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MedSurg II - Mech Ventilation

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olanjones's version from 2017-04-03 01:23

Intubation

Question Answer
Most common artificial airway in critical careEndotracheal tube (can be placed either orally or nasally) Indications for placement - upper airway obstruction, apnea, high aspiration risk, ineffective secretion clearance, respiratory distress
ET insertion PrepExplain procedure to pt - they won’t be able to talk while they are intubated, You will need a bag valve mask available & attached to oxygen, Est. IV access, Keep suctioning equipment at bedside
Rapid sequence intubationRapid, concurrent administration of both a sedative and paralytic agent during emergency airway management, ↓ risk of aspiration
Sedative/hypnotics usedmidazolam for sedation, fentanyl blunts pain; succinylcholine or pancuronium produce skeletal muscle paralysis
Assisting w/ ET PlacementPt’s head in sniffing position
Oral placement: tube is placed btwn vocal cords to bifurcation of the bronchi
Once placement is verified, the patient will be attached to ventilator
Verifying ET Placement-End-tidal CO2 monitor (presence of CO2 verifies placement; if no CO2 tube is in esophagus & will need to be repositioned)
-Watch for symmetric chest movement & auscultate lungs for b/l breath sounds
-GOLD STANDARD: Obtain a CXR to verify placement
Assessments for ET pts-Monitor ABG’s, SP02
-Assess for signs of hypoxemia (change in mental status, anxiety, dusky skin, dysrhythmia)
-Assess pt’s RR, rhythm, use of accessory muscles
-Oral secretions ↑when intubated -require frequent mouth suctioning using a Yankaeur (allow pt to hold if able–gives them some control)
-Need for oral care
Indications for SuctionVisible secretions in ET, sudden onset of respiratory distress, suspected aspiration of secretions, ↑peak airway pressures, auscultation of adventitious breath sounds, ↑RR/sustained coughing, sudden or gradual ↓PaO2 or SPO2
Oral Care (Very important - their mouth is always open)-Use soft toothbrush 2x day to remove plaque, Use 0.12% chlorhexidine oral rinse 2x day, Oral swabs with a 1.5% hydrogen peroxide solution every 2-4 hr
-Lips, gums, tongue should be kept moist w/ saline/water swabs to prevent drying
-Monitor for skin breakdown because of pressure from ET tube (may cause necrosis); Tape/velcro needs to be changed & tube repositioned every 24 hours/prn
What should you do if someone extubates themselvesStay w/ pt & call for help; Manually ventilate w/ a bag valve mask & 100% oxygen (pt may need to be re-intubated or may do okay w/ O2 mask/NC - re-intubation may be difficult d/t edema from the trauma of extubation)
PPVDuring inspiration the ventilator pushes air into the lungs under positive pressure
Volume ventilationDelivers a determined tidal volume w/ each inspiration
What is used to determine vent settingsPt lung compliance/resistance, ABGs, ideal body weight, level of consciousness, muscle strength
What may cause alarm to go offmechanical malfunction, apnea, unplanned extubation, or patient asynchrony with a ventilator
A high pressure alarm could mean pt needs to be suctioned or is biting the tube
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Modes

Question Answer
Controlled mandatory ventilation (CMV)Pt’s respirations are completely controlled by the ventilator (used in Sx/PACU)
Assist-control ventilation (ACV)Ventilator delivers a preset tidal volume at a preset frequency; Patient can breathe faster than the preset rate but not slower (allows pt some control over ventilation)
Synchronized intermittent mandatory ventilation (SIMV)Ventilator provides a preset tidal volume at a preset frequency & synchrony w/ pt's respirations (between ventilator breaths, pt is able to breathe spontaneously but still receives a preset FIO2)
Pressure support ventilation-Positive pressure is applied to the airway only during inspiration in conjunction w/ pts breathing (must be able to initiate own breathing, may deliver a set FIO2)
-Mode used most frequently for weaning pts from ventilator – do they have the muscle strength to breathe on their own
Positive end-expiratory pressure (PEEP)Deliverers positive pressure during exhalation - keeps alveoli open, improving oxygenation using less O2 * usual setting: 5cm H2O
-↑levels may cause barotrauma & ↓CO
Benefits of PEEPImproves gas exchange, vital capacity, inspiratory force
Contraindications for PEEPPts w/ highly compliant lungs (COPD), hypovolemia, or low cardiac output
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VAP

Question Answer
DefinitionPneumonia that occurs 48 hrs or more after intubation
RFintubation & ventilation, poor nutritional status, immobility, underlying disease process
Clinical evidence of VAPFever, ↑WBC, purulent/odorous sputum, crackles/rhonchi on auscultation, pulmonary infiltrates CXR
PreventionHOB elevation at a minimum of 30 - 45° unless contraindicated, No routine changes of ventilator circuit tubing, Subglottal suctioning
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Extubation

