Advanced Nursing Concepts Part 2

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Advanced Nursing Concepts Part 2

• Ventilatory Assistance
• Sandra H. Lewis, ARNP-BC-ADM

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Review of Anatomy and Physiology

• Respiratory system is divided into
• The Upper Airwaynasal cavity, the pharynxit
  conducts, warms humidifies and filters.
• The Lower Airway the larynx, trachea, and right
  and left main stem bronchi ( the bifurcation at
  the angle of Louis is at the level of the 5th
  thoracic vertebra and is called the carina)

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Cont..

• The right bronchus is wider, straighter and
  shorter (making it easier to accidentally
  intubate)
• The lungs consist of two lobes on the left and
  three lobes on the right. Each lobe is further
  divided into lobules that are supplied by one
  bronchiole. The lungs are covered by the pleura.
  The visceral pleura covers the lung surfaces and
  the parietal pleura covers the internal surface
  of the thoracic cavity. Between the pleura there
  is a thin fluid layer that allows the sliding
  action as respiration occurs.

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Human Respiration
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Regulation of Breathing

• The rate, depth and rhythm of ventilation are
  controlled by The respiratory centers in the
  medulla and the pons.
• When CO2 is HIGH or the O2 level is LOW,
  chemoreceptors in the respiratory center, the
  carotid arteries, and the aorta send messages to
  the medulla to stimulate respiration.
• Persons with NORMAL lung function are stimulated
  by HIGH levels of CO2

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Continued..

• In persons with COPD, the stimulus to breathe is
  the LOWER level of O2.higher levels of CO2 are
  baseline
• So what do you think is a major nursing
  consideration about O2 therapy for persons with
  COPD?

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WOB (Work of Breathing)

• Compliance The measure of stretchability of the
  lung and chest wall is primarily determined by
  the elastic recoil that must be overcome before
  lung inflation can occur.
• EXAMPLES OF GREATER ELASTIC RECOIL ARDS,
  pulmonary fibrosis, pulmonary edemalungs are
  stiffer and difficult to distend Compliance is
  LOWgreater pressures are required to expand
  lungs.

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WOB cont..

• ARDS, X-RAY

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• In emphysema, destruction of lung tissue and
  enlarged air spaces cause the lungs to lose their
  elasticity.
• The decrease in elastic recoil causes compliance
  to be high.
• Therefore lower pressures are need to expand the
  lungs.

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Cont

• EmphysemaNotice the flattening of diaphragms,
  Increased lung volumes, Diffuse hyperlucency

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Resistance

• The opposition to gas flow in the airways.
• Examples mucous, edema, bronchospasm
• Rememberthe smaller the internal diameter of
  artificial airway increases resistance to air
  flow..

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Spirometer

• Used to measure lung volumes.
• Allows the practitioner to assess baseline
  pulmonary function and to monitor changes.

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Lung volumes

• Volumes and capacities are usually stated for
  healthy men
• Volumes for women are 20-25 less
• Volumes decline with age.
• Tidal Volume Volume of normal breath

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Health History

• Tobacco use, type, amount, years usedpack
  yearspacks cig a day x years smoked
• Occupationalasbestos, coal mining, farming
• Sputum
• SOB, CP, dyspnea, cough, anorexia, weight loss
• Respiratory med hx inhaled, steroids,
  bronchodilators
• OTC Drugs
• Allergies
• Last CXR and TB screening

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Physiological Changes with Age

• Decreased alveolar surface
• Decreased alveolar elasticity
• Decreased chest wall distensibility
• Decreased physiological compensatory mechanisms
  (resp, cardiac, renal, immune)

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Physical Exam
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Respiratory Assessment

• INSPECTION
• landmarks scapula , vertebrae
• Respiratory rate
• Position and use of accessory muscles
• Colour
• Breath sounds

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PERCUSSION

• Posteriorly
• upper and lower lobes
• Start with apical areas, moving L to R and then
  slowly moving down to 10 ICS.
• Resonance - long, low pitch sound, heard over
  most lung fields
• Hyperresonance - low sounds (abnormal) heard when
  emphysema
• Flatness/dullness - pneumonia and atelectasis.

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PALPATION

• breathing excursion
• position palms of hands on patients back between
  8th and 10th ribs. Thumbs are free floating.
  Ask patient to take a breath. Each hand should
  move the same distance (3-5 cms)
• tactile Fremitus
• Using the ball of your hand , place them on the
  posterior wall of the chest, starting in the
  apical lobe area, ask your patient to say 99.
  You should feel vibrations. In pneumonia, there
  is increased intensity of the vibrations and with
  pneumothorax, reduced intensity.

