Unit C
ARDS: meds
*-prophylactic for DVT and stress ulcers (pantoprazole)* -IV sedation PRN: propofol, lorazepam -pain: fentanyl -steroids (inflammation) -ABX (sepsis) -NM blocking agent: vecuronium
ARF: labs
-ABG's 1) PaO2 <50 on RA (hypoxemic) OR 2) PaCO2 >50 and pH <7.35 (hypercapnic) AND 3) POX <90%
ARDS: diagnostics
-CXR: bilateral, patchy infiltrates, worsen quickly -chest CT: bilateral, patchy infiltrates with consolidation especially posterior *P/F ratio: used to assess pulmonary status -ratio of pt's PaO2 (from ABG's) and FiO2 (amount of O2 inspired) ex: 1) PaO2 is 75mm Hg, FiO2 is 45% 2) 75/0.45 3) PF ratio = 167*
prior to mechanical ventilation, may try:
-NC -HFNC -bipap
Assist Control (AC)
-Tidal volume and minimal ventilatory rate are pre-set. -Allows patient to initiate breaths. -Ventilator delivers same tidal volume with a machine-initiated breath and a patient-initiated breath -patient can increase number of breaths above the pre-set rate -used as resting mode -minimal patient effort -guarantees minimal tidal volume at preset rate as a minimum -not used for weaning
Synchronized Intermittent Mandatory Ventilation (SIMV)
-Ventilator delivers a pre-set tidal volume at a pre-set rate -Allows the patient to breathe spontaneously at patient's own tidal volume between ventilator breaths -Ventilator senses the patient's spontaneous breaths and synchronizes the pre-set breaths with patient's breath -low RR set, so patient can breathe between -Frequently used for weaning
ARF: NM
-check ABG's, POX, VS -resp. assessment at least q1h -assist with intubation -maintain mech. vent. -monitor for pneumothorax (increased PEEP l/t lung collapse) -cont. ECG can indicate increased hypoxemia especially when repositioning or suctioning -position changes: if pneumonia on L side, turn to R side to increase POX still need to turn to L side, will decrease POX -mouth care q2h -skin care -ROM -daily weights, I/O -check LOC -need form of communication if mech. vent.
trach NM:
-check cuff pressure q8h (<25 mm Hg) -secure trach tapes, do not change until OK from surgeon -know size always keep spare trach and obturator at bedside -should be able to fit 2 fingers under tie -sterile gauze between tube and skin to decrease infection -IF PLUGGING TRACH ALWAYS DEFLATE AIRWAY CUFF FIRST -If cuff inflated, patient cannot talk: deflate to allow to speak
Nasal airway NM:
-check necrosis, sinusitis
ETT NM:
-check placement: CO2 detector, auscultate bilateral BS's, CXR -inflate cuff to seal (<20-25 mm Hg) -communication board, cannot talk if cuff inflated -shift tube from side to side of mouth q24h -cm marks on ETT - measure at lip: check q24h -know size of ETT -must keep ambu bag and suction at bedside -may need oral airway to stop biting -may need sedation if mech. vent.
ARF: advanced s/s
-confusion -lethargy -tachycardia -tachypnea -cyanosis -diaphoresis -respiratory arrest -pallor
ETT
-cuffed to provide seal for mech. vent. and stop aspiration -risk of infection/VAP -pt cannot speak
mechanisms leading to ARF: increased physiologic dead space
-impaired perfusion d/t: PE
mechanisms leading to ARF: shunting
-impaired ventilation l/t deoxygenated blood gas to left side of heart d/t: septal defects, pneumonia, ARDS, pulmonary edema
ARDS: medical management
-intubation -mechanical ventilation -supplemental O2 -patient needs arterial catheter b/c of frequent ABG's -pulmonary compliance testing -PEEP: increases FRC, PaO2, reverses alveolar collapse, decreases V/Q mismatch
Peak airway inspiratory pressure
-measurement at the end of inspiration -don't want high number bc can l/t barotrauma ex: pneumothorax -keep lowest tidal volume possible
mechanisms leading to ARF: alveolar hypoventilation
-no delivery of O2 to alveoli -no removal of CO2 from alveoli d/t: obesity, chest wall deformity, COPD, CNS depression
positive end-expiratory pressure (PEEP)
-positive pressure exerted during expiratory phase of ventilation -improves oxygenation by enhancing gas exchange -prevents atelectasis -opens up alveoli -causes increase in intrathoracic pressure which leads to decrease in CO and BP. Pt will have fluid retention and decreased UOP -an increase in PEEP can l/t pneumothorax -no valsalva maneuver bc further increases intrathoracic pressure
continuous positive airway pressure (CPAP)
-positive pressure throughout respiratory cycle -helps get air in and out -increased FRC and increased O2 -frequently use bipap -can use thru vent.
