Airway Disorders
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| Pulmonary Blood Supply | To lungs for gas exchange
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| Bronchial Blood Supply | From thoracic aorta
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| Conducting Airway | Nasopharynx-Oropharynx-Larynx/Endolarynx-Trachea-Bronchi-Carina-Hili-Pulmonary & Lymphatic Vessels
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| What is Acinus | Cluster of cells, thin walled 16th-23rd divisions, alveolar ducts, the alveolar sacs contain 300 million alveoli
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| Respiratory Functions | Exchange CO2 & O2, maintain acid-base balance
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| Factors Affecting Respirations | *Neurochemical= Medulla @ base of brain-brain stem (pattern) & Pons (rate & debth) *Mechanical= Irritant, stretch & pressure receptors *Hering-Breuer= Keeps us from over stretching
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| Mechanisms Of Breathing-Ventilation | *Inspiration= Air flows into lungs 1-1.5 seconds *Expiration= Longer, gasses flow out of lungs 2-3 seconds *Normal= 12-20 times per minute
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| Examples Of Respiratory Passageway Resistance | Constriction, edema, mucus, tumors, infectious materials, spasms
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| This Happens In Non-Lung Compliance | Use of accessory muscle
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| This Improves Aveolar Surface Tension | Surfactant secretion (sigh)Surfactant lowers surface tension
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| Example Of Diffusion | O2 & CO2 exchange across alveolar capillary membrane, determined by pH, changes from area of high to low concentration, need good perfusion/cardic output
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| Accessory Muscles | *Sternocleidomastoid & Scalenus= Lift up thorax to expand volume * Intercostal and Scalene= Expand A&P (retractions) *Expiration= Abdominal and internal intercostal are compensatory
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| Pulmonary Blood Flow And Gravity | Air rises, blood drops to dependent area, "good lung down" More blood and less O2 lower, less blood and more O2 upper in lobe
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| Cues To Respiratory Illness | SOB, wheezing, pleuritic chest pain, cough, sputum production, hemoptysis , voice change, fatigue
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| Pt. History Assessment | Predominant complaints, family hx, health hx, smoking hx, occupational exposure
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| Patterns Of Breathing | *Kussmauls= Rapid breathing (compensatory) *Tachypnea= Fast >20 (intervine 30-40) *Tachy-Brady= OH SHIT *Brady= <12, start looking for reasons *Biots= Varies in rate, debth & rhythm w/ irregular periods of apnea (sign of brain stem problem)
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| Bronchospasms | Constriction (vagus nerve) Histamine release= >mucus/prostoglandin= more constriction
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| Causes Of Bronchospasms | NSAID, ASA, -olol, ACE, some inhalers
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| Symptoms Of Bronchospasm | SOB, chest tightness, fatigue, "silent chest"
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| Steps In Respiratory Assessment | #1 Inspection #2 Palpation #3 Percussion #4 Auscultation
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| Significance Of Positioning | *Lying=mild distress *Sitting=moderate *Upright=severe *Tripod=increases A&P diameter *Orthopnea="one,two,three pillow"
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| Finger Clubbing | Angle normally 20, occurs when body trying to compensate for hypoxia-develops collateral circulation
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| Significance Of Speech | Sentence= mild/moderate dyspnea *Phrase= moderate *Words= severe "1-2-3 word dyspnea"
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| Palpation | With pads of fingers, crepitus-crackles, nodes-if swollen should move, mediastinal shift- trachea shifts to opposite side of lung injury.