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AUSCULTATION

• Follow same pattern as used when percussing.
• Observe for expected breath sounds in the region
  assessing
• Bronchial
• Bronchovesicular
• vesicular
• Listen for Crackles Wheezes
• Pleural rub

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DOCUMENTATION

• Respiration rate, skin colour, physical position
  and respiration sounds -INSPECTION
• Tactile fremitus, and respiratory excursion -
  PALPATION
• Breath sounds, describe and compare from lung
  apex to base as well as from L?R
• Presence of crackles and/or wheezes state their
  location - AUSCULTATION

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Signs and Symptoms of Hypoxemia

• Integument Pallor, cool, dry, diaphoresis,
  cyanosis
• Respiratory Dyspnea, tachypnea, accessory
  muscle use
• Cardiovascular Tachycardia, dysrhythmias, CP,
  HTN with increased heart rate, hypotension with
  decreased heart rate.
• CNS Anxiety, restlessness, combativeness,
  fatigue, confusion, coma

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Common Acid-Base Abnormalities

• See Box 8-2 page 172
• Resp. Acidosis (CO2 retention) COPD,CNS
  Depression, restrictive lung disease
• Resp. Alkalosis (hyperventilation) Anxiety,
  pain, stimulants, pneumonia CHF, pulmonary edema

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Cont..

• Metabolic Acidosis (increased acids) Renal
  failure, DKA, Lactic acidosis, drug OD Methanol,
  salicilates, ethylene glycol (loss of
  base)..diarrhea
• Metabolic Alkalosis ( gain of base) excess
  antacids, or sodium bicarb. or (loss of acids),
  vomiting, NG suction, Low K or CL, diuretics,
  increased aldosterone level

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ABGs

• Blood Gas Analysis Handout
• Pages172-173.Critical Care Nursing

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Pulse Oximetry

• Measures SpO2, reflects SaO2 (arterial
  saturation)
• A light emitting diode measures pulsatile flow
  and light absorption of the hemoglobin.
• Accurate readings require a warm, well perfused
  area.
• Patient motion and edema at the site adversely
  effect resultsnail polish, sunlight and
  florescent light also interfere

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Oxygen Administration
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IF YOUR PATIENT ISBLUE....TRY SOME O2
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HeadTilt/ChinLiftProcedure

• Tongue, the most common cause of airway
  obstruction
• One hand on patients forehead, fingers of
  opposite hand under bony part of the chin
• Lift the chin forward and support the jaw,
  helping to tilt the head back

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Modified Jaw Thrust

• Used when possibility of C-spine injury exists
• Grasp the angles of the patients lower jaw and
  lift with both hands, displacing the mandible
  forward
• If the lips close, retreat the lower lip with
  thumb

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Oral Airways

• are designed to keep the tongue from falling back
  and blocking the upper airway
• easily available in six to nine sizes
• are only used in unresponsive patients without a
  gag reflex
• do not eliminate the need to monitor airway for
  patency

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Oral Airway Sizing

• To choose the proper size, hold the airway
  against the side of the patients face. It should
  extend from the corner of the patients mouth to
  the angle of the jaw.

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Oral Airway Insertion

• Open mouth with cross finger technique. Insert
  airway with tip pointing up to avoid pushing
  tongue backward.
• Rotate airway tip slowly downward until its curve
  matches the curve of the tongue.
• The flange of the airway should rest against the
  patients lips.

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Nasopharyngeal Airways

• Curved, flexible rubber or plastic tubes inserted
  into the patients nostril
• Use on responsive patients who need an airway
  assist

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Nasopharyngeal Airway Sizing

• Measure length from tip of patients nose to
  earlobe
• Diameter of airway should fit patients nostril
  without excessive tightness

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Oxygen Tanks and Regulators

• Always green-designates O2
• Various tank sizes
• D, E, M
• Yoke vs. Threaded outlet
• Tank pressure-2000 lbs. per sq. in.
• Common regulators
• fixed orifice, bourdon gauge

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Delivery Devices

• Nasal cannula
• Flow rate 2-6 lpm
• Non-Rebreather mask
• Flow rate 10-15 lpm
• Two rescuer Bag Valve Mask (BVM)
• Flow rate 15 lpm

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Set up of Tank/Regulator

• Step 1-open tank to blow out dust
• Step 2-Attach regulator (o-ring)
• Step 3-Open tank, check pressure
• Step 4-Attach proper delivery device
• Step 5-Open flow to proper lpm for
  device
• Step 6-Place delivery device on patient

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Break down of Tank/Regulator

• Step 1-Turn off flow
• Step 2-Remove mask/cannula , turn off tank
• Step 3-Open flow meter to relieve/bleed
  pressure-close when complete
• Step 4-Remove regulator

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Safety Considerations

• Position/placement of tank
• Properly fitting regulator
• Close all valves when not in use
• O2 fuels fire-not a flammable gas
• Do not roll tanks on side or bottom
• Inspect valve seats and o-rings
• Store tanks in cool, well ventilated area
• Have tanks tested on regular basis

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Oral Vs Nasotracheal Intubation

• Box 8-6 on page 181 in Critical Care Nursing
• Look carefully at advantages and disadvantages.

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Equipment for Intubation

• See Figure 8-19 page 182
• Be able to set up for an intubation and discuss
  choosing ET size and rationale for nasal or
  tracheal intubation.

