Respiratory and Hemodynamics
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What does hemodynamics tell us?
- quantitative info about:
- vascular capacity
- blood volume
- pump effectiveness
- tissue perfusion
What does central venous pressure measure?
fluid volume status...and pressures in right atrium
looks at blood volume and venous return
What side filling pressure does central venous pressure measure?
What causes decreases in central venous pressure, pulmonary artery pressure and pulmonary capillary wedge pressure?
- decreased venous return
Normal central venous pressure #s
What causes increase in central venous pressure?
- Impedance to right atria emptying
What does the pulmonary artery pressure evaluate in the heart?
- evaluates how the left ventricle is working
- overall cardiac fxn
What does Pulmonary Capillary Wedge Pressure measure?
left ventricle function by measuring the amount of pressure generated by the left ventricle
Normal pulmonary capillary wedge pressure values?
What causes an increase in pulmonary capillary wedge pressure?
- Impedence to LA emptying
the volume that fills the L ventricle at the end of diastole
wall tension generated by the LV during systole to open the aortic valve and eject it's contents
reflects the balance btwn oxygen supply and demand
Systemic Vascular Resistance
What does it measure?
What does systemic intra-arterial monitoring measure?
arterial blood pressure and correlates it to cuff BP
What increases preload?
- blood products
- volume expanders
What decreases preload?
- ACE inhibitors
- Venous dilators
What increases afterload?
What decreases afterload?
- Calcium channel blocker-anti hypertensives
ROME in ABG's
Respiratory opposite (pH and CO2 going in opposite directions)
Metabolic equal (pH goes down so does HCO3...or both go up)
Define respiratory failure
inability of the cardiac and pulmonary systems to maintain an adequate exchange of oxygen and carbon dioxide in the lungs
What characterizes respiratory failure?
abnormal blood gas
What is oxygenation failure?
inadequate O2 transfer between the alveoli and the pulmonary capillary bed.
Common causes of oxygenation failure/hypoxemia?
- mismatch of ventilation and perfusion
What is ventilatory failure?
mismatching in which the perfusion is normal, but ventilation is inadequate.
Thoracic pressure cant be changed enough to move air in and out of the lungs
What causes ventilatory failure?
- abnormalities of the alveoli and airways
- CNS depression
- neuromuscular conditions
- abnormalities of the chest wall
Crucial things to assess with impaired gas exchange
- lung sounds
- LOC/cap refill/skin color
Crucial things to assess with ineffective breathing pattern
- RR and depth
- changes in tidal volume and tidal capacity
- ventilator management
Crucial interventions with inability to sustain spontaneous ventilation
- monitor weaning from vent
- decrease use of respiratory muscle depressant meds
- provide periods of rest and activity
Interventions for ineffective airway clearance
- assess secretions
- monitor tidal volume and vital capacity
- chest physiotherapy
What makes a person be put on a vent?
- severely inadequate gas exchange
- progressive alveolar hypoventilation
- respiratory acidosis
What is the goal of mechanical ventilation?
- to maintain alveolar ventilation appropriate for the client's metabolic needs
- to correct hypoxemia
- maximize oxygen transport
What characterizes a person is in ARDS?
- acute onset of hypoxemia
- bilateral chest imaging opacities
- damaged alveolar capillary membrane causing it to become filled with fluid
Interventions for a person with ARDS
- intubation and mechanical ventilation with PEEP
Medications given to a person with ARDS
- sedatives and paralytics
Complications from ARDS
- stress ulcers
Why do people on a ventilator go in to renal failure?
the renal tissue doesnt get perfused due to hypotension, hypoxemia or hypercapnia
Also....they are given vanco a lot to prevent/treat infections
Indications for a person to be put on a vent
- apnea...or impending apnea
- acute respiratory failure
- severe hypoxia
- respiratory muscle fatigue
What are the goals of a person on a vent?
- resolve hypoxemia and hypoxia
- maximize oxygen carrying capacity of arterial blood
- adequate cardiac output, Hgb
What is the purpose of a ventilator?
