Exam 1 pulmonary blueprint Flashcards
Prevention of complications for mechanical vent
Gastric ulcers = proton pump inhibitors and enteral nutrition
Venous thromboembolism (VTE) = pneumatic compression devices and anticoagulation prophylaxis
Acute Kidney Injury (AKI) = monitor intake and output, weights, and labs, be mindful of fluid status, and administer IV fluids and diuretics
Patient safety-mechanical ventilation
HOB elevated 30-40 degrees
Good hand hygiene
Sterile technique
Thorough oral care
Admin ordered antibiotics
PEEP settings
Prevent barotrauma
Intubation
Provides an endotracheal tube through the nose or mouth into the trachea. Provides patient airway, access for mechanical ventilation, facilities removal of secretions. Maintain cuff pressure between 20 and 25 mmHg. Intubation for no longer than 14 to 21 days (after will require a tracheotomy).
Immediately after intubation
- Check symmetry of chest expansion
- Auscultate breath sounds of anterior and lateral chest bilaterally
- Obtain capnography or end-tidal CO2 as indicated
- Ensure chest x-ray obtained to verify proper tube placement
- Check cuff pressure every 6-8 H
- Monitor for S & S of aspiration
- Ensure high humidity; a visible mist should appear in the T-piece or vent tubing
- Admin O2 concentration as prescribed by the HCP
- Secure the tube to the pts face with tape and mark the proximal end for position maintenance
– Cut proximal end of tub if it is longer than 7.5 cm (3 inches) to prevent kinks
– Insert an oral airway or mouth device if orally intubated to prevent the pt from biting and obstructing the tube - Use sterile suction and airway care to prevent iatrogenic contamination and infection
- Continue to reposition pt every 2 H and as needed to prevent atelectasis and to optimize lung expansion
- Provide oral hygiene and suction the oropharynx whenever necessary
Nurses responsibilities following intubation
Work with RT to ensure that the tube is placed correctly and remains in place.
Remember once the airway is secure, it is the nurses primary job to ensure that the pt is safe. That includes:
– Checking cuff pressure to make sure that we aren’t causing tracheal tissue damage
– Prevent aspiration (often that includes use of a proton pump inhibitor which will also help prevent stress ulcers.
– Ensuring that the tube is secure and that surrounding skin is cared for.
– Proper suctioning technique to prevent infection and tissue injury
– Reposition the pt
– ORAL CARE
normal pH
7.35 (A) -7.45 (B)
normal PaCO2
35 (B) -45 (A)
normal HCO3
22 (A) -26 (B)
A = & B=
acidosis
alkalosis (base)
acidosis &/or alkalosis
if pH is low its acidosis and if it is high it is alkalosis
respiratory &/or metabolic
if pH is acidosis and the CO2 is high = respiratory acidosis, if the pH is alkalosis and the bicarb is high = metabolic alkalosis.
If PaCO2 and HCO3 are both out of range, determine which one is the most out of range to determine if it is respiratory or metabolic.
PaCO2 = respiratory & HCO3 = metabolic.
fully compensated
pH is within normal range (7.35-7.45).
uncompensated
pH is out of range, either the PaCO2 or HCO3 is in range.
partially compensated
pH, PaCO2, and HCO3 are all out of range.
Chest tube management: patient
Ensure that the dressing on the chest around the tube is tight and intact.
Assess for difficulty breathing
Assess breathing effectiveness by pulse ox
Listen to breath sounds for each lung
Check alignment of traces
Check tub insertion site for contain of the skin. Palpate area for puffiness or crackling that may indicate subQ emphysema
Observe site for signs of infection (redness, purulent drainage) or excessive bleeding
Check to see if tube “eyelets” are visible
Assess for pain and its location and intensity, and admin drugs for pain as prescribed
Assist patient to deep breathe, cough, perform maximal sustained inhalations, and use incentive spirometry
Reposition the pt who reports a “burning” pain in chest
