Respiratory - Chapter 21

The sign mechanism on an assist-control ventilator needs to be adjusted to provide ______ sigh(s) per hour at a rate that is _________ times the total tidal volume.

1-3, 1.5

Trach Suctioning Steps

1. assess lung sounds and oxygen sat 2. explain procedure 3. hand hygiene, non sterile gloves, goggles, gown and mask 4. turn on suction source (pressure not to exceed 120mmHg for open system and 160mmHg for closed system) 5.Open suction catheter kit 6. fill basin with sterile water 7. put on sterile gloves 8. ventilate pt with manual bag and high flow oxygen for 30 seconds 9. pick up suction catheter in sterile gloved hand and connect to suction 10. insert suction cath at least as far as the end of the tub without applying suction, just far enough to stimulate cough reflex 11. apply suction while withdrawing and gently rotating cath 360 degrees (no longer than 10-15 seconds) 12. reoxygenate and inflate pt's lungs for several breaths 13. rinse catheter by suctioning a few ml's of sterile water from basin 14. Repeats steps 8-13 as necessary until airway is clear 15. suction oropharyngeal cavity after completing trach suctioning 16. rinse suction tubing and discard catheter, gloves and basin 17. assess lung sounds and oxygen sat 18. document amount, color and consistency of secretions

For a patient to be safely weaned from a ventilator, the vital capacity should be ________mL/kg; the minute ventilation should be ________L/min; and the tidal volume shoudl be ________mL/kg.

10-15, 6, 7-9

The water seal used in a disposable chest drainage system is effective if the water seal chamber is filled to the level of ____ cm H2O

2 cm

A patient has a dry water seal connected to a chest tube. When the water seal rises above _______cm level, intrathoracic pressure increases.

2cm

Oxygen toxicity may occur when oxygen concentration at greater than ______% is administered for ________________(length of time).

50%, more than 48 hours

The oxygen flow rate for a nasal cannula should not exceed ________L/min.

6

A patient is brought to the ED with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for? a) Anemic Hypoxia b) Histotoxic Hypoxia c) Hypoxic Hypoxia d) Stagnany Hypoxia

A - Anemic Hypoxia

The nurse is observing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber? a) Notify the physician b) Place the head of the patient's bed flat c) Milk the chest tube d) Disconnect the system and get another

A - Notify the physician

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia? a) PaO2 b) pH c)PCO3 d) HCO3

A - PaO2

The nurse assesses a patient with a HR of 42 and BP of 70/46. What type of hypoxia does the nurse determine this patient is displaying? a) anemic hypoxia b) circulatory hypoxia c) histotoxic hypoxia d) hypoxic hypoxia

A - anemic hypoxia

A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned? a) Auscultate the lung for adventitious sounds b) have the patient inform the nurse of the need to be suctioned c) assess the CO2 level to determine if the patient requires suctioning d) have the patient cough

A - auscultate the lung for adventitious sounds

The nurse is educating a patient with COPD about the technique for performing pursed lip breathing. What does the nurse inform the patient is the importance of using this technique? a) it prolongs exhalation b) it increases the respiratory rate to improve oxygenation c) it will assist with widening the airway d) it will prevent the alveoli from overexpanding

A - it prolongs exhalation

Oxygen transport to the tissues is dependent on what four factors? Select all that apply a) cardiac output b) atrial oxygen content c) hemoglobin concentration d) metabolic requirements

A, B, C, D oxygen transport to the tissues is dependent on cardiac output, atrial oxygen content, hemoglobin concentration, metabolic requirements

The nurse is educating a patient in the use of a mini nebulizer. What should the nurse encourage the patient to do? Select all that apply. a) Hold breath at the end of inspiration for a few seconds b) cough frequently c) take rapid, deep breaths d) frequently evaluate progress e) prolong the expiratory phas after using the nebulizer