- supports patients until they recover the ability to breathe independently
- a bridge to long term mechanical ventilation...or until a decision is made to withdraw ventilatory support
How do you verify appropriate placement of an endotrachial tube?
- End tidal CO2 detector...watch for a color change
- Auscultate lungs for breath sounds
- Auscultate epigastrum for the absence of air
- X RAY!!!
Details about a Pressure Regulated Volume Control Ventilator
the ventilator monitors each breath and compares it to the tidal volume
If the delivered volume is too low, the pressure is increased on the next breath, and vice versa
Details about a Pressure Support Ventilator
used to assist with the weaning of a patient off a vent
patient must be able to initiate breath in this modality
Name and describe 2 non invasive mechanical ventilators
BIPAP-two different pressure levels, one for inspiration and one for expiration
CPAP-constant pressure is delivered
**Have to be able to breathe spontaneously on their own
How does an invasive ventilator work?
ET or trach is placed in the patient and air is pushed in to the patients lungs(inhalation) and exhalation is passive
What is PEEP?
positive pressure applied at the end of expiration to improve oxygenation by opening collapsed alveoli
What is the purpose of PEEP?
to maintain or improve oxygenation while limiting the risk of O2 toxicity
What does PEEP prevent?
small airway collapse at the end of expiration to increase oxygenation
List ongoing nursing care of a patient on a vent
- assess position/placement of tube
- doc tube placement in cm at teeth/lips
- soft wrist restraints to prevent extubation
- suction oral/tracheal secretions
- assess respirotary status q1-2 hrs
- reposition ET tube q24h
- assess for skin breakdown
- provide adequate nutrition
Monitoring of cuff pressure on a vent patient
- do q8h
- must be below 20mmHg
- assess for air leaks
How can you tell that there is a possible air leak in a ventilated patient?
- clients speaking
- air hissing
- decreasing SaO2
What is a low pressure alarm signaling on a ventilated patient?
possible disconnection or leak in the system
- loss of airway from total/partial extubation
- ET tube/Trach cuff leak
What is a high pressure alarm signaling on a ventilated patient?
an increase pressure from sputum, fluid condensation, coughing, pneumothorax, bronchospasm, kink in tube
anything that will cause an increased resistance, obstruction
When do you suction? Rules of suctioning....
coughing, coarse rhonchi, high pressure, decreased spo2
- sterile technique
- hyperoxygenate....120max for 15 sec
- assess for dysrhythmias....stop
- monitor SaO2....<85% stop
- dont put saline down ET Tube
How do you prevent VAP?
- hand hygiene
- oral care with Peridex and tooth brushing
- prophylactic antibiotics
- positioning to prevent aspiration...HOB at 30
- residual checks
- prophylactic stress ulcer meds
- dont change tubes regularly
S/S of VAP
- increased WBC
- purulent sputum
- odorous sputum
- CXR with pulmonary infiltrates
ABCDE bundle to facilitate weaning from mechanical ventilation is aimed at reducing....
- development of delirium
all of which harm patients
- Awakening trial
- Breathing trial..see if can spont. breath on own
- Coordination....work with RT to get off vent
- Delirium...are they delirious?
- Early...can they get up and walk around the room while vented?
RN's collaborate with RT and Critical Care MD to wean a patient from vent....what criteria needs to be met to wean them....
- awake and alert
- negative inspiratory pressure >-20 H2O
- Not on resp. depressant meds or anesthesia
- Protective reflexes in tact
- patent airway
- Stable CVS....WNL
- clear breath sounds
- ABG WNL
Most common way to wean a person from a ventilator
Indicators that vent weaning isnt going well...
- SBP increase/decrease by 20
- RR increase by 10 or above 30
- HR increase/decrease by 20 or above 120
- TV <300
- Increased PaCO2
- Increased WOB
Most common sign that an older person is suffering from hypoxemia
change in mental status
Low SVO2 means....and caused by?
persons consuming more oxygen than the body has in reserves
High SVO2 means...
there's a maldistribution of blood related to SEPSIS
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