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| Tactile Fremitus | Vibration, ask pt. to say 99, decreased in atelectasis, emphysema, asthma, pleural effusion & pneumothorax, increased in pneumonia, tumor, secretions
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| Sounds Of Percussion | *Flat=solid (sternum) *Dull=no air/fluid (liver) *Tympanic=air (stomach) *Resonant=echo (lung) *Hyperresonant=low pitch, air free
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| How To Auscultation Pt. | Deep breath through mouth, not through gowns, listen laterally with an effusion, R= 3 lobes L= 2 lobes
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| Normal Breath Sound Locations | *Bronchial= loud, high pitched, over large airways, expiratory * Bronchiovesicular= medium pitch, R&L bronchus, i=e *Vesicular= soft/low pitch, i>e *E-I-E-I-I
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| Crackles | Rales, not cleared by coughing, fluid scruntching down on aveoli, ex. pulmonary edema
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| Sonorous Wheezes | Rhonchi-gurgle, heard on expiration, occurs in conducting area, ex. COPD, asthma
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| Stridor | High pitched, harsh, inspiratory ex. laryngeal spasms due to tetany w/ low calcium, croup
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| Friction Rub | Loud, dry, creaking, loss of lubricant, most often heard laterally ex. pleurisy, pleuritis, effusion, poss pneumonia
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| Absent Or Diminished | Ex. atelectasis, pleural effusion, pneumonia, worsening bronchonconstriction
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| Pulse Ox | SaO2= saturation of oxygen on hemoglobin**Does not determine acid-base status
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| Inaccurate Pulse Ox Reading | Hypothermia, hypotension, vasoconstriction, IV dyes, HGB bound with other gas other then O2 eg. coal miner, <70% is + or - 4%
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| Pulse Ox Results | **<90-91% (12 hrs)= Report & corrective nursing action **<80% (4 hrs)= Hurry **<70% (1 hr)= You better run!
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| Normal VQ Scan (Ventilation/Perfusion) | 0.8-0.9, Perfect= 1mL O2 per 1mL of blood, Abnormal VQ= hypoxia, most often done for pulmonary embolism or baseline for someone with ARDS
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| Shunt | Low ventilation, "STUNT"= stump
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| Silent Unit | Poor VQ, compensatory-diverts blood to better ventilated areas, ex. PE, chronic alveolar collapse
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| Dead Space Unit | Poor perfusion=horrible blood flow to pick up O2, nothing wrong w/ lungs, ex. PE, decreased CO
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| PFT's | Based on age, height, wt, sex, monitor the course of pulmonary disease, evaluate meds, determine need for mechanical ventilation
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| Pre-Procedure For PFT | No..tobacco,bronchiodilators,heavy meal,sedatives,narcotics,distended abdomen. Instruct pt how to breathe for test= nose clip,tight seal
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| PFT Results | *FeV1= Low in COPD *VC= vital capacity *RV= Increased w/ COPD, the air left in the lungs after expiration *Tidal Volume= How much air w/ each breath the pt. draws in
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| Post PFT | Maintain airway, prevent injury-may be dizzy
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| Sputum Specimines | Gm stain= Identifies Gm + or - organisms, if + need C&S to identify best ATB therapy (lower the # the better) Acid-fast smear= TB identification. Cytology= looking @ cells and identifying maligancies
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| Pre Bronchoscopy procedure | Informed consent, clarify info, NPO, baseline VS, remove dentures/partials, sedative/conscious sedation, sterile set up
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| Post Bronchoscopy Procedure | NPO until gag reflex returns= cranial nerve #9, VS q hr, discourage coughing, smoking, talking for several hrs, expect hoarse voice, low fever common 1st 24 hrs, designated driver, notify dr. persistent cough, bloody, purulent sputum
