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rnst resp

respiratory block 4

ICU patients Sedated In a severe amount of pain Changed LOC Respiration and Cardiac status can be compromised
Although we have technology Assess the patient-identify what's happening with them and implement if needed
Be prepared-What can potentially go wrong Assess-know patient's history and what can I anticipate, be on the lookout for Expect more serious things can happen with these patients
alarm First assess the patient Look before you intervene-adding oxygen or repositioning Look at history, why they're there and how they look What do I need to do right now to take care of this patient
difficulty breathing interventions Oxygen therapy Reposition - move up in bed if slumped Cough/deep breath suction Medications- look at standing orders or current orders
Social history Smoking-how long? Smokers tend to do much worse d/t damage to lungs and mucosa, don't have as good responses, especially older smokers Young smokers in traumas harder to manage Smoker is more difficult to get off breathing machines
Cardiopulmonary history Do they have an underlying heart failure Respiratory system problems cause an ↑ in heart rate. If the heart can't pump as well as it should it exacerbates the HF symptoms, it compromises the ability to perfuse the body
Elimination history Listen for crackles, assess urine output
Sleep/Rest history Some people have issues breathing while lying down Be aware of things like orthopnea , obstructive apnea
Dyspnea assessment At rest or upon exertion? Postop pts can have dyspnea upon exertion-are they tolerating it? Sats still ok?
Chest pain assessment Commonly ask-could have obstacles to communication ie lines, tubes
Cough / Sputum assessment listen to cough, productive?, thick?, wheezy sounding? how does sputum look
Voice changes assessment More hoarse, dry sounding with distress
Fatigue assessment Overwhelming tiredness even when person is resting Could be another issue
Disease processes (past and current) Flu season? Immunizations current? History of any lung disease; use oxygen at home; dependent upon oxygen when not in ICU; acute disease effects the chronic problem
cardinal s/sx of respiratory distress Hypoxia Restlessness Diaphoresis Tachycardia Cool skin
Cool skin d/t hypoxia? They are vasoconstricting - sympathetic nervous system is kicking in causing that systemic reaction
S/SX if cardiac involvement of respiratory distress Dyspnea, wheezing, cough, sputum, palpitations, swollen feet Fatigue Chest pain Anxiety-anxiety is big Dizziness Bradycardia
Medications mask Don't rely on monitor-s/sx can be masked ie., tachycardia masked by beta blockers
Factors that cause hypoxia Blocked airway Secretions Underlying condition asthma, COPD, PE Allergies, allergic reaction Meds-watch SE Sedatives can impede breathing Age Elderly ↓elastic recoil, ↓ ability of the chest cage to move in and out Positioning
Blocked airway Secretions
Age Elderly ↓elastic recoil, ↓ ability of the chest cage to move in and out
Respiratory Assessment auscultation In the critical care area head-to-toe every 1-2 hours Full respiratory assessment Listen to back when repositioning patient Pleural effusion will start somewhere, starts small and gets larger
Observing the chest Shape of the chest Equal in expansion Observe abdomen when they breath-assess for belly breathing Chest is going one way, belly the other using abdominal muscles d/t weak diaphragm-ominous sign What's normal for the patient?
Observable s/sx of RD Pursed lip breathing Pallor, clammy, cool skin ↓ cap refill Clubbing-long-term sign Barrel chest Respiratory rate (12-20) However, all pts are different Open mouth breathing Gasping for air
Inspiration length Inspiration is usually shorter than expiration on most pts
COPD has a longer A pt with COPD has a longer expiratory time, trying to keep the alveoli open COPD can also have cardiac involvement-observe for JVD and distant heart tones COPD and emphysema will cause expiration to be longer 1:2 Normally 1:3- 1:4 on COPD patients
Common abnormal breathing patterns Most are due to CNS changes Cheynes stokes, BIOTs, Kussmals, Apneustic
Cheynes stokes deep then shallow then apneic followed by a pause; many times caused by CNS issues
BIOTs brain stem CNS disorders; severe anesthetic depression
Kussmals deep and rapid --- Acidosis
Apneustic shallow breathing – often caused by someone who has been anoxic for too long
Before assessment Will I see this, What does it mean? How will I respond?
Chest wall excursion symmetrical, Rib fracture, pneumothorcias
Tracheal deviation Pushing to one side or the other, pneumothorax, pleural effusions
Chest wall tenderness Inflammation, Pleuritis, rib fractures, infection
Crepitus Subcutaneous emphysema Air trapped underneath the skin, dissipates with time, central venous catheter, new tracheostomy
Tactile Fremitus Vibration during speaking – indicates consolidation
Normal breath sounds include: bronchial bronchovesicular Vesicular
bronchial bronchial
bronchovesicular bronchovesicular
Vesicular Vesicular
Adventitious breath sounds include: Crackles, Wheezes, Rhonchi, Pleural friction rub, Stridor, Rales
Crackles Fluid or mucous moving through the smaller airways Crackles can't be cleared with coughing, need loop diuretics, ↓ fluids
Wheezes High-pitched musical sounds. High-pitched sounds produced by narrowed airways heard on expiration, bronchial tube, smooth muscle. Sometimes can be heard without a stethoscope.
