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Advanced Nursing Concepts Part 2

Advanced Nursing Concepts Part 2. Ventilatory Assistance Sandra H. Lewis, ARNP-BC-ADM. Review of Anatomy and Physiology. Respiratory system is divided into: The Upper Airway=nasal cavity, the pharynx…it conducts, warms humidifies and filters.

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Advanced Nursing Concepts Part 2

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  1. Advanced Nursing Concepts Part 2 Ventilatory Assistance Sandra H. Lewis, ARNP-BC-ADM

  2. Review of Anatomy and Physiology • Respiratory system is divided into: • The Upper Airway=nasal cavity, the pharynx…it conducts, warms humidifies and filters. • The Lower Airway= the larynx, trachea, and right and left main stem bronchi ( the bifurcation at the angle of Louis is at the level of the 5th thoracic vertebra and is called the carina)

  3. Cont.. The right bronchus is wider, straighter and shorter (making it easier to accidentally intubate) The lungs consist of two lobes on the left and three lobes on the right. Each lobe is further divided into lobules that are supplied by one bronchiole. The lungs are covered by the pleura. The visceral pleura covers the lung surfaces and the parietal pleura covers the internal surface of the thoracic cavity. Between the pleura there is a thin fluid layer that allows the sliding action as respiration occurs.

  4. Human Respiration

  5. Regulation of Breathing • The rate, depth and rhythm of ventilation are controlled by The respiratory centers in the medulla and the pons. • When CO2 is HIGH or the O2 level is LOW, chemoreceptors in the respiratory center, the carotid arteries, and the aorta send messages to the medulla to stimulate respiration. • Persons with NORMAL lung function are stimulated by HIGH levels of CO2

  6. Continued.. • In persons with COPD, the stimulus to breathe is the LOWER level of O2….higher levels of CO2 are baseline… • So what do you think is a major nursing consideration about O2 therapy for persons with COPD?

  7. WOB (Work of Breathing) • Compliance= The measure of stretchability of the lung and chest wall… is primarily determined by the elastic recoil that must be overcome before lung inflation can occur. • EXAMPLES OF GREATER ELASTIC RECOIL: ARDS, pulmonary fibrosis, pulmonary edema…lungs are stiffer and difficult to distend Compliance is LOW…greater pressures are required to expand lungs.

  8. WOB cont.. • ARDS, X-RAY

  9. In emphysema, destruction of lung tissue and enlarged air spaces cause the lungs to lose their elasticity. • The decrease in elastic recoil causes compliance to be high. • Therefore lower pressures are need to expand the lungs.

  10. Cont… • Emphysema…Notice the flattening of diaphragms, Increased lung volumes, Diffuse hyperlucency

  11. Resistance • The opposition to gas flow in the airways. • Examples: mucous, edema, bronchospasm • Remember…the smaller the internal diameter of artificial airway increases resistance to air flow..

  12. Spirometer • Used to measure lung volumes. • Allows the practitioner to assess baseline pulmonary function and to monitor changes.

  13. Lung volumes • Volumes and capacities are usually stated for “healthy men” • Volumes for women are 20-25% less • Volumes decline with age. • Tidal Volume= Volume of normal breath

  14. Health History • Tobacco use, type, amount, #years used…pack years=packs cig a day x years smoked • Occupational…asbestos, coal mining, farming • Sputum • SOB, CP, dyspnea, cough, anorexia, weight loss • Respiratory med hx: inhaled, steroids, bronchodilators • OTC Drugs • Allergies • Last CXR and TB screening

  15. Physiological Changes with Age • Decreased alveolar surface • Decreased alveolar elasticity • Decreased chest wall distensibility • Decreased physiological compensatory mechanisms: (resp, cardiac, renal, immune)

  16. Physical Exam

  17. Respiratory Assessment • INSPECTION • landmarks; scapula , vertebrae • Respiratory rate • Position and use of accessory muscles • Colour • Breath sounds

  18. PERCUSSION • Posteriorly • upper and lower lobes • Start with apical areas, moving L to R and then slowly moving down to 10 ICS. • Resonance - long, low pitch sound, heard over most lung fields • Hyperresonance- low sounds (abnormal) heard when emphysema • Flatness/dullness - pneumonia and atelectasis.

