Exam 2 Resp Failure And Mechanical Ventilation Flashcards
(87 cards)
1
Q
What is acute respiratory failure
A
Loss function of lungs needed to provide adequate O2 to organs and tissue/blood
2
Q
Hypoxemia value
A
PaO2 < 60
3
Q
Hyper capnea value
A
Paco2 > 50
4
Q
Acidosis valué
A
Ph < 7.35
5
Q
What happens in hypoxemic RF (type 1 ARF) with Pao2? What conditions may cause it and how does it effect lungs and oxygenation?
A
- think interference of proper lung function
- Pao2 decreases below 50 mmhg on room air
- Pulmonary edema and acute lung injury —> interferes with lungs ability to bring in O2
6
Q
What happens in hypercapnic RF (type 2 ARF)with PCO2? What conditions cause this to happen?
A
- Paco2 > 50 mmhg
- increased work of breathing can occur due to airflow obstruction (secretions) or poor respiratory compliance, decreased muscle power (nueromuscular diseases or spinal injury), patients on PCA/too many sedatives depresses resp drive —> high Paco2 and low oxygen
7
Q
What are signs and symptoms of a patient in RF?
A
- altered mental (agitation, somnolence, sleet, anxiety, confusion)
- peripheral or central cyanosis
- low sao2 on pulse ox
- tachypnea
- tachycardia, HTN, diaphoresis
- accessory muscle use (nasal flare, retractions, intercostal indraw, abdominal paradoxical breathing, increased work of breathing)
- abnormal ABGs (low pao2, high co2, etc)
8
Q
What is the goal/plan of care during the urgen resuscitation phase of ARF? What about the ongoing care phase?
A
- urgent resuscitation = stabilize patient (intubation occurs here)
- ongoing phase = identify or diagnose underlying cause and implement therapies aimed to alleviate/treat cause of ARF
9
Q
What are some examples of care that is involved in ARF management?
A
- Airway control is number one!!!
- oxygen admin
- ventilator management
- stabilize circulation
- bronchodilators/ steroids
- identification of cause
10
Q
What is type 4 cause of ARF?
A
- shock, leads to CV collapse which prevents proper oxygenation to lungs and body
11
Q
What are some therapeutic management techniques that go with ARF and how do they help physiologically?
A
- peep (keeps alveoli open)
- fluid support (maintain cv)
- inotropes or vasopressors to manage hypotension due to hypovolemia (with ARD fluid may be in lungs instead of in CV)
- paralysis, neuromuscular blocks, sedatives, analgesics to improve patient/ventilator synch
- nutrition enteral or parenteral to maintain GI needs
- repositioning patient to promote drainage of secretions, prone position to help with oxygenation
12
Q
What is ARDS?
A
Inflammation from lung injury leads to alveolar damage, increasing permeability of capillaries —> pulmonary edema —> poor gas exchange, hypoxemia, infiltrates on X-RAY, poor lung compliance, more dead space, REFRACTORY HYPOXEMIA
13
Q
What type of things can trigger ARDS
A
Shock, trauma, COPD, HF
14
Q
What is Pao2/Fio2 ratio and what does it tell us? What is a normal value?
A
- This is a ratio of arterial oxygen to percent of inspired oxygen
- will tell us if hypoxemia is happening
- PF ratio of 380 or more is normal
15
Q
What formula gives us pao2 value?
A
Pao2 = fio2 x 500
16
Q
What does the patient with ARDS present with in regards to sxs?
A
-sever SOB
- arterial hypoxemia (Pao2 <60)
- refractory hypoxemia (does not respond to supplemental o2)
- cheat X-ray with bilateral infiltration
- intercostal retractions
- crackles
- cyanosis, pallor
- retractions
- altered LOC
17
Q
What are classifications of ARDS
A
Mild = 200-300 p/f ratio
Moderate = 100-200 p/f ratio
Severe = < 100 p/f ratio
18
Q
What is the difference between ventilation and respiration?
A
- Ventilation is the process of moving gasses in and out of the lungs
- respiration involves the exchange of gas in the alveoli
19
Q
What are some aspects of mechanical ventilation?
A
- fio2, Vt, respiratory rate, and mode
20
Q
What is fraction of inspired air or fio2? What percentages can this be set at?
A
- Fio2: preset oxygen concentration
- can be set between 21-100%
21
Q
What is tidal volume (Vt)? What are the 3 ranges this can be set to?
A
- tidal volume : preset volume
- 8-10 ml / kg
- 6-8 ml / kg(COPD)
- 4-6 ml / kg(ARDS)
22
Q
What is rate (r) or frequency(f)? What is the tang for this?
A
- rate or frequency is the RR set
- the range is 12-20 bpm
23
Q
What is PEEP/CPAP? What is the range for this?
A
- partial end expiratory pressure (also referred to as CPAP)
- range for PEEP is 2-5 mmHg
24
Q
What are modes meant for?