Suctioning
-pressure <150 mm Hg -hyperoxygenate patient -suction off, insert catheter, pull back 1-2 cm -rotate catheter, intermittent suction, withdraw, wait at least a minute between suction passes -NEVER SUCTION MORE THAN 15 SECONDS -NEVER PUT ANYTHING DOWN ETT, NO SALINE BEFORE SUCTIONING
mechanisms leading to ARF: diffusion abnormalities
-problem with GE across alveolar-capillary membrane d/t: increased resistance, increased thickness of membrane or pathology, ARDS (silent unit)
Controlled Mandatory Ventilation (CMV)
-rarely used -ventilator delivers predetermined volume of air at fixed rate -patient does not take own breaths -no patient effort -not used for weaning
Oral airway (bite block) NM:
-remove 3x/day and clean with half strength H2O2 -NO TAPING
ARF: early s/s
-restlessness -fatigue -headache -dyspnea -air hunger -mild tachycardia -mild tachypnea -HTN
Acute Respiratory Distress Syndrome (ARDS): patho
-severe acute lung injury (ALI) -sudden and progressive pulmonary edema -increased bilateral infiltrates on CXR -hypoxemia refractory to supplemental O2 -decreased lung compliance (stiff lungs) l/t decreased FRC l/t severe hypoxemia -no L sided HF
Mechanical ventilation NM:
-stress ulcer prophylaxis: PPI like pantoprazole -may need wrist restraints: remove q2h, new order q24h -I/O, daily weight -never disconnect vent. -check ETT cuff pressure: aspiration can l/t pneumonia -suction on ETT = closed system -oral care q2h -HOB >30 degrees -CXR confirms ETT placement -switch ETT side q24h -monitor tube placement: marking at lips -know tube size -bite block PRN -always communicate with pt -check CVP
Pressure Support Ventilation (PSV)
-ventilator delivers a pre-set amount of positive pressure as the patient inhales and maintains it throughout the inspiratory phase -gives little "boost" at beginning of patient's own breaths during SIMV -only gives pressure assist if patient initiates breath -allows patient to overcome resistance of artificial airway and ventilator demand valve -helps get air in -patient decides tidal volume -more comfortable if patient can breathe in -used for weaning
3 types of trachs:
1) cuffed trach tube: required for vent. pt cannot talk AMBU BAG WILL NOT WORK, AIR WILL GO OUT NOSE. NEED SAME SIZE TUBE WITH CUFF AT BEDSIDE 2) fenestrated tube: allows some airflow patient can talk 3) uncuffed trach tube: cannot use mech. vent. patient can talk
ARDS: RF's
1) direct lung injury: -pneumonia -aspiration -smoke inhalation -near drowning 2)indirect lung injury: -sepsis -burns -blood transfusion -drug overdose
Acute Respiratory Failure ARF ABG's
1) hypoxemic (decreased Pa O2 <50 on RA) OR 2) hypercapnic (increased CO2 >50 with pH < 7.35) AND 3) SaO2 <90% (POX)
POX of 90 = PaO2 of ____
60
A R D S
A: atelectasis, alveolar collapse R: refractory hypoxemia, increased O2 with no increase in patient O2 D: decreased lung compliance (stiff lungs) S: surfactant cell damage
ARDS: labs
ABG's
The nurse is mentoring a new graduate nurse. Today, the two of you are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. What would the nurse respond? Select all that apply. Absence of secretions Aspiration Infection Injury to the laryngeal nerve Penetration of the anterior tracheal wall
Aspiration Infection Injury to the laryngeal nerve
The nurse is caring for a client who has just been intubated and started on mechanical ventilation in the intensive care unit. The nurse recognizes that it is possible to inadvertently intubate the right lung only. What nursing assessment and monitoring is required to determine if this complication has occurred? Select all that apply. Auscultate both sides of the chest Mark the endotracheal tube at the corner of the mouth and nose Monitor for both high and low pressure alarms Apply suctioning to clear the airway Re-set the ventilator rate as needed
Auscultate both sides of the chest Mark the endotracheal tube at the corner of the mouth and nose Monitor for both high and low pressure alarms
ARF: diagnostics
CXR: may have pulmonary edema
A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea? Observe for mist in the endotracheal tube. Listen for breath sounds over the epigastrium. Call for a chest x-ray. Attach a pulse oximeter probe and obtain values.
Call for a chest x-ray.
