respiratory block 4
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| ICU patients | Sedated
In a severe amount of pain
Changed LOC
Respiration and Cardiac status can be 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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| 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
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| difficulty breathing interventions | 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
Smoker is more difficult to get off breathing machines
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| 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
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| Elimination history | Listen for crackles, assess urine output
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| Sleep/Rest history | Some people have issues breathing while 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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| 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
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| cardinal s/sx of respiratory distress | Hypoxia
Restlessness
Diaphoresis
Tachycardia
Cool skin
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| Cool skin | d/t hypoxia? They are vasoconstricting - sympathetic nervous system is kicking in causing that systemic reaction
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| S/SX if cardiac involvement of respiratory distress | Dyspnea, wheezing, cough, sputum, palpitations, swollen feet
Fatigue
Chest pain
Anxiety-anxiety is big
Dizziness
Bradycardia
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| Medications mask | Don't rely on monitor-s/sx can be masked ie., tachycardia masked by beta blockers
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| 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
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| Blocked airway | Secretions
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| Age | Elderly ↓elastic recoil, ↓ ability of the chest cage to move in and out
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| 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
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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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| 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
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| Inspiration length | Inspiration is usually shorter than expiration on most pts
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| 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
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| Common abnormal breathing patterns | Most are due to CNS changes
Cheynes stokes, BIOTs, Kussmals, Apneustic
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| Cheynes stokes | deep then shallow then apneic followed by a pause; many times caused by CNS issues
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| BIOTs | brain stem CNS disorders; severe anesthetic depression
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| Kussmals | deep and rapid --- Acidosis
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| Apneustic | shallow breathing – often caused by someone who has been anoxic for too long
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| Before assessment | Will I see this, What does it mean? How will I respond?
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| Chest wall excursion | symmetrical, Rib fracture, pneumothorcias
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| Tracheal deviation | Pushing to one side or the other, pneumothorax, pleural effusions
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| Chest wall tenderness | Inflammation, Pleuritis, rib fractures, infection
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| Crepitus | Subcutaneous emphysema
Air trapped underneath the skin, dissipates with time, central venous catheter, new tracheostomy
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| Tactile Fremitus | Vibration during speaking – indicates consolidation
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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, Rales
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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.
High-pitched sounds produced by narrowed airways heard on expiration, bronchial tube, smooth muscle.
Sometimes can be heard without a stethoscope.
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| 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
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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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| 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
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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 muscle use | Ominous sign
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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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| Check adventitious sounds often | 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
Dysrhythmias-early or late
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| Pulse Oximetry | Can be affected by cold extremities, low b/p, fingernail polish
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| 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?
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| SVO2 pts | monitored for sepsis or shock, Manytimes used with pts w/ resp and cardiac problems – central line ill
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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 perfusing that oxygen and exchanging gas, (we can see what is inhaled as compared to what is perfusing)
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| Balance in Ventilation | We want a normal balance of our ventilation and perfusion
NO MISMATCHES WANTED
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| Alterations in Ventilation: | Blockage
Gravity
Atelectasis, tumors, pneumonia; position
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| Alterations in Perfusion: | Pressures (airway/PA)
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| V/Q ratio | Relationship between_the alveoli to _the flow of blood of the lungs__
-ventilation to flow of blood
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| V/Q is greatest | in __base of the lungs because that where the majority of our gas exchange takes place
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| 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
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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 | Amount of inhaled and exhaled air in mL, normally 6 - 10 mL/kg
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| Vital capacity | how much can a person expel from lungs after inspiring – important when weaning off vent
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| Inspiratory capacity | how much can a person take in
Measured with incentive spirometer
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| 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
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| ET placement | about 4 cm above the carina, usually 4 centimeters out of the mouth, Note and chart ET tube depth measurement at lips
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| 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
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| Improper ET Placement | Breath sounds not equal; unequal chest movement; ventilator settings may indicate, 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
Within 1st 4 hours they are at risk for pneumothorax due to baro trauma; may become tachycardic; dyspnic
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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
7.25 pH and CO2 above 50 mechanical ventilation is likely required
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| Decreases Left ventricle requirements | Left ventricle requirements are decreased d/t ↓ O2 requirements
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| Reduce ICP | Hyperventilation reduces ICP, ICP cause brain swelling; keep CO2 levels low through Mechanical Ventilation
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| Secure airway | Too much sedation causes respiratory depression
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| 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
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| Assist Control | (assist control), full support, Delivers preset breaths & tidal volume
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| SIMV | (Synchronized intermittent mandatory ventilation), Partial control, Will always deliver the breath (rate) but will allow the patient to pull their own tidal volumes
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| CPAP | CPAP (PEEP), Giving continuous positive airway pressure
No support-used when weaning pt
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| PS | Preset amount of inspiratory positive pressure
Applied throughout inspiration
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| 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?
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| 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
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| 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?
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