A
- this is how the machine and patient interact (like a couple communicating with each other)
- provide different levels of support
25
What kind of things do you report in regards to the ventilator to the oncoming nurse during shift report?
1. Say wether it is volume or pressure controlled
2. Say what mode is being used
3. Say RR
4. Vt being delivered
5. Fio2
6. PEEP
7. Pressure support added
26
What is hypoxemic RF? What conditions are associated with this?
- hypoxic RF means failure to oxygenate, where hypoxemia is severe (pao2 < 60 on fio2 > 60%)
- conditions associated with Hypoxemic RF are ARDS, severe pneumonia, HF pulmonary edema, PE
27
What is hypercapnic RF? What conditions are associated with this?
- hypercapnic RF is considered failure to ventilate, with paco2 >50 and PH <7.30
- conditions associated with this are obstructive lung diseases (COPD, asthma), CNS depression(sedatives, narcotics, OD), neuromuscular (head injury, spinal injury), neuropathies (polio, GBS, muscle dystrophy)
28
What is combined hypoxemia with hypercapnic RF? What conditions cause this?
- severe hypoxemia with respiratory acidosis
- pneumothorax , pleural effusion
29
How does recovery from anesthesia contribute to potential need for mechanical ventilation?
- operational recovery from anesthesia and paralyzing agents can contribute to decrease in proper lung functioning
30
What are pressure cycled ventilators?
Preset pressure is sent for inhalation
31
What are volume cycled ventilators?
-delivers preset constant amount of tidal volume of air each inspiration
32
What is a potential complication from volume cycled ventilators?
- barotrauma can occur from excess positive pressure, which can cause pneumothorax
33
How does decrease in lung compliance pose a risk for barotrauma?
If there is more resistance due to decrease in lung compliance, vent will still wants to push set amount of volume so will increase pressure to force it in leading to Barotrauma
34
What is assist control ventilation? What type of patients might benefit from this?
- full support from vent
- Ventilator is in control of breathing
- set volume or pressure will be sent to patient each inspiration and set RR
-patient can still breath but set volume or pressure still determined by vent
- paralyzed patients, apneic patients
35
What is SIMV? What pts can use this type of mode? What do we look at to determine if pt is ready for this mode?
- team effort
- Preset volume or pressure and RR delivered but “steps back” when pt takes breath
-weaning mode
- patients who demonstrate decent resp drive or able to generate spontaneous breaths or pts who tired easily by breathing
- balanced ABGs
36
What is pressure support ventilation? What other mode can it be used on? What type of pts would this be used on?
- NO VENT BREATHS
- maintains airways open using positive pressure to support patients own breathing
- volume is determined by patient (not constant or guaranteed)
- can be used on SIMV
- pts with muscle weakness or are hard to wean
37
What value indicates respiratory acidosis?
Paco2 increased (from patient not breathing enough) and low Ph
38
What ventilation changes would need to be made for a patient in respiratory acidosis?
- increase RR to blow off CO2
- increase tidal volume or minute ventilation(RR x tidal volume)
39
What value indicates respiratory alkalosis?
LOW paco2, high pH
40
Why might a patient be in respiratory alkalosis (causes)?
- Decreased lung compliance (lung stiff) so work hard to breath
- pain, anxiety can also cause tachypnea
41
What can we change on the vent to help with respiratory alkalosis?
- decrease RR (allow co2 to go back up)
- mode change bc being HYPERVENTILATED and may need less support (cause of tachypnea maybe from breathing over vent)
42
What value indicates hypoxemia?
Low Pao2 and or dropping Spo2
43
What would you do if patient is experiencing hypoxemia?
- assess for cause of hypoxemia
- adjust fio2 to maintain spo2 at ordered level (ie above 90%)
- adjust PEEP to involve alveoli (5+ or more)
- patient positioning (prone and good lung down can improve O2 levels
44
How can we prevent patient from pulling out tubing or self extubation
Alternatives to decrease agitation, titration sedation, restraints if needed
45
What pressure should ET cuff be kept at?
20-25 mmHg
46
How can we promote skin integrity for vent patients?
Skin assessments, reposition patient
47
What are ways to address possible agitating factors?
- pain relief
- promoting comfort measures
- anxiety management
- explaining procedures before
48
How can mobility be encouraged on vent patients
Collaborate with PT/OT, passive ROM exercises
49
What measures can help prevent VAP?
-maintain bed at 30-45 degrees (never supine!!!)
- tracheostomy care Q8H
- daily chlorohexidine Q4H
- continuous assessment if patient can be extubated (weaning, spontaneous breathing trials)
- report fever or temp increase (100.4F)
- report changes in sputum color
- suction PRN (ie ronchi)
50
What causes barotrauma and pneumothorax? What would we see if patient is experiencing this?
- Positive pressure on airways (high volumes, high PEEP)
- look for indications of low O2 (low O2 sat, signs of respiratory distress)
51
What causes low cardiac output in vent patients?
Caused by excess pressure into lungs —> decrease CO from poor venous return and hypotension
52
How can we assess for low CO?