A, B, D

Care of pt being weaned from mechanical vent - chart 21-17 p. 219

Assess for weaning criteria: a. vital capacity 10-15ml/kg b. MIP at least 20cm H20 c. tidal volume: 7-9ml/kg d. minute ventilation 6L/min Monitor activity level, assess dietary intake, monitor lab results Assess pt's understanding of weaning process (pt may feel SOB) if attempt not successful will try again later Implement weaning as prescribed monitor VS, pulse ox, ECG and resp pattern constantly for first 20-30 min maintain patent airway, monitor ABG's Terminate if adverse reactions occur Measure tidal volume and minute ventilation q 20-30 minutes Assess for psychological dependence

Decreased gas exchange at the cellular level resulting from a toxic substance is classified as? a) Hypoxia b) Histotoxic Hypoxia c) Circulatory Hypoxia d) Anemic Hypoxia

B - Histotoxic Hypoxia Histotoxic Hypoxia is defined as a toxic substance that interferes with the ability of tissues to use oxygen. Hypoxia is a decrease in oxygen supply to the tissues Circulatory Hypoxia results from inadequate capillary circulation Anemic Hypoxia is the result of decreased effective hemoglobin concentration Hypoxemia is a decrease in the arterial oxygen tension in the blood Hypoxemic hypoxia is decreased oxygen level in the blood

A patient is to receive oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration? a) Nasal Cannula b) An oropharyngeal catheter c) A partial rebreathing mask d) A venturi mask

C - a partial rebreathing mask

The nurse is transporting a patient with chest tubes to a treatment room. The chest tub becomes dislodged and falls between the bed rail. What is the priority action by the nurse? a) Immediately reconnect the chest tube to the drainage system b) clamp the chest tub close to the connection site c) cut the contaminated tip of the tube and insert a sterile connector and reattach d) call the physician

C - cut the contaminated tip of the tube and insert a sterile connector and reattach

A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time? a) the patient will be extubated and another endotracheal tube will be inserted b) the patient will be extubated and a nasotracheal tube will be inserted c) the patient will have an insertion of a tracheostomy tube d) the patient will begin the weaning process

C - the patient will have an insertion of a tracheostomy tube

A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25mmHg. The nurse is aware of what complications that can be caused by this pressure? Select all that apply. a) tracheal aspiration b) hypoxia c) tracheal ischemia d) tracheal bleeding e) pressure necrosis

C - tracheal ischemia D - tracheal bleeding E - pressure necrosis

A patient with COPD requires oxygen administration. What method of delivery does the nurse know would be best for this patient? a) nasal cannula b) oropharyngeal catheter c) nonbreathing mask d) venturi mask

D - a venturi mask

A patient with emphysema is placed on continuous oxygen at 2L/min at home. Why is it important for the nurse to educate the patient and family to place No Smoking signs on the doors? a) Oxygen is combustible b) Oxygen is explosive c) Oxygen prevents the dispersion of smoke particles d) Oxygen supports combusion

D - oxygen supports combustion

What are the postop risk factors for atelectasis and pneumonia?

Immobilizaton Supine Position Decreased LOC Inadequate Pain Management Intubation / Mechanical Ventilation NG Tube Inadequate Pre-op education

A _____________ is used when a patient requires a low to medium concentration of oxygen for which precise accuracy is not essential

Nasal Cannula

evidence of respiratory failure

PaO2 < 55mmHg PaCO2 > 50mmHg and pH < 7.32 Vital Capacity < 10ml/kg Negative Inspiratory Force < 25cm H20 FEV1 < 10ml/kg

The term used to describe thoracic surgery in which an entire lung is removed is known as a?

Pneumoectomy

Home ventilator Care - chart 21-16 p. 518

Pt or caregiver should be able to state the following at end of education: - proper care of pt on ventilator - observe for physical signs of color, secretions, breathing pattern, consciousness - perform suctioning, postural drainage and ambulation - observe tidal volume and pressure manometer regularly and intervene if abnormal - monitor VS - use predetermined signal to indicate when feeling SOB or in distress - check vent settings twice daily and whenever pt is removed from vent - adjust volume and pressure alarms if needed - fill humidifier as needed and check level 3x daily - empty water in tubing as needed - use clean humidifier when circuitry is changed - keep exterior clean and free of objects - change external circuitry 1x weekly or as indicated - report malfunction or strange noises immediately

What are the sign and symptoms of oxygen toxicity?