Rhonchi Soring sounds, more course and larger airway than crackles. Occurs when air is blocked or becomes rough through the large airways - mucous. Can be cleared with coughing and suctioning
Pleural friction rub Course, grating leather on leather rubbing sound Pneumonia, TB, pleural effusions
Stridor Narrowing of the large airways Anaphylactic reaction or extubated pt
Rales Small clicking, bubbling, or rattling sounds in the lung. They occur when air opens closed air spaces. Rales can be oist, dry, fine, or course. Rub your hai, lower airway, CHF, fluid
Restlessness and agitation Look at the pulse ox, what is the pt restlessness and agitated for, it there something else going on? Could it be a pain situation?
Decreased LOC Underlying medication causing LOC? Or hypoxic? We can give oxygen, but it doesn't mean they will perfuse it.
Change in breathing pattern Reposition. Did it help?
Cyanosis or dusky Usually a late sign - can happen quickly sometimes
Accessory muscle use Ominous sign
Dyspnea or orthopnea Turn our pts every 2 hours-chg quickly If they don't recover put in fowlers position, administer ↑ O2 if low sats
Check adventitious sounds often Changes from assessment to the next things are moving around Be prepared for issues that might arise
Onset of S/S distress Early s/sx Restlessness/irritability & confusion Tachypnea/DOE Tachycardia/HTN
Onset of S/S distress Late s/sx Combativeness Dyspnea at rest Cyanosis Dysrhythmias-early or late
Pulse Oximetry Can be affected by cold extremities, low b/p, fingernail polish
SV02 Mixed venous oxygen saturation (mixed venous hemoglobin level), How well does the oxygen saturate with the hemoglobin at the venous level , is the body demanding more oxygen to perfuse the tissues than what we're giving them?
SVO2 pts monitored for sepsis or shock, Manytimes used with pts w/ resp and cardiac problems – central line ill
Pulmonary angiograms Femoral artery to pulmonary vasculature Most accurate to diagnose and locate PE's, CAT scan 2nd
ETCO2 monitoring (end tidal), At the end of respiration we assess CO2 levels because: Gas exchange takes place at the end of expiration down in the alveoli
V/Q scans Ventilation perfusion scan, how well are they ventilating and then are they perfusing that oxygen and exchanging gas, (we can see what is inhaled as compared to what is perfusing)
Balance in Ventilation We want a normal balance of our ventilation and perfusion NO MISMATCHES WANTED
Alterations in Ventilation: Blockage Gravity Atelectasis, tumors, pneumonia; position
Alterations in Perfusion: Pressures (airway/PA)
V/Q ratio Relationship between_the alveoli to _the flow of blood of the lungs__ -ventilation to flow of blood
V/Q is greatest in __base of the lungs because that where the majority of our gas exchange takes place
Surface area of alveoli Emphysema and COPD reduces the surface area of the alveoli , Surface area of alveoli, pneumonia, can alter diffusion of gases and V/Q
Possible VQ States Normal-ventilation matches perfusion, Low ventilation/ perfusion exceeds, High ventilation/ low perfusion
Tidal volume Amount of inhaled and exhaled air in mL, normally 6 - 10 mL/kg
Vital capacity how much can a person expel from lungs after inspiring – important when weaning off vent
Inspiratory capacity how much can a person take in Measured with incentive spirometer
Endotracheal intubation 7-8 ml tube; chin up; sedation; maybe paralyze to avoid muscle tightness while intubating; ET tube less than two weeks if possible
ET placement about 4 cm above the carina, usually 4 centimeters out of the mouth, Note and chart ET tube depth measurement at lips
ET tube is in the appropriate position Bilateral breath sounds O2 sats come up nicely End-tidal CO2 within normal limits Then, look at chest x-ray for final confirmation
Improper ET Placement Breath sounds not equal; unequal chest movement; ventilator settings may indicate, Common to get placed in the right stem bronchus
If a patient extubates themselves Assess pt-need more O2? Bag, non-rebreather? Call for physican Within 1st 4 hours they are at risk for pneumothorax due to baro trauma; may become tachycardic; dyspnic
MECHANICAL Ventilation Indications: Inability to breath or apneic Severe impaired ABG imbalance-not primary reason Severe failure, hypoxia despite O2 therapy Muscle fatigue 7.25 pH and CO2 above 50 mechanical ventilation is likely required
Decreases Left ventricle requirements Left ventricle requirements are decreased d/t ↓ O2 requirements
Reduce ICP Hyperventilation reduces ICP, ICP cause brain swelling; keep CO2 levels low through Mechanical Ventilation
Secure airway Too much sedation causes respiratory depression
Ventilators We deliver volume and pressure into the lungs, We can control the patient or support the patient, Control or support modes COPD have difficulty getting off vent due to vent dependent resp failure
Assist Control (assist control), full support, Delivers preset breaths & tidal volume
SIMV (Synchronized intermittent mandatory ventilation), Partial control, Will always deliver the breath (rate) but will allow the patient to pull their own tidal volumes
CPAP CPAP (PEEP), Giving continuous positive airway pressure No support-used when weaning pt
PS Preset amount of inspiratory positive pressure Applied throughout inspiration
FiO2 Fraction of Inspired Oxygen (FiO2) Oxygen delivery on a ventilator, Fraction of Inspired oxygen required to keep sats up RA 21% O2, usually 30-100 Need to observe vent and monitor-need to look at both Is the patient breathing over the vent?
PEEP used to keep alveoli open; it can cause trauma to alveoli; can cause them to react differently; can make them stiff Normal PEEP is 5 cmH2O, PEEP of higher than 5 means their oxygen requirements are not being met
PIP highest level of pressure applied to the lungs during inhalation. We don't want to see the resistance pressure go up and up. Are they biting down on the tube?
Created by: rnst