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describe the different oxygenation criteria for nasal cannula, face masks, non-rebreathers, venturi masks and face tents
- Nasal Cannula: 1-6 L/min, common skin breakdown behind ears
- Simple Facemask: 40-60% O2 equal to about 5-8L/min. Make sure it fits
- Partial Rebreather: 60-75% O2 equal to about 6-11L/min. Rebreaths about 1/3 of exhaled volume
- Non-rebreather: Provides the highest amount of O2 at above 90%. Flaps over exhalation port vent out CO2 and need to be checked to prevent aspiration
- Venturi mask: delivers a set percentage of oxygen. Best delivery before intubation. Combines RA with O2
- Fact tent: provides high humidity with O2
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What is a CPAP?
- Continuous Positive Airway Pressure
- Mild air pressure to keep airway and alveoli open during the entire respiratory cycle, commonly used for sleep apnea
- Prevents snoring
- Used for infants with respiratory distress syndrome and bronchopulmonary dysplasia
- An overnight sleep apnea study determines the client needs
- Risk for nonadherance
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What are the indications for a Tracheotomy?
- Airway obstructions
- Laryngeal trauma
- Head/neck injury
- Weak chest muscles
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Describe the procedure for a tracheostomy?
- General anesthesia
- ET tube is inserted and removed once tracheostomy is placed in surgical incision
- Tracheostomy goes into trachea and through vocal cords
- A fenestrated tracheostomy tube may be used in the future to restore verbal communication
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What is a PE? what are the risk factors?
- An air bubble, plaque, fat or clot that lodges in the pulmonary vessels and prevent oxygenation and gas exchange
- A large clot can be fatal
- Usually begins as a thromboembolism (DVT is common) or a thrombosis, air bubble from large IV tubing
- Risk factors: immobility, advanced age, hist of DVT, surgery to pelvis or long bones, gastric bypass, central lines, nonadherance to anticoags
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What are the s/s of a PE? How is it diagnosed?
- S/S:
- -dyspnea
- -diaphoresis
- -restlessness
- -syncope
- -feeling of impending doom
- -decreased LOC
- -cyanosis
- -decreased BP and increased HR
- -decreased SaO2
- -chest pain
- -JVD
- -petechiae over chest
- Diagnostics:
- -CT scan
- -TEE
- -D-dimer blood test
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How can PEs be prevented?
- ROM exercise
- Frequent and early ambulation
- SCDs and TED hose
- Foot pumps and circles (no massage)
- Pillow under knees (not above heart level, tibia parallel to ground)
- Do not cross legs
- Turn q2hr
- No Smoking
- Anticoag therapy
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What is FES?
- Fat embolism syndrome
- Fat is released from long bones during trauma or surgery
- Can obstruct blood vessels
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What are the s/s of FES?
- Respiratory failure: tachypnea, dyspnea, cyanosis, decreased O2 sat
- Cerebral dysfunction: confusion, drowsiness, seizures, coma
- Skin Petechiae: chest, axilla, neck, conjunctiva
- S/S usually develop 24-72 hrs after trauma or surgery
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How is FES diagnosed?
- ABG shows hypoxia with PO2 <60
- Possible increased sedimentation rate
- Decreased H/H if petechiae present
- Snow storm appearance on chest xray
- MRI will show any changes in brain
- TEE
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What is the treatment and nursing care for FES?
- TX is supportive
- Oxygenation and mechanical ventilation
- Steroids, Heparin and dextran
- Assess lung sounds
- High flowers
- EKG
- 2 large bore IVs
- Anticoag therapy
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What lab studies are used for Heparin? what lab studies are used for Warfarin?
- Heparin:
- PTT/aPTT
- 1.5-2x the normal range of 20-40 sec
- Antidote is Protamine Sulfate
- Warfarin (Coumain):
- PT
- 1.5-2x the normal range of 11-12.5 sec
- INR
- 2.5-3 is therapeutic
- Antidote is vitamin K
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What is ARF?
- Acute respiratory failure
- 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
- ARF is either a failure to oxygenate (at blood level) or failure to ventilate (lung movement) or both
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What lab/diagnostic studies are used for ARF?
- Altered gas exchange on RA
- - P O2 <60 m<m Hg (normal is 80-100)
- - P CO2 >50 mm Hg (normal is 35-45)
- - pH < 7.3 (normal 7.35-7.45)
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What are the indications for mechanical ventilation?