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| Bronchoalveolar Lavage (BAL) | Diagnose pneumocystic pneumonia
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| Mediastinoscopy | Incisions for lymph node biopsy
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| Methemo-Globinemia | Benzocaine anesthestic spray- sx usually w/in 1st hr= central cyanosis, O2 ineffection, choclate brown blood, impairs Hgb to carry O2 (functional anemia)Allows CO2 binding, need co-oximeter, Antidote= Methyl Blue
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| Thoracentesis | Lg bore needle through chest wall, position client in supine or sitting postion, affected lung accessible
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| Low Flow O2 systems | NC: 24-45% Simple face mask: 40-60% Humidification needed at >4L
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| High Flow O2 systems | Venturi mask: 24-50% Partial/Non rebreather: Up to 100% New O2 cannulas: Up to 15L Heliox
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| Difference Between O2 Flow And O2 Concentration? | Flow= Force (# of liters) Concentration= Percent
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| Oral Airway | Holds tongue away from pharynx, insert with tip pointed upward then rotate
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| Advantages And Disadvantages To Oral Airway | Advantages=easy to insert, preserves airway. Disadvantages=easy to dislodge,unconscious pts,no use in facial/oral surgery
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| Endotracheak Tubes (ET) | Mechanical ventilation up to 100% O2, can be inserted oral or nasal
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| Oral vs. Nasal ET | Oral= Rapid, easier to insert-chip teeth, need bite block, excess salivation. Nasal= More comfortable, more secure-more resistence
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| Indications for ETT & Mechanical Ventilation | Respiratory failure- pH <7.25 CO2>50% O2<50%
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| Nursing Role For Insertion Of ET | Only nurses with training can perform, RN-sets up equpiment, verify placement, check cuff leaks, monitoring location, care vent. settings, teach conscious pt. about gagging/feelings of suffocation
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| Function Of Cuff On ET Tube | Keep secretions from going into lungs/keep O2 from escaping back upwards
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| Rapid Sequence Intubation (RSI) | *Fast acting narcotic ex. Fentyl *Sedative ex. Versed *Paralytic agent ex. curare derivative. **Do not use in narcotic overdose or code**
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| Procedure for RSI | Gather supplies. test cuff inflation, supine position/head extended "sniffing position" Nasal insertion=greater resp. effort
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| Correct ET location | 3-5cm above carina (bifurcation of mainstem bronchus) most likely to be accidently intubated in right mainstem
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| Verifying Placement Of ET | #1 CO2 indicator #2 Auscultate breath sounds bilaterally #3 Observe symmetric chest movement #4 Feels warm/exhaled air at end of tube #5 Confirm by chest x-ray
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| Quick Check Verification For ET | "Lip Line" Q-24 hrs, women 21cm, men 23cm, move side to side but not up and down, x-ray is absolute look!
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| O2 AND Ventilation | PaCO2=best indicator of hypo/hyper ventilation
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| Complications of ET | Aspiration and unplanned extubation **Assess, stay with pt. put on call light, airway assistance- bag or NC**
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| Maintaining Tube Patency | Suction PRN NOT routinely, hyper-oxygenate pre and post, hydration not NS spritzer, suction >120=mucosal damage
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| Closed Suction Technique | Useful for PEEP >7-8cmH20,secretions,freq. suctioning need,unstable
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| Nursing Dx | Impaired gas exchange & Decreased cardiac output
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| Negative Pressure Vent | Negative pressure on chect, pulls air into lung, Pneumowrap=Poncho fits over body & creates a vacuum which expands thoracic cage.
