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Describe a nasal cannula, simple facemask, partial rebreather, venturi mask, face tent
- nasal cannula: 1-6L/min; monitor for skin breakdown behind the ear
- Simple facemask: 40-60% (5-8L/min); check fit
- Partial rebreather: 60-75% (6-11L/min), rebreathes 1/3 of exhaled volume
- Non rebreather: provides higest amount of O2-vents CO2; check flaps-prevent aspiration
- Venturi mask: next best delivery to intubation; combines room air with oxygen
- Face tent: high humidity with O2
What is a CPAP machine?
- Continuous positive airway pressure
- mild air pressure to keep airway open, used for sleep apnea and for infants with respiratory distress syndrome and bronchopulmonary dysplasia
- An overnight sleep study determines patient need.
- Corrects snoring
What is a tracheotomy?
Whats the procedure?
- Tracheotomy is the procedure
- tracheostomy is the stoma opening to the airway
- Indications include airway obstructions, laryngeal trauma, head/neck surgery, and weak chest muscles (emphysema)
- Procedure: general anesthesia is used; endotracheal tube inserted; the tube is removed as the trach tube is inserted through a surgical incision
What is a tracheostomy?
- cuffed tube used for ventilated patient
- noncuffed tube for patient on room air; reusable inner cannula-clean PRN; Disposable inner cannula-replace PRN
What is a PE? What are the risk factors? Prevention? Diagnostics? S&S?
- pulmoanry embolism
- an air bubble, plaque, fat or clot that lodges in the pulmonary vessels
- large emoboli can cause death
- Usually begins as thrombolism or thrombosis, Lg IV tubing bubble
- Leads to impaired gas exchange
- Risk factors: immobility, CLs, surgery to pelvis, gastric bypass, obesity, advancing age (immobility) hx of DVT, noncompliant with anticoagulants
- Prevention: ROM, early ambulation, SCDs, TEDs, frequent ambulation, foot pumps, foot circles, no massage, Maybe pillow under knees, Elevate with tibia level to the ground, turn q 2 hr, do not cross legs, no smoking, anticoagulants
- Diagnostics: CT Scan (X-rays not helpful), transesophageal echocardogram (TEE)
- S&S: dyspnea, restlessness, diaphoresis, feeling of impending doom, syncope, decreased LOC, cyanosis, decreased BP, O2 sat, HR, and chest pain, distended neck veins, petechiae over chest
What is Fat embolism syndrome?
- FES arises from surgery to long bones such as intramedullary nailing (reaming of intramedullary cavity), traumatic femur fx, pelvis, lower legs, closed fx, multiple fractures
- Larger fat droplets that are fluid in nature are released into the venous system. FES causes obstruction to vessels in bowel, legs, etc
- Complications: Respiratory failure( tachypnea, dyspnea, cyanosis, decreased 02 sat) Cerebral dysfunction (confusion, drowsiness, sz, coma) Skin petechiae(chest, axilla neck, conjunctiva) usually develop 24-72 hr after surgery/trauma
- ABGs will show hypoxia wit PO2<60; Increased Sed rate; decreased H&H (due to petechiae)
- Diagnosed: by chest x ray (increased diffuse bilateral pulmonary infiltrates-snow storm appearance; MRI of brai-hypodense canges in periventricular region; TEE
- Treatment: Tx is supportive; oxygenation, mechanical ventilation; steroids, heparin, dextran, early fixation of long bone fx; fixation with plate and screws; ex fix less likely to produce FES
- Nursing care: O2 therapy, POX, ling sounds, anticoagulant therapy, VS, Dyspnea, CSM, High fowlers, EKG, 2 large bore IVs
What is acute respiratory failure?
- a condition in which the pulmonary system fails to maintain adequate gas exchange
- results from a deficiency in the pulmonary system
- occurs secondary to another disorder
- Altered gas exchange (room air)
- P O2 < 60 mm Hg (normal is 80-100)
- PCO2 > 50 mm Hg (normal is 35-45)
- pH < or = 7.3 (normal 7.35-7.45)
- occurs on a cellular level at the alveoli
What do ABGs do?
- measure the patients respiratory (ventilation) and metabolic (renal) acid base and electrolyte homeostasis. Used for patients on ventilators, critically ill patients, to establish preop baselines, and guide electrolyte therapy
- pH: measures acidity/alkalinity (hydrogen ion concentration) in blood
- PO2: oxygen, measures oxygen content in arterial blood
- pCO2: measures CO2 in blood; controlled primarily by the lungs. Stimulates breathing
- HCO2: bicarb, an ion regulated by the kidneys
- O2 Saturation: measures by pulse ox the amount of hemoglobin that is saturated with oxygen (92-100%)
What is the etiology of respiratory failure?
- Failure of oxygenation (oxygen on hemoglobin)
- Failure of ventilation (movement of air into and out of the lungs)
What is mechanical ventilation used for?