  19. PALPATION • breathing excursion • position palms of hands on patients back between 8th and 10th ribs. Thumbs are ‘free floating’. Ask patient to take a breath. Each hand should move the same distance (3-5 cms) • tactile Fremitus • Using the ball of your hand , place them on the posterior wall of the chest, starting in the apical lobe area, ask your patient to say ‘99’. You should feel vibrations. In pneumonia, there is increased intensity of the vibrations and with pneumothorax, reduced intensity.

  20. AUSCULTATION • Follow same pattern as used when percussing. • Observe for expected breath sounds in the region assessing • Bronchial • Bronchovesicular • vesicular • Listen for Crackles & Wheezes • Pleural rub

  21. DOCUMENTATION • Respiration rate, skin colour, physical position and respiration sounds -INSPECTION • Tactile fremitus, and respiratory excursion - PALPATION • Breath sounds, describe and compare from lung apex to base as well as from LR • Presence of crackles and/or wheezes; state their location - AUSCULTATION

  22. Signs and Symptoms of Hypoxemia • Integument: Pallor, cool, dry, diaphoresis, cyanosis • Respiratory: Dyspnea, tachypnea, accessory muscle use • Cardiovascular: Tachycardia, dysrhythmias, CP, HTN with increased heart rate, hypotension with decreased heart rate. • CNS: Anxiety, restlessness, combativeness, fatigue, confusion, coma

  23. Common Acid-Base Abnormalities • See Box 8-2 page 172 • Resp. Acidosis (CO2 retention): COPD,CNS Depression, restrictive lung disease • Resp. Alkalosis (hyperventilation): Anxiety, pain, stimulants, pneumonia CHF, pulmonary edema

  24. Cont.. • Metabolic Acidosis (increased acids): Renal failure, DKA, Lactic acidosis, drug OD… Methanol, salicilates, ethylene glycol (loss of base)..diarrhea • Metabolic Alkalosis ( gain of base): excess antacids, or sodium bicarb…. or (loss of acids), vomiting, NG suction, Low K+ or CL, diuretics, increased aldosterone level

  25. ABG’s • Blood Gas Analysis Handout • Pages172-173.Critical Care Nursing

  26. Pulse Oximetry • Measures SpO2, reflects: SaO2 (arterial saturation) • A light emitting diode measures pulsatile flow and light absorption of the hemoglobin. • Accurate readings require a warm, well perfused area. • Patient motion and edema at the site adversely effect results…nail polish, sunlight and florescent light also interfere

  27. Oxygen Administration

  28. IF YOUR PATIENT ISBLUE…....TRY SOMEO2

  29. HeadTilt/ChinLiftProcedure • Tongue, the most common cause of airway obstruction • One hand on patient’s forehead, fingers of opposite hand under bony part of the chin • Lift the chin forward and support the jaw, helping to tilt the head back

  30. Modified Jaw Thrust • Used when possibility of C-spine injury exists • Grasp the angles of the patient’s lower jaw and lift with both hands, displacing the mandible forward • If the lips close, retreat the lower lip with thumb

  31. Oral Airways • are designed to keep the tongue from falling back and blocking the upper airway • easily available in six to nine sizes • are only used in unresponsive patients without a gag reflex • do not eliminate the need to monitor airway for patency

  32. Oral Airway Sizing • To choose the proper size, hold the airway against the side of the patient’s face. It should extend from the corner of the patient’s mouth to the angle of the jaw.

  33. Oral Airway Insertion • Open mouth with cross finger technique. Insert airway with tip pointing up to avoid pushing tongue backward. • Rotate airway tip slowly downward until its curve matches the curve of the tongue. • The flange of the airway should rest against the patient’s lips.