- General anesthesia
- Chronic progressive neuromuscular disease such as MS, ALS
- Long term treatment (10-14 days until trach)
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Describe entotracheal intubation and nasal intubation
- Used to maintain a patent airway, remove sections and provide ventilation (oxygen)
- The tip of the tube rests just above the carina, cuff of the tube seals the trachea when pilot balloon is filled with area
- Correct placement done by c-ray or CO2 (gold standard)
- Chest rise and sounds should be equal bilat when done correctly
- Nasal intubations used for clients have oral surgery, distorted oral anatomy or with maxillofacial trauma
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What is the nursing care for an ET tube?
- Auscultate lung sounds
- Check balloon
- Suction tube
- Make sure tape is in place
- Assess for skin breakdown
- Provide frequent oral care
- Restrain pt if appropriate
- *Fistula can develop between esophagus and traches
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Describe positive pressure ventilation and BiPAP
- Positive pressure: pressure is pushed into the lungs and expands the chest. Uses an ET tube
- BiPAP: provides noninvasive positive pressure support by nasal mask or face mask. Often used for sleep apnea
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What is PEEP?
- Positive end expiratory pressure
- positive pressure exerted during expiration
- Prevents atelectasis because lungs are kept partially inflated
- Gas exchange in promoted throughout respiratory cycle
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What is the nursing care for a client with mechanical ventilation?
- Anxiety: explain procedures and offer approp meds. Allow pt and family to express concerns. Recognize fatigue or distress. Provide for alternative means of communication. Encourage patient to participate in self care
- Monitor vital signs and respirations
- Suction, turn, position
- Passive and active ROM
- Admin medications as ordered
- Patient teaching
- Keep machine and plastic equipment clean-prevent pneumonia
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What are some prioritized nursing diagnoses for a client on mechanical ventilation?
- R/F ineffective airway clearance
- Altered Gas exchange
- Altered breathing pattern
- Decreased CO
- Impaired physical immobility
- Anxiety
- Dysfunctional ventilatory weaning response
- Risk for Infection
- Imbalanced nutrition
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What is the procedure for extubation? What is the nursing care?
- ET tube, lubricant, laryngoscope should be at bedside
- Hyperoxygenate patient and suction prior to removal
- Deflate cuff and remove tube
- Provide supplemental O2 post removal
- Monitor VS q5min then q15 for 1 hr, then 30min for 2 hrs when q 1hr
- Monitor for laryngospasm
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What are some different types of thoracic surgery?
- Video assisted thoracic surgery
- Open Thoracotomy
- Lung volume resection, lobectomy, pneumonectomy
- Lung transplantation
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What are the postop nursing interventions for thoracic surgery?
- Maintain adequate breathing patterns:
- -assess chest/resp status
- -lab work. ABGs, H/H, WBC
- -monitor vital signs
- -suction
- -encourage cough and deep breathing
- -positioning on uneffected side or supine
- Stabilizing hemodynamic status
- -monitor vital signs
- -assess chest tube drainage
- -I/O
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Describe chest tube placement and purpose
- Insertion of tube into the pleural space between visceral and parietal pleurae
- Purpose: evacuate air or fluid, regain negative pressure
- Mechanical systems can use a single bottle water seal system or a three bottle water seal system
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describe how a chest tube drainage system works
- First section (bottle 1) drains air or fluids from client
- Second section (bottle 2) prevents air or water from moving back into the client. section contains water. This section should bubble initially until air has been evacuated from the pleural space and then the bubbling stops. Water will rise and fall with inspir/expir (tidaling)
- Third section (bottle 3) is connected to suction at the wall. This should bubble gently. Contains water
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What are the nursing interventions for chest tube drainage?
- Assessment of respirations- rate, rhythm, depth, anterior, posterior, lung bases
- Monitor vital signs
- Assessment of chest tubes (mark placement on tube) and drainage system
- Assess puncture site
- Admin pain medications
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What is the protocol for chest tube removal?
- Supplies needed: sterile gloves, goggles, mask, gown, chux, vaseline gauze, tegaderm, sterile suture removal kit, rubber tipped hemostats, occlusive tape
- Admin pain medication
- Place the client in semi fowlers and put chux under tube site
- After dressing is removed and sutures are cut, MD clamps tube
- Instruct patient to perform valsalva or hold breath
- MD removes tube and occlusive (vaseline) dressing is immediately placed
- VS q15min for 1 hr, q30min for next 2hrs, then q1hr for 4hrs
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