Substernal discomfort, parasthesias, dyspnea, restlessness, fatigue, malaise, respiratory difficulty, refractory hypoxemia, alveolar atelectasis, alveolar infiltrates on chest x-ry

Preventing Complications with endotrach's and tracheostomy's

admin adequate warm humidity maintain cuff pressure at appropriate level (less than 25mmHg, but more than 15mmHg) suction as needed maintain skin integrity auscultate lung sounds monitor for infection & cyanosis admin prescribed oxygen maintain adequate hydration use sterile technique when suctioning and performing care

Tracheostomy LONG term complications

airway obstruction from secretions or protrusion of the cuff over the opening of the tube, infection, rupture of the innominate artery, dysphagia, tracheoesophageal fistula, tracheal dilation, tracheal ischemia, necrosis, tracheal stenosis

Postural drainage

allows force of gravity to assist in removal of bronchial secretions by coughing or suctioning - bronchodilators or mucolytic agents given before hang improve drainage of bronchial tree auscultated chest before and after usually performed 2-4x daily before meals and at bedtime start in lower lobes, followed by positions to drain upper lobes make pt comfortable, provided emesis basin, sputum cup and tissue, pt should remain in each position 10-15 minutes, breath in slowly through nose and out through pursed lips

CPAP

application of a positive airway pressure through the entire respiratory cycle for non ventilated pts, keep alveoli open during inspiration and prevents alveolar collapse

Tracheostomy SHORT term complications

bleeding, pneumothorax, air embolism, aspiration, subcutaneous or mediastinal emphysema, recurrent laryngeal nerve damage, posterior tracheal wall penetration

General Breathing Exercises - Chart 21-4 pg. 500

breathe slowly and rhythmically, exhale completely, empty lungs completely inhale through nose (to filter, humidify and warm air) for SOB - breath more slowly by prolonging exhalation time keep air moist with humidifier

Oxygen Toxicity

can occur with >50% oxygen delivery for extended period of time (longer than 48hrs) S/S: substernal discomfort, parastesias, dyspnea, restlesness, fatigue, malaise, resp difficulty, refractory hypoxia, alveolar atelectasis, alveolar infiltrates on chest x-ray Vitamins E, C and beta carotene may help defend against Use of PEEP or CPAP can help to prevent

Hypoxia

change in neuro status fatigue drowsiness apathy inattentiveness

Endotracheal Tube Care

check symmetry of chest expansion auscultate breath sounds in all lobes obtain chest x-ray check cuff pressure q 6-8 hrs monitor for S/S of aspiration ensure HIGH humidity; a visible mist should appear in the t-piece or vent tubing secure tube to face with tape and mark proximal end for position maintenance use sterile suction technique and airway care reposition q 2 hrs provide oral hygiene and suction when necessary

high frequency ventilation

deliver very high respiratory rates w/ low tidal volume and high airway pressures, allows alveolar air to exit the lungs along the margins of the airways, used to open the alveoli in closed small airways (atelectasis, ARDS), protects lung from injurygiven

Pressure-Cycled ventilation

delivers a flow of air until it reaches a preset pressure, volume of air/oxygen can vary as pt's airway resistance or compliance changes, tidal volume delivered may be inconsistent

What are the goal of chest physiotherapy?

dislodge mucous remove secretions improve ventilation increase efficiency of respiratory muscles

Chest Percussion

dislodges mucus adhereing to the bronchioles and bronchi cup hands and lightly strike the chest wall in a rhythmic fasion of the lung to be drained performed for 3-5 minutes over each section pt uses diaphragmatic breathing and administer pain meds before starting Stop if pt experiences: SOB, weakness, lightheadedness, hemopytsis

removal of Endotracheal tube

explain procedure have bag and mask ready in case ventilation assistance is needed after removal suction tracheobronchial tree and oropharynx, remove tape, deflate cuff give 100% O2 for a few breaths and insert a new, steril suction catheter inside tube have pt inhale, at peak inhalation remove tube suctioning the airway through the tube as it is pulled out