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| Positive Pressure Ventilator (PPV) | Inflates aveoli, must be intubated or trach, creates decreased cardiac output
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| Pressure Cycled Ventilators | Preset pressure, if increased airway resistance or decreased compliance=tidal volume may not be delivered
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| Volume Cycled Ventilators | Preset volume, tidal volume delivered regardless of resistance or compliance, more frequently used
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| Tidal Volume (TV or VT) | Amt. of air delivered w/ each ventilator breath, 7mL/kg of body weight
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| FiO2 | 21-100% ex. ARDS, Can have O2 toxicity (lost nitrogen) or absorbtion atelectasis (alveolar collapse)
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| Continuous Mandatory Ventilation (CMV) | Vent only delivers TV & breaths per min. that have been set, total control for pt. by decreasing work of breathing, but can cause muscle atrophy=harder to wean
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| Assist/Control Ventilation (ACV) | Senses & controls volume for each present breath, moderate control of pt. NOT for use in COPD
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| Synchronized Intermittent Mandatory Ventilation (SIMV) | Least control=used for weaning, pt. can take own additional breaths @ own TV, vent. rate gradually decreased, will not breathe as pt. breaths on their own
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| Continuous Positive Airway Pressure (CPAP) | + pressure applied via facemaskor ET helps maintain open airways and aveoli >5cm Used mostly for weaning and sleep apnea
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| Positive End Expiratory Pressure (PEEP) | 3-5cm, increases amt. of air remaining in the lungs during expiratory phase, allows for reduction of FiO2
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| Peak Inspiratory Pressure | Amt. of pressure required to deliver TV, Plateau pressure: 30cm H20 or less, if increased=bad, decreased=good
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| Low Pressure Alarm | Little/No pressure generated duringdelivery of machine breaths**Check for disconnection, placement, cuff leak/tear
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| High Pressure Alarm | Pre-set peak inspiratory pressure limit is reached b4 venthas delivered set TV, Fix the problem! Check for obstruction, placement..
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| If In Distress With An Alarming Vent.. | Take care of client first!! Manually vent pt. and have someone else fix vent
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| Pressure Support | 5-10cm, pt. receives increased TV
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| Sighs | Prevents microatelectasis, pulses of air delivered at 100-300x per min. or 1-5mL/kg, high frequency but low pressure
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| Hypoventilation | Acidosis
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| Hyperventilation | Alkalosis, check for arrythmias/calcium imbalances, may be caused by overventilation/overinflation
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| V/Q Mismatch | Uneven blood flow in lungs
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| Decreased CO | + pressure in thorax instead of - pressure, decreased CO=decreased BP, increased HR, vasoconstriction. May require Dopamine to increase BP
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| Volu or Barotrauma | Assess crepitus
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| O2 Toxicity | Exposed to >50% FiO2, exposure time and concentration
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| Pressure Necrosis R/T Tubings | Reposition side to sidein mouth, release cuff pressures via protocol
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| Pneumothorax | May be caused by high vent pressure
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| When to draw ABGs | Anytime a vent setting is changed**Wait 15-30 minutes after vent setting change
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| Nursing Assessments | Breath sounds, VS, chest movement, need for suctioning, hypoxia/hypercapnea, vent settings, pule ox, PEEP (decreased CO) skin, stress ulcers, joint mobility, nutrition, bowels, emotions
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| Nursing Implementations | Humidified/warmed air, HOB 30 degrees, position change, suction, ABGs, keep vent alarms on, correst bucking, decrease anxiety, respect sleep/wake cycles, high calorie need
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| Weaning Phase #1 Pre-Weaning | Assess resp. and non-resp. factors, spontaneous breathing trial
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| Weaning Phase #2 Weaning Process | *Short term pt-linear *Long term pt. peaks & valleys *Psych support for pt. and family
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| Weaning Phase #3 Outcome | Continue O2 therapy, oral care, monitor VS & resp. distress, ABGs within 1 hr
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| Ready To Wean? | Stabilized condition, stable chest wall, resp rate 12-20, PEEP <5cms, good nutrition, improved vital copacity, stong cough, no accessory muscle use, lungs clear, ABG WNL, adequate CO, afebrile
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| Weaning Guidelines | Trust=essential, initiate in the AM not PM, watch for compromise (HR >20bpm from baseline, BP changes, RR changes, ABG deterioration) put back on vent on original settings
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| Spontaneous Breathing Trial | 30 min-2 hrs, increasing time, stop before fatigue
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| T-Piece | Remove pt. from vent, place on t-piece which delivers specified FiO2 back on vent then gradually increase time (10 min or so) off until pt. breaths spontaneously for prolonged period
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| SIMV | Gradually decrease # of breaths that machine delivers until pt. breathing totally on own. Vent is there for support, do not need to return to original vent settings
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| CPAP | Vent in CPAP mode, used commonly and provides monitoring that t-piece doesn't
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