- patients after gen anesthesia, with chronic progressive neuromuscular disease such as MS; if long term tx is needed (10-14 days) the pt will Have a trach
- begins with endotracheal intubation with an ET
- purposes: maintain a patent airway, remove secretions, provide ventilation
- can be orally or nasally inserted
What is endotracheal intubation?
- after placement the tip of the tube rests just above the bifurcation of the mainstem bronchus
- Nasal intubation is used for pts having oral surgery, or pts with maxillofacial trauma
- the cuff of the tube seals the trachea; the proximal balloon (aka pilot balloon), when inflated, is a way to determine the inflation of the distal balloon
- A resuscitation bag and mask may be necessary to maintain oxygenation before intubation can be done
- Correct placement of the ET tube can be confirmed by X-Ray or by checking carbon dioxide levels. If the tube is incorrectly place in the esopagus, air will fill the abdomen. You should be able to see chest wall movement and hear breath sounds with correct placement
- Nusing care: auscultate lung sounds, check balloon, suction tube, make sure tape is in place, restain pt to prevent extubation, fistula can develop between trachea and esophagus
explain mechanical ventilation
- purpose: improve gas exchange and decrease the work of breathing.
- Types of mechanical ventilation
- Positive pressure ventilation: pressure is pushed into the lungs and expands the chest; uses ET tube.
- BiPAP: provides noninvasive pressure support ventilation by nasal mask or facemask. For sleep apnea
- CPAP: provides continuous pressure during inspiration and expiration to keep alveoli open at all times throughout the respiratory cycle. Designed for patients who breathe on their own
- PEEP: Positive end expiratory pressure is exerted during expiration. Prevents alveoli from collapsing because the lungs are kept partially inflated so that gas exchange is promoted throughout the cycle
- Nursing care: explain procedures, offer antianxiety meds, allow pt and family to express fears and concerns. Recognize fatigue or distress in te pt. Provide for alternate means of communication. Encourage pt to participate in self care
What interventions are necessary for mechanical ventilation?
monitor vital signs and resps, suction, turn, position, passive and active range of motion, administer medications, patient teaching, keep machine and plastic equipment clean, prevent pneumonia
- removal of the ET tube
- have equipment nearby for reintubation (ET tube, lubricant, laryngoscope)
- hyperoxygenate the pt and suction ET tube
- deflate cuff and remove tube
- give oxygen by facemask or cannula, HOB up, TCDB
- Monitor VS q 5 minutes then every 15 minutes for 1 hour then every 30 mins for 2hrs, then q 1 hour; observe for laryngospasms
Why are thoracic surgeries performed? Types?
- performed for diseases (CA) and injuries (trauma, GSW, MVA)
- Types: video assisted thoracic surgery, open thoracotomy, lung volume reduction surgery-wedge resection, lobectomy, pneumonectomy, Lung transplant
What are the postop nursing interventions for thoracic surgery?
- Maintain adequate breathing patterns: assess chest/respiratory status, lab work-ABGs, H&H, WBC, monitor vital signs, suction, encourage cough and deep breathing, positioning on unaffected side or supine
- Stabilizing hemodynamic status: monitor vital signs, assess chest tube drainage, intake and output
What is a chest tube?
- insertion of a tube into the pleural space between visceral and parietal pleurae
- Purpose: evacuate air or fluid, regain negative pressure
- Principles of chest drainage: uses the water-seal principle
- Mecanical systems: single-bottle water seal system; 3 bottle water system seal
explain the chambers of a chest tube
- "bottle 1": collection chamber, collects drainage from the patient
- "bottle 2": water seal chamber, prevents air or water from moving back into the patient. This chamber should bubble initially until air has been evacuated from the pleural space. Then the bubbling stops. A kinked chest tube can also cause it to stop. Water will rise and fall with inspiration and expiration (tidaling)
- Bottle 3: suction regulator, connected to wall suction. this chamber should bubble gently at all times
What is tidaling?
water level increases during spontaneous inspiration and decrease with expiration. With positive pressure mechanical ventilation the opposite is true
What are the interventions for chest tube?
- assessment of respiration: rate, rhythm and depth, anterior and posterior inclding bases. Monitor vital signs,
- Assessment of chest tube and drainage system: record drainage q 4 hours, administer pain meds, assess puncture site,
explain chest tube removal
- Gather supplies: sterile gloves, goggles, gown, mask, chux, dressing supplies (vaseline gauze, tegaderm), sterile suture removal kit, rubber-tipped hemostats, occlusive tape
- place clients in semi-fowlers, chux under chest tube site, after dressing is removed and sutures cut, MD clamps chest tube, instruct pt to perform valsalva (to prevent air from entering the pleural space), MD removed chest tube, apply occlusive dressings, medicate pt prior, provide vaseline gauze and sterile dressing for removal of chest tube, monitor vital signs q 15 x 1 hour, q 30 mins x 2 hours, then q 1 hr x 4 hours