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ET More info

• How quickly should the ET be placed? 30 seconds
• Where should the tip end? 3-4 cm above the carina
• What is the role of rapid sequence intubation?
  Emergency airway management, while decreasing the
  risk of aspiration, combativeness and injury to
  the patient.
• HOW is RSI achieved? Neuromuscular blocking agent
  (Succinylcholine) potent sedative (fentanyl or
  other).
• What is Sellecks maneuver? Pressure on the
  cricoid is applied.
• Why is it used? To decrease risk of vomiting and
  therefore aspiration
• When can blind intubation be done? Only if the
  patient is capable of spontaneous respirations.
• How long can a ET tube generally be left in
  place? 3-4 weeks.
• Where is the incision made for a tracheostomy?
  At the level of the cricoid or between the 1st
  and second tracheal ring.

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Suctioning the Intubated Patient

• See box 8-9 page 188 Critical Care Nursing
• Discuss proper suctioning technique

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Negative Pressure Ventilation

• Used for sleep apnea, neuromuscular problems and
  when Chronic Respiratory Failure patients need
  short periods of ventilation.
• See figure 8-24
• Examples iron lung, tank ventilator

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Noninvasive positive pressure ventilation

• See figure 8-25 page 189 Critical Care Nursing
• Face Mask covers mouth and nose.
• Used in those requiring ventalatory support post
  intubation to resolve hypercapnia and short
  termpulmonary edema, or for patient who refuses
  intubation

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Controlled Ventilation

• Rarely used because of the superiority of
  Assist/Control (causes less anxiety, less
  hemodynamic instability).
• Locks out patients attempts at respiration
• Indicated for high c-spine injuries, patients
  with NO respiratory effort, chemically paralyzed
  patients

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Assist Control

• Helps preserve muscle tone, reduces dyssynchrony
  (fighting the vent)
• Potential complication of A/Cresp alkalosis
  (patients own resp rate too high triggering the
  ventthis can be adjusted by adjusting the
  sensitivity, sedating the patient if needed, or
  using IMV)

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SIMVSynchronized Intermittent Mandatory
Ventilation

• Delivers a preset Vt at a preset rate and allows
  the patients own breaths at his own rate and
  depth between the ventilator breaths.
• Guarantees at set number of breaths
• Helps prevent muscle weakness and
  hyperventilation.
• Can increase muscle fatigue associated with
  patient efforts

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PEEPPositive End Expiratory Pressure

• Higher that atmospheric pressure at the end of
  expiration
• Increases oxygenation by preventing the collapse
  of small airways and maximizing the number of
  alveoli available for gas exchange.
• Often ordered to reduce the FiO2 needed for
  optimal oxygenation

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PEEP cont

• physiologic peep 3-5 cm H2O
• Usual peep range 3-20 cm H2O
• Can decrease cardiac output (secondary to
  decreased venous return.)
• Increases risk of volutrauma
• Increased ICP from decreased venous return to the
  head
• Can cause alterations in renal function secondary
  to reduced renal blood flow.

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CPAPContinuous Positive Airway Pressure

• The concept of peep is used to augment the
  patients residual functional capacity and
  oxygenation during spontaneous breathing
• Administered through nasal of face mask or
  through artificial airway
• Often used in obstructive sleep apnea

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Some Ventilator Terminology

• Tidal Volume- amount of air delivered with each
  preset breath, usually 10-15 ml/kg, however,
  recent research indicates lower Vtless
  volutraumathis could not be used in head injured
  patients because of the resultant
  hypercapniaincreases intercranial pressure
  because of vasodilation from CO2

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Cont.

• Respiratory Rate- Frequency of breaths delivered
• FiO2- The percentage of inspired oxygen 21-100,
  after emergency intubation 50-100...adjustments
  made based on ABGs
• Sigh-A mechanically set breath with greater Vt.
  (volume), used to prevent atelectasis.

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Complications of Mechanical Ventilation

• Volutrauma
• Intubation of Right main stem bronchus
• ET out of place or unplanned extubation
• Tracheal Damage
• Oral or Nasal mucosa damage
• Problems associated with O2 administration
• Resp Acidosis or Alkalosis
• Aspiration
• Infection
• Inability to wean
• Communication

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Care of the Patient with Mechanical Ventilation

• Medications
• Nutritional Support

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Trouble shooting the Vent

• Never Shut off alarms
• Manually ventilate the patient if you cannot
  trouble shoot the problem or suspect mechanical
  failure.
• Volume alarms-lowpatient not receiving preset
  Vt.
• Pressure Alarms-High pressure exceeding preset
  limit, Look at patient factors..coughing , biting
  tube, excess secretions, pulmonary
  edema,bronchospasm, pneumo or hemothorax.also
  kinks in the ventilator tubing

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Cont

• Apnea Alarms- Ventilator does not detect
  spontaneous respiration within the preset
  intervalespecially important when patient has
  low set rate.