PA: *Proximal port- right atrim and measures, administer fluid, meds and ontain CO *Distal Port- measures PA&PAOP, draw samples, Co thermal *Balloon- ability to inflate and deflate 1.5 mL at distal top measure PAOP left heart -developed continous measurement of SvO2 INSERTION- consent, education on positioning, and procedure, anxiety relief -similar process to CVC, Proper position of patient Trendelenburg common Towel roll between shoulder blades Inserted with balloon deflated, selected inflation to "float" catheter into PA Waveform changes as catheter progresses Check for proper "wedging" for PAOP (infate only for PAOP measurement) Chest x-ray, document depth of catheter, insertion site . COMP- infection, hemothorax, pneumothorax, perforation vein cardiac chamber, dysrrhythmias CONTROVERSY- increased mortality, limited to assess RAP nad PAOP for preload.

continuous cardiac output (CO)

•via specialized PAC •Copper filament at distal catheter end •Pulses of energy at intervals warm blood rv •Accurate with head of bed up to 45 degrees -measures over the last 60 sec ADVANTAGE- no extra fluidno need for constant computation. DRAWBACKS- inaccurate for >40 C temp, it does not reflect acute changes, delay may be common.