The intensive care unit nurse is caring for a client who has severe brain injury with no neurological drive to breathe. This client would receive which type of mechanical ventilation? Assist control (AC) Controlled mandatory ventilation (CMV) Synchronized intermittent mandatory ventilation High-frequency ventilation (HFV)
Controlled mandatory ventilation (CMV)
An older adult patient has experienced a severe exacerbation of chronic obstructive pulmonary disease and requires mechanical ventilation. Which of the following settings will be specified by the primary care provider? Select all that apply. Fraction of inspired oxygen Respiratory rate Tidal volume Positive end expiratory pressure CO2 saturation level
Fraction of inspired oxygen Respiratory rate Tidal volume Positive end expiratory pressure
A patient is recovering from a motor vehicle accident, which has necessitated mechanical ventilation in the intensive care unit (ICU). The ICU nurse is aware that multiple nursing diagnoses are associated with mechanical ventilation. Which of the following nursing diagnoses is a consequence of mechanical ventilation? Moral Distress Impaired Verbal Communication Acute Confusion Risk for Imbalanced Body Temperature
Impaired Verbal Communication
A client had a tracheostomy two hours ago. The nurse assesses the client and finds the client's breathing is shallow, with a respiratory rate of 30. The nurse notes increased mucus production around the tracheostomy and on the dressing. What are the priority nursing concerns? Select all that apply. Ineffective airway clearance Risk for infection Knowledge deficit Impaired gas exchange Disturbed body image
Ineffective airway clearance Impaired gas exchange
A patient receiving plasma develops transfusion-related acute lung injury (TRALI) 4 hours after the transfusion. What type of aggressive therapy does the nurse anticipate the patient will receive to prevent death from the injury? (Select all that apply.) Serial chest x-rays Oxygen Fluid support Intubation and mechanical ventilation Intra-aortic balloon pump
Oxygen Fluid support Intubation and mechanical ventilation
A client suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. A nurse would implement which intervention to improve oxygenation and provide comfort for the client? Position the client in the prone position Force fluids for the next 24 hours Assist the client into a chair Administer small doses of pancuronium
Position the client in the prone position
A critical care nurse is aware of the high incidence and prevalence of ventilator-associated pneumonia (VAP) in high-acuity settings. In order to reduce patients' risks of developing VAP, what intervention should the nurse prioritize? Provide frequent, thorough mouth care. Auscultate the patient's lungs at least every 6 hours. Administer prophylactic intravenous antibiotics as ordered. Maintain the patient in a supine position whenever possible.
Provide frequent, thorough mouth care.
Intubation placement
R main bronchus wider, shorter than left sometimes only right lung is intubated listen to bilateral BS's to check placement
The nurse is preparing to perform the care of a patient's tracheostomy tube. Which of the following actions should the nurse perform during this procedure? Clean the stoma and the skin surrounding the stoma with chlorhexidine. Perform deep suctioning before and after the trach care. Remove the soiled twill tape after new tape has been put in place. Wash the inner cannula with soap and warm tap water if it is not disposable.
Remove the soiled twill tape after new tape has been put in place.
The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation? Copious mucous secretions Sudden restlessness Harsh cough Rhonchi in lung fields
Sudden restlessness
While caring for a patient with an endotracheal tube the nurse recognizes that suctioning is required: Every 2 hours When adventitious breath sounds are auscultated To prevent the patient from coughing To stimulate the cough reflex
When adventitious breath sounds are auscultated
A mechanical ventilation patient has a PCO2 of 60. What change in ventilator setting will help normalize PCO2? a) increase FiO2 b) add 5 cm PEEP c) decrease tidal volume d) increase rate
a) increase FiO2 (will increase POX) b) add 5 cm PEEP (increases oxygenation, opens alveoli) c) decrease tidal volume (will l/t shallow breaths) *d) increase rate (correct. gets rid of more CO2)
The nurse is caring for a ventilated client after coronary artery bypass graft surgery. What are the criterions for extubation for the client? Select all that apply. adequate cough and gag reflexes inability to speak acceptable arterial blood gas values labile vital signs breathing without assistance of the ventilator
adequate cough and gag reflexes acceptable arterial blood gas values breathing without assistance of the ventilator
low exhaled volume alarm
alarms when exhaled volume coming back to ventilator does not reach the setting occurs when vent becomes disconnected or when patient is not getting set volume