Question Answer
Spontaneous breathing trialSpontaneous breathing trial (pressure support) or a T-tube that fits on the ET tube
S/S pt is not tolerating trialTachypnea, dyspnea, arrhythmias, tachycardia, agitation, anxiety, sustained saturation <91%
Prior to extubationHyper-oxygenat & suction pt. Dr/RT will have pt take a deep breath, then will deflate the cuff & pull the tube in one motion
After extubation-Instruct pt to take deep breaths & cough; supplemental O2 admin
-Monitor VS, respiratory status, oxygenation immediately after extubation, within one hour, and per institution policy
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Delegation

Question Answer
RNAuscultate breath sounds & respiratory effort, assess for ↓ventilation or adventitious sounds
RNMonitor ventilator settings and alarms; Maintain appropriate cuff inflation on ET tube
RNDevelop plan for communication w/ pt who has a trach/ET tube; Teach pt & caregiver about mechanical ventilation & weaning procedures
RNDetermine need for ET tube suctioning. Implement suctioning for unstable patients; Reposition and secure ET tube (may delegate to respiratory therapist, depending on agency policy).
RNAdmin sedatives, analgesics, paralytic medications prn; Monitor oxygenation level and signs of respiratory fatigue during weaning procedure
LPNSuction trach/ET tube for stable patients as directed by RN (after being educated and evaluated in this procedure)
LPNAssist RN or RT w/ repositioning/securing ET tube
LPNAdminister routinely scheduled medications; Administer enteral nutrition to stable patients
UAPObtain VS, measure I&O & report these to RN; Perform bedside glucose testing
UAPProvide personal hygiene and skin care/oral care; Perform passive or assisted range-of-motion exercises
UAPAssist with frequent position changes, including ambulation
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Settings of Mech Vent

Question Answer
Respiratory rate (f)Number of breaths the ventilator delivers per minute *Usual setting: 6-20 breaths/min
Tidal volume (VT)Volume of gas delivered to patient during each ventilator breath *Usual volume: 6-10 mL/kg
FIO2Fraction of inspired O2 delivered to pt, May be set btwn 21%-100% *Usually adjusted to maintain PaO2 >60 mm Hg / SpO2 >90%
PEEPPositive pressure applied at the end of expiration of ventilator breaths *Usual setting: 5 cm H2O
Pressure supportPositive pressure used to augment patient’s inspiratory pressure *Usual setting: 6-18 cm H2O
I:E ratioDuration of inspiration to duration of expiration *Usual setting: 1:2 to 1:1.5 unless IRV is desired
Inspiratory flow rate & timeSpeed w/ which the VT is delivered *Usual setting: 40-80 L/min and time is 0.8-1.2 sec
SensitivityDetermines amount of effort pt must generate to initiate a ventilator breath; It may be set for pressure triggering or flow triggering *Usual setting: A pressure trigger is set 0.5-1.5 cm H2O below baseline pressure and a flow trigger is set 1-3 L/min below baseline flow
High-pressure limitRegulates the maximal pressure the ventilator can generate to deliver the VT; When pressure limit is reached, the ventilator terminates the breath & spills undelivered volume into the atmosphere *Usual setting: 10-20 cm H2O above peak inspiration
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O2 Admin

Question Answer
NC/prongs23-42% at 1-6 L/min; Assess nostril patency, Apply water-soluble jelly to nares q 3-4 hrs, Mouth care
Face mask40-60% at 6-8 L/min (min flow 5 L); Remove q 1-2 hrs, Skin care, Emotional support (claustrophobia)
Partial rebreather mask50-75% at 8-11 L/min; Adjust flow to keep reservoir bag 2/3 full during inspiration
Nonrebreather mask80-100% at 12 L/min; Adjust flow to keep reservoir bag 2/3 full
Venturi mask24-40% at 4-8 L/min; Provides high-humidity & fixed concentration, Keep free of kinks
Trach collar/T-piece30-100% at 8-10 L/min; Assess for fine mist, Empty condensation from tubing, Keep water container full
Oxygen hood30-100% at 8-10 L/min; Used for infants/children, Cooled humid air
-Check O2 concentrations w/ O2 analyzer q 4 hrs, Uses sterile, distilled water
-Clean humidity jar daily, Change linens frequently
-Cover client w/ light blanket & towel/cap for head, Monitor pt temp frequently
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O2 Hazards

Question Answer
InfectionChange masks, tubing, mouthpieces daily
Drying/irritation of mucosaAdmin humidified O2
Respiratory depression
(CO2 narcosis)
*Monitor RR frequently, Alt breathing room air/O2 at prescribed intervals
*Admin mixed O2/air, rather than pure O2, Use minimal concentration necessary
*Periodically inflate lungs fully
O2 toxicity-Premature infants may develop retinopathy/irreversible blindness d/t vasoconstriction of retinal vessels
-Clients on respirators are most susceptible to pulmonary damage
-Pulm damage = atelectasis, exudation of protein fluid into alveoli, damage/proliferation of pulm capillaries, interstitial hemorrhage
-S/S: cough, nasal congestion, sore throat, reduced vital capacity, substernal discomfort
-Can occur in any patient who breathes O2 concentrations >50% for >24 hours
CombustionBe sure electrical plugs/equipment are grounded, NO SMOKING, No oils on client or equipment
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