  34. Nasopharyngeal Airways • Curved, flexible rubber or plastic tubes inserted into the patient’s nostril • Use on responsive patients who need an airway assist

  35. Nasopharyngeal Airway Sizing • Measure length from tip of patient’s nose to earlobe • Diameter of airway should fit patient’s nostril without excessive tightness

  36. Oxygen Tanks and Regulators • Always green-designates O2 • Various tank sizes • D, E, M • Yoke vs. Threaded outlet • Tank pressure-2000 lbs. per sq. in. • Common regulators • fixed orifice, bourdon gauge

  37. Delivery Devices • Nasal cannula • Flow rate 2-6 lpm • Non-Rebreather mask • Flow rate 10-15 lpm • Two rescuer Bag Valve Mask (BVM) • Flow rate 15 lpm

  38. Set up of Tank/Regulator • Step 1-open tank to blow out dust • Step 2-Attach regulator (o-ring) • Step 3-Open tank, check pressure • Step 4-Attach proper delivery device • Step 5-Open flow to proper lpm for device • Step 6-Place delivery device on patient

  39. Break down of Tank/Regulator • Step 1-Turn off flow • Step 2-Remove mask/cannula , turn off tank • Step 3-Open flow meter to relieve/bleed pressure-close when complete • Step 4-Remove regulator

  40. Safety Considerations • Position/placement of tank • Properly fitting regulator • Close all valves when not in use • O2 fuels fire-not a flammable gas • Do not roll tanks on side or bottom • Inspect valve seats and o-rings • Store tanks in cool, well ventilated area • Have tanks tested on regular basis

  41. Oral Vs Nasotracheal Intubation • Box 8-6 on page 181 in Critical Care Nursing Look carefully at advantages and disadvantages.

  42. Equipment for Intubation • See Figure 8-19 page 182 • Be able to set up for an intubation and discuss choosing ET size and rationale for nasal or tracheal intubation.

  43. ET & More info • How quickly should the ET be placed? 30 seconds • Where should the tip end? 3-4 cm above the carina • What is the role of rapid sequence intubation? Emergency airway management, while decreasing the risk of aspiration, combativeness and injury to the patient. • HOW is RSI achieved? Neuromuscular blocking agent (Succinylcholine) + potent sedative (fentanyl or other). • What is Sellecks maneuver? Pressure on the cricoid is applied. • Why is it used? To decrease risk of vomiting and therefore aspiration • When can blind intubation be done? Only if the patient is capable of spontaneous respirations. • How long can a ET tube generally be left in place? 3-4 weeks. • Where is the incision made for a tracheostomy? At the level of the cricoid or between the 1st and second tracheal ring.

  44. Suctioning the Intubated Patient • See box 8-9 page 188 Critical Care Nursing • Discuss proper suctioning technique

  45. Negative Pressure Ventilation • Used for sleep apnea, neuromuscular problems and when Chronic Respiratory Failure patients need short periods of ventilation. • See figure 8-24 • Examples: iron lung, tank ventilator

  46. Noninvasive positive pressure ventilation • See figure 8-25 page 189 Critical Care Nursing • Face Mask covers mouth and nose. • Used in those requiring ventalatory support post intubation to resolve hypercapnia and short term…pulmonary edema, or for patient who refuses intubation

  47. Controlled Ventilation • Rarely used because of the superiority of Assist/Control (causes less anxiety, less hemodynamic instability). • Locks out patients attempts at respiration • Indicated for high c-spine injuries, patients with NO respiratory effort, chemically paralyzed patients

  48. Assist Control • Helps preserve muscle tone, reduces dyssynchrony (fighting the vent) • Potential complication of A/C=resp alkalosis (patients own resp rate too high triggering the vent…this can be adjusted by adjusting the sensitivity, sedating the patient if needed, or using IMV)

  49. SIMVSynchronized Intermittent Mandatory Ventilation • Delivers a preset Vt at a preset rate and allows the patients own breaths at his own rate and depth between the ventilator breaths. • Guarantees at set number of breaths • Helps prevent muscle weakness and hyperventilation. • Can increase muscle fatigue associated with patient efforts

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