NIPPV (noninvasive positive pressure ventilation)

given via facemasks, or oral/nasal devices, eliminates need for endotracheal intubation or tracheostomy. Used in pts with acute or chronic respiratory failure, COPD, acute pulmonary edema, CHF or sleep related breathing disorder. Contraindicated in pts with respiratory arrest, dysrhythmias, head trauma, cognitive impairment

Mini Nebulizer Therapy

handheld apparatus that dispenses a moisturizing agent/medication to the lungs as patient inhales, to be effective a visible mist must be available for patient to inhale pt must breathe through the mouth, taking slow/deep breaths and hold each breath for a few seconds at the end of inspiration to increase intrapleural pressure and reopen collapsed alveoli, encourage pt to cough and monitor effectiveness of therapy

Partial rebreather

has a reservoir bag that must remain inflated during both inspiration and expiration - high concentration of oxygen can be delivered b/c both mask and bag serve as reservoirs for oxygen flow rates 8-11L/min, 02 = 50-75%, moderate O2 concentration

Nonrebreather Mask

have a one-way valve located b/w the reservoir bag and bask of mask that allows gas from reservoir bag to enter mask on inhalation but prevents gas in mask from flowing back into reservoir during exhalation - reservoir bag must be inflated at all times - is a low-flow oxygen delivery system flow rate = 12L/min, O2 = 80-100%, High O2 concentration

care after removal of endotracheal tube

heated humidity and oxygen by facemask maintain pt in high fowlers monitor resp rate and not stridor, color change, mental status change or behavior change monitor O2 level Keep NPO or give only ice chips for few hours provide mouth care educate pt on cough/deep breathing exercises

Hypoxemia usually leads to ___________, a decrease in oxygen supply to the tissues

hypoxia

Risk Factors for Surgery related Atelectasis & Pneumonia (chart 21-19 p.523)

increased age obesity poor nutritional status smoking history abnormal pulmonary function tests preexisting lung disease emergency surgery thoracic incision prolonged anesthesia immobilization supine position decreased LOC inadequate pain management prolonged intubation/mecanical ventilation presence of NG tube inadequate preoperative education

PEEP - Positive End-expiratory pressure

indicated a severe gas exchange disturbance, higher amounts > 15 increase risk of complications such a barotrauma & tension pneumothorax positive pressure is exerted at the end of expiration of ventilation which improves oxygenation by enhancing gas exchange and preventing atelectasis

Pursed-Lip Breathing, chart 21-4, pg. 500

inhale through nose while slowly counting to 3 exhale slowly and evenly through pursed lips while tightening abdominal muscles Count to 7 slowly while prolonging expiration through pursed lips

Incentive Spirometry

inspired air helps inflate lungs, ball or weight rises in response to the intensity of the inhalation, the higher the rise - the deeper the breath. Pt should be in a semi-fowler or sitting position if possible, use diaphragmatic breathing, place mouthpiece firmly in mouth and inhale through mouth and hold breath at the end for about 3 seconds, coughing before and after is encourage (make sure to splint incisions when coughing), perform 10x every hour while awake

Venturi Mask

most reliable and accurate mask, allows constant flow of room air blended with fixed flow of oxygen, primarily used for COPD pts, constant O2 concentration is delivered regardless of pts depth or rate of respiration flow rate = 4-6L/min, O2 = 24,26,28%

Diaphragmatic Breathing - chart 21-4 p.500

place on hand on abdomen and other on middle chest breathe slowly and deeply through nose, letting the abdomen protrude as far as possible breath out through pursed lips while tightening the abdominal muscles press firmly inward and upward on the abdomen while breathing out repeat for 1 minutes, follow with 2 min rest period gradually increase to 5 min duration several times a day

Nasal Cannula

used when pt requires low/medium concentration of oxygen without precise accuracy flow rate should not exceed 4-6L/min to reduce swallowing of air

Volume cycled ventilation

vent delivers a preset volume of air with each inspiration, ensures adequate and consistent breaths - barotrauma is a possibility b/c pressure required may be excessive

A patient will require a ______________ which is the most reliable and accurate method of delivery when a precise concentration of oxygen deliver is require.

venturi mask

Antioxidants such as ____________, _____________, and _____________ may help defend against oxygen free radicals.

vitamin A, vitamin E, beta carotene