High pressure alarm limit
alarms when pressure needed to deliver volume exceeds preset limit. when this pressure is reached, the breath is cut off. prevents barotrauma occurs with increased secretions, mucus plug, patient biting on ETT, decreased lung compliance (stiff lungs)
Passy-Muir Valve (PMV)
allows patient to speak cuff must be deflated before PMV placed
Tidal Volume (TV)
amount of air, in cc's, delivered by each ventilator controlled breath
ARDS: early s/s
barely noticeable confusion and agitation
ETT high cuff pressure
bleeding, ischemia, necrosis barotrauma, pneumothorax
Which is not an appropriate action with ARDS: a) initiate PEEP b) FiO2 1.0 c) pt in prone position d) IVF's at 200 mL/hr
d) IVF's at 200 mL/hr (FVO)
ARDS: cause
d/t inflammatory trigger -injury of alveolar-capillary membrane -leakage of fluid into lung space -decreased surfactant and alveolar collapse and filling -increased pulmonary edema, impaired GE, and refractory hypoxemia -severe V/Q mismatch
Which ventilation-perfusion ratio is exhibited in a client diagnosed with a pulmonary embolus? Low ventilation-perfusion ratio Dead space Silent unit Normal perfusion-to-ventilation ratio
dead space
A critical care nurse is providing care to a client being mechanically ventilated. The low pressure alarm sounds. The nurse would assess for which situation? disconnection from the ventilator biting of the endotracheal tube kinking of the tubing evidence of bronchospasm
disconnection from the ventilator
after extubation
encourage coughing deep breathing use of IS frequent position changes (to mobilize secretions)
Which of the following is true of positive-pressure ventilators? a vacuum pulls air into the lungs alveoli constrict to conserve air in the bronchi expiration occurs passively a preset pressure forces expiration
expiration occurs passively
If O2 problems
increase PEEP and FiO2
if PCO2 is high:
increase RR
s/s pain on PEEP:
increased HR, BP diaphoresis
ETT low cuff pressure
increased aspiration, l/t pneumonia
ARF: causes: dysfunction to chest wall
muscular dystrophy chest wall trauma myasthenia gravis ALS GBS cervical SCI: collar stays until HCP confirms c-spine stable. injury above C4 increases risk of resp. paralysis flail chest
S/S of oxygen toxicity
non-productive cough substernal pain nasal congestion N/V fatigue headache sore throat
fraction of inspired oxygen (FiO2)
oxygen concentration delivered to the patient. How much O2 the patient is set at. Goal is lowest possible. If too high can lead to O2 toxicity
if pt is on O2 for a long time, increases risk of:
oxygen toxicity and decreases lung compliance
What indicates oxygen toxicity?
peak inspiratory pressure will increase
ARF: causes: dysfunction of lung parenchyma
pleural effusion hemothorax pneumothorax airway obstruction no lung expansion pneumonia status asthmaticus atelectasis pulmonary edema COPD exacerbation PE ARDS
avoiding combustion:
post no smoking signs avoid synthetic or wool fabrics no flammable materials like alcohol or acetone
ARF: causes: other
post-op anesthetics analgesics sedatives pain
PEEP does not decrease work of breathing, will need:
pressure support
ARDS: acute phase s/s
rapid onset -severe dysnpea 12-48h after event -arterial hypoxemia with no response to supplemental oxygen -bilateral noncardiogenic pulmonary edema -decreased lung compliance (stiff lungs) -intercostal retractions -crackles -air hunger -tachycardia -change in mental status -fatigue -confusion -cyanosis
early signs of hypoxemia
restlessness and irritability tachypnea, tachycardia, pale skin, HTN, nasal flaring, use of accessory muscles, adventitious lung sounds
ARDS: NM
same as ARF -supp. O2 -nebulizer -mech. vent. -ETT/trach -CPT -suction -O2 MAY IMPROVE IN PRONE POSITION -frequent turns -daily weights/UOP *-pulmonary artery wedge pressure: measures left arterial pressure pulmonary catheter with balloon wedged in pulmonary arterial branch <18 mm Hg = ARDS > 18 mg Hg = cardiac issue*
ARF: causes: decreased respiratory drive
severe brain injury with increased ICP lesions, trauma of brainstem MS sedation meds hypothyroidism
A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether: she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. nutritional protocol will be effective after the client sedation therapy is tapered. to continue IV administration of other scheduled medications. payment status will change if the client isn't sedated.
she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.
Which ventilation-perfusion ratio is exhibited by acute respiratory distress syndrome (ARDS)? Silent unit Dead space Low ventilation-perfusion ratio Normal ratio of perfusion to ventilation
silent unit
The amount of air inspired and expired with each breath is called: dead-space volume. tidal volume. vital capacity. residual volume.
tidal volume
mechanisms leading to ARF: V/Q mismatch
ventilation/perfusion V/Q should match 4:5