- Assess hemodynamics (BP, HR, CVP, wedge, urine output )
- patient would show signs of hypoxia such as tachycardia, tachypnea, cyanosis, etc
53
What causes aspiration? How can we prevent this?
- low cuff pressure of ET tube can cause aspiration (maintain cuff at 20-25 hhmg)
- suction patient as indicated
54
How do we promote GI health? What are vent patients at risk for?
- pud prophylaxis
- risk for stress ulcers, GI bleed risk, risk for aspiration
55
How can we promote pyschosocial well being in patients on vent?
- explain purpose for procedures and points of care to alleviate anxiety
- identify alternative communication techniques (communication board, hand signals)
- stress management alternatives (comfort measures, music, tv, relaxation techniques)
- openly discuss hard topics and address questions (ie DNR preferences)
56
What are causes of high pressure alarm?
Bronchospasm, pulmonary secretions, coughing, kinked vent tube, kinked ET tube, biting tubing, fighting ventilator, improper vent settings
57
What do you do if patient has excess secretions
Suction patient PRN
58
What does rattling sound indicate?
Patient has ronchi and needs suction
59
What do you do if the vent tubing is kinked?
Assess tubing and straighten out
60
How would we know if the ET tube is kinked and what would you do to fix this?
- you wouldn’t be able to get suction in, O2 sat dropping, or would see on CX
- BAG PATIENT bc airway is compromised
61
Patient is biting tubing, intervention??
- Mouth guard device to prevent biting
- if patient is agitated made need more sedation
- or patient may be fighting vent (mode change)
62
What do you do if there is water in tubing?
Empty drain reservoir and tubing if needed
63
What do you do when patient is fighting the vent?
- May require mode change, discuss with RT
- assess O2 levels
64
If vent settings are suspected to be improper for patient, what do you do?
- assess for hypoxia
- assess for poor coordination between patient and vent
- BAG PATIENT
65
What causes low pressure alarm to go off?
Leak in circuit or tube cuff, disconnected tubing, self extubation
66
How would you know if there is a leak in the ET cuff? What would you do if there is a leak in ET cuff?
- patient able to talk, possibly can hear leak, or pilot would be under-deflated
- cuff would need to be replaced
- BAG PATIENT
67
What do you do if there is a leak in the system?
- BAG PATIENT
- vent tubing needs to be changed
68
What do you do if the patient self extubates
BAG PATIENT
CALL FOR HELP
69
If apnea alarm keeps going off and patient is on RR of 2 bpm as back up rate, what would the nurse do?
- patient may require more assistance breathing
- identify cause of apnea, increase RR, BAG PATIENT
70
What if the vent alarm indicates the vent is inoperable, what would you do?
BAG PATIENT
71
If you are unsure of what is wrong with the vent what would you do?
BAG PATIENT
72
If patient is in respiratory distress and you do not know what is causing it, what should you do?
BAG PT, CALL FOR HELP
73
What is spontaneous breathing trial?
Periods of spontaneous breathing with added pressure support or CPAP to help with work of breathing, used for weaning
74
How would we use SIMV to wean patients
Gradually decrease RR with added pressure support or CPAP
75
What does rapid weaning look like?
SIMV to CPAP to extubation
76
What does gradual weaning look like
AC to SIMV to CPAP to extubation
77
What does periodic weaning look like?
Back and forth (from AC to cpap then AC to cpap)
78
What would RR, Vt, fio2 value, and respiratory pattern look like in a successfully weaned patient
- RR <30
- Vt <300 no
- fio2< 50%
- unlabored breathing
79
What is the nurses responsibility during the weaning process
- titration of sedation
- monitoring vitals for pt response
- collab with RT and MD
80
What value reflects hyperventilation?
- LOW paco2 (less than 35)
- LOW pH (less than 7.35)
81
What changes can be made in regards to mechanical ventilation when the patient is being hyperventilated?
- decrease RR to bring CO2 back UP
- Patient also may require different level of support bc patient may be breathing over machine leading causing tachypnea
82
What values might reflect hypoventilation?
- high Paco2 (above 45)
- High pH (above 7.45)
83
When the patient is being hypoventilated, what changes on ventilation should be made?
- increase RR to lower CO2
- increase tidal volume or minute ventilation (RR x tidal volume)
84
A patient is hypoxemic AEB what value?
- LOW pao2, LOW sao2
85
When a patient is hypoxemic, what ventilator changes should be made?
- adjust fio2 to maintain proper O2 sat (ie: above 90%)
- adjust PEEP to bring in more oxygen
86
A patient is hypoxic with respiratory acidosis, what ABG values would reflect this?
- LOW Pao2( less than 80 mmhg)
- HIGH paco2 (>50)
- LOW pH
87
In a patient with hypoxemia and respiratory acidosis, what ventilator changes would you expect?
- increase RR to blow off CO2
- increase fio2 to bring up O2
- increase PEEP to bring in more O2
