Advanced Respiratory: Oxygenation/Ventilation
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| ICU patients are very ill and that's why there're in the ICU | Sedated...
In a severe amount of pain.
Changed LOC.
Respirator and Cardiac status are compromised
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| Although we have technology | Assess the patient-identify what's happening with them and implement if needed
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| 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
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| With a higher acuity patient | Anything can happen at any minute
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| If an alarm goes off or a number looks abnormal | 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
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| If a patient looks like they are having difficulty breathing | Oxygen therapy
Reposition - move up in bed if slumped
Cough/deep breath
suction
Medications- look at standing orders or current orders
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| 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
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| Cardiopulmonary history | Do they have an underlying heart failure
Taxing causes ↑ HR and exacerbation of HF symptoms, perfusion
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| Elimination history | Listen for crackles, assess urine output,
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| Sleep/Rest history | Some people have issues lying down
Be aware of things like orthopnea , obstructive apnea
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| Dyspnea assessment | At rest or upon exertion?
Postop pts can have dyspnea upon exertion-are they tolerating it? Sats still ok?
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| Chest pain assessment | Commonly ask-could have obstacles to communication ie lines, tubes
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| Cough / Sputum assessment | listen to cough, productive?, thick?, wheezy sounding? how does sputum look
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| Voice changes assessment | More hoarse, dry sounding with distress
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| Fatigue assessment | Overwhelming tiredness even when person is resting
Could be another issue
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| Nursing Assessment Past | Disease processes (past and current)
Flu season? Immunizations current?
Environmental exposures/Behaviors (past and current)
Medical/surgical hospitalizations
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| cardinal s/sx of respiratory distress | Hypoxia
Restlessness
Diaphoresis
Tachycardia
Cool skin
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| S/SX if cardiac involvement of respiratory distress | Dyspnea, wheezing, cough, sputum, palpitations, swollen feet
Don't rely on monitor-s/sx can be masked ie., tachycardia masked by beta blockers
Fatigue
Chest pain
Anxiety-anxiety is big
Dizziness
Bradycardia
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| Key Factors that cause hypoxia or impede pts breathing | 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
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| 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?
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| Signs of respiratory distress What you may see………. | Pursed lip breathing
Pallor, clammy, cool skin
↓ cap refill
Clubbing-long-term sign
Barrel chest
Respiratory rate (12-20)
However, all pts are different
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| A pt with COPD expiratory time? | 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
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| Cheyne-stokes | Respirations gradually increase in depth, then become more shallow, followed by a period of apnea.
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| Biot's | Highly irregular breathing pattern with abrupt pauses between efforts
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| Kussmaul's | Respiration faster and deeper without pauses
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| Apneustic | Respirations prolonged, gasping, followed by extremely short, inefficient expiration
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| Factors that alter a good wave form on a monitor | Nail polish, Cold fingers, lotions
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| Respiratory Assessment | Will I see this, What does it mean? How will I respond?
Chest wall excursion, symetrical
Rib fracture, pneumothorcias
Tracheal deviation
Chest wall tenderness
Crepitus
Tactile Fremitus
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| Normal breath sounds include: | bronchial
bronchovesicular
Vesicular
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| bronchial | bronchial
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| bronchovesicular | bronchovesicular
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| Vesicular | Vesicular
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| Adventitious breath sounds include: | Crackles, Wheezes, Rhonchi, Pleural friction rub, Stridor
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| Crackles | Fluid or mucous moving through the smaller airways
Crackles can't be cleared with coughing, need loop diuretics, ↓ fluids
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| Wheezes | High-pitched musical sounds
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| Rhonchi | More course and larger airway than crackles
Can be cleared with coughing and suctioning
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| Pleural friction rub | Course, grating leather on leather rubbing sound
Pneumonia, TB, pleural effusions
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| Stridor | Narrowing of the large airways
Anaphylactic reaction or extubated pt
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| 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?
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| Decreased LOC | Underlying medication causing LOC? Or hypoxic?
We can give oxygen, but it doesn't mean they will perfuse it.
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| Change in breathing pattern | Reposition. Did it help?
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| Cyanosis or dusky | Usually a late sign - can happen quickly sometimes
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| Accessory muscles | Ominous sign-don't want to see
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| 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
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| Adventitious sounds | Changes from assessment to the next things are moving around
Be prepared for issues that might arise
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| Onset of S/S distress Early s/sx | Restlessness/irritability & confusion
Tachypnea/DOE
Tachycardia/HTN
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| Onset of S/S distress Late s/sx | Combativeness
Dyspnea at rest
Cyanosis
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| Dysrhythmias | early or late
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| SV02 | Mixed venous oxygen saturation
How well does the oxygen saturate with the hemoglobin at the venous level
"ABG at venous level"
Tells us if they need more oxygen if on supplemental O2
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| SV02 tissue perfusion | At what rate is the body using oxygen, is the body demanding more oxygen to perfuse the tissues than what we're giving them?
Manytimes used with pts w/ resp and cardiac problems
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| Don't start ? before Sputum tests | Don't start ABX before new sputum sample
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| Pulmonary angiograms | Femoral artery to pulmonary vasculature
Most accurate to diagnose and locate PE's, CAT scan 2nd
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| 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
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| V/Q scans | Ventilation perfusion scan, how well are they ventilating and then are they perfusiing that oxygen and exchanging gas
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| Balance and Imbalance in Ventilation Perfusion (VQ) | We want a normal balance of our ventilation and perfusion
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| Alterations in Ventilation: | Blockage
Gravity
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| Alterations in Perfusion: | Pressures (airway/PA)
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| Ventilation-Perfusion Relationships V/Q ratio | Relationship between_the alveoli to _the flow of blood of the lungs__
-ventilation to flow of blood
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| Emphysema and COPD | Emphysema and COPD reduces the surface area of the alveoli
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| V/Q is greatest in | V/Q is greatest in __base of the lungs because that where the majority of our gas exchange takes place
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| Possible VQ States | Normal-ventilation matches
perfusion
Low ventilation/ perfusion
exceeds
High ventilation/ low perfusion
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| Tidal volume (VT) | Amount of inhaled and exhaled air in mL, normally 6 - 10 mL/kg
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| Inspiratory capacity (IC) | Measured with incentive spirometer
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| Placement of ET tube Proper placement | Endo-tracheal - about 4 cm above the carina
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| How would you know the tube was not 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
Note and chart ET tube depth measurement at lips
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| Improper Placement | With improper ET tube placement too low you will hear going into one lung but not the other
Common to get placed in the right stem bronchus
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| If a patient extubates themselves | Assess pt-need more O2? Bag, non-rebreather?
Call for physican
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| Ambu bag | Need in room! Need bag and valve!
Need O2 wall or cylinder.
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| MECHANICAL Ventilation Indications: | Inability to breath or apneic
Severe impaired ABG imbalance-not primary reason
Severe failure, hypoxia despite O2 therapy
Muscle fatigue
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| Benefits of MV | Decreases system & MVO2 requirements
Helps L ventricle, decreases O2 requirements of the L ventricle
Permit sedation
Reduce ICP
Hyperventilation reduces ICP
Prevent atelectasis
Secure airway
Too much sedation causes respiratory depression
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| Goals of MV | Reduction in work of breathing
Assurance of patient comfort
Synchrony with ventilator
Adequacy of ventilation and oxygenation
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Created by:
mgyger
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