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Unit 1 > Gas Exchange: ARDS > Flashcards

Gas Exchange: ARDS Flashcards

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1
Q

How to determine proper placement of tracheostomy tube

A

Chest X-ray

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2
Q

Immediate post-op care for tracheostomy

A

Ensure airway,
Confirm bilateral breath sounds,
Resp assessment Q 2hr,
Assess for complications

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3
Q

Complications after tracheostomy

A 
Tube obstruction,
Dislodgement and accidental decannulation,
Pneumothorax,
Subcutaneous emphysema,
Bleeding,
Infection
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4
Q

S/S of Tracheostomy tube obstruction

A 
Difficulty breathing,
Noisy respirations,
Difficulty inserting suction catheter,
Thick, dry secretions,
Unexplained peak pressures (w/ mech. Vent.)
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5
Q

Prevention of tracheostomy tube obstruction

A 
Assess at least hourly for patency,
Prevent obstruction by having pt cough & deep breathe,
Provide inner cannula care,
Humidify O2 source,
Suction as needed
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6
Q

How to prevent trach tube dislodgement and decannulation

A

Secure tube in place
(If happens in 1st 72 hrs is emergency),
Trach tube replacement of same size or one size smaller should be at bedside along with trach insertion tray

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7
Q

Assess for subcutaneous emphysema in pt with Tracheostomy

A

Inspect and palpate for air under the skin (crepitus)

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8
Q

Assess for bleeding in pt with new tracheostomy

A

Small amounts are normal; constant oozing is not,

Wrap gauze around tube and pack into the wound to apply pressure to bleeding sites

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9
Q

Infection prevention for tracheostomy tubes

A

Use sterile technique during suctioning and trach care,
Assess stoma for s/s of infection,
Use stoma dressings to keep clean & dry,
General careful wound care

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10
Q

Tissue damage prevention for tracheostomy pt

A

Keep cuff pressure between 14-20 mm Hg or 20-30 cm H2O,

Check pressure once per shift

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11
Q

Other issues for potential tissue damage in pt with trach

A 
Malnourished,
Dehydrated,
Hypoxia,
Older,
Receiving corticosteroids,
Tube friction and movement
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12
Q

Reduce tracheostomy tissue damage

A 
Maintain proper cuff pressure,
Stabilize tube,
Suction only PRN,
Prevent and treat malnutrition, dehydration, and hypoxia,
Humidify the air
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13
Q

Practices for suctioning pts with artificial airway

A 
Assess need,
Check suction source; pressure should be between 80-120 mm Hg,
Set up sterile field,
Preoxygenate pt for 30 sec-3 min,
Insert catheter until resistance,
Withdraw over 10-15 sec with int suction,
Hyper oxygenate 1-5 min to pt baseline,
Repeat PRN up to 3 times,
Suction mouth and provide mouth care,
Document secretions and pt response
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14
Q

When to suction tracheostomy pt

A 
Secretions are audible or noisy,
Crackles or wheezes are heard on auscultation,
Increased pulse or resp rates,
Mucus in artificial airway,
Pt request,
Increase in peak airway pressure
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15
Q

Prevent hypoxia when suctioning tracheostomy pt

A

Hyperoxygenate pt with 100% O2

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16
Q

Prevent tissue trauma from frequent suctioning of trach pt

A 
Suction only as needed,
Lubricate catheter,
Apply suction only during withdrawal,
Use twirling motion during withdrawal,
Use intermittent suction for 10-15 sec only,
Use sterile technique,
Suction mouth AFTER airway
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17
Q

Tracheostomy care

A

Wash hands; don PPE,
Suction if needed,
Remove old dressings and excess secretions,
Set up sterile field,
Remove and clean inner cannula or replace it,
Clean stoma site,
Change trach ties (secure new in place before removing old),
Document secretions, stoma, surrounding skin, pt response, and teaching/learning

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18
Q

Oral hygiene

A 
Use sponge tooth cleaner or 
Soft bristled toothbrush moistened in water,
Help pt rinse with NS Q4 while awake,
Examine mouth for sores or dental probs,
Apply lip-balm
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19
Q

Prevent aspiration in pt with trach

A

Avoid meals when pt fatigued,
Provide smaller more frequent meals,
Don’t hurry the pt,
Provide close supervision if pt is self-feeding,
Keep emergency suction equip nearby and ready,
Avoid thin liquids; thicken liquids,
Position pt as upright as possible,
Partially or completely deflate cuff during meals as tol,
Suction after cuff deflation to clear airway,
Encourage to eat slowly and dry swallow,
Avoid consecutive swallows of liquids,
Teach to tuck chin and move forehead forward while swallowing,
Pt controls next bite,
Monitor resp status,
HOB elevated for >30 min

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20
Q

Promote communication for trach pt

A 
Writing tablet,
Magic slate,
Communication board,
Flash cards,
Hand signals,
Computer,
"Yes" or "no" questions
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21
Q

Promote psychosocial needs of pt with trach

A

Allow time for communication,
Set realistic goals,
Promote self-care,
Provide encouragement & positive reinforcement,
Provide acceptance & caring behaviors,
Assess for need for counseling

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22
Q

Discharge needs/teaching for trach pt

A

Care for trach tube,
Clean suction technique,
Use shower shield over trach tube when bathing,
Cover airway lightly with cotton cloth to protect during the day,
Increase humidity in the home,
Use communication method that began in hosp,
Wear Med Alert bracelet identifying inability to speak,
Provide outside referrals as needed

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23
Q

Priority problems for pt’s requiring tracheostomy

A 
Reduced oxygenation,
Inadequate communication,
Inadequate nutrition,
Potential for infection,
Damaged oral mucosa
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24
Q

How to prevent VAP

A

“Ventilator Bundle”:
Hand hygiene,
Oral care,
HOB elevation

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25
ARDS is acute respiratory failure with:
``` Hypoxemia persisting with 100% O2, Decreased pulmonary compliance, Dyspnea, Noncardiac associated bilat pulmonary edema, Dense pulmonary infiltrates on XR ```
26
What is associated with ARDS?
``` Occurs after acute lung injury such as: Sepsis, Pulmonary embolism, Shock, Aspiration, Inhalation injury, History of hyper-inflammatory response, Severe neurological damage, Fluid leads to alveolar collapse, Unresponsive to oxygenation ```
27
Direct lung injury causes of ARDS
``` Aspiration of acidic gastric contents, Lung radiation, Submersion in water with aspiration, Inhalation of toxic gases, Trauma, Sepsis, Drowning, Burns, DIC ```
28
Prevention of ARDS
Early recognition of pts at high risk for the syndrome, Monitor those at risk for aspiration, Follow meticulous infection control
29
Diagnostic of ARDS
ABG that shows lowered partial pressure of arterial O2, Diffuse haziness of lung on X-RAY, Hemodynamic monitoring with pulmonary artery catheter, Respiratory acidosis
30
Interventions for ARDS
``` Intubation, Conventional mechanical ventilation with PEEP, Sedation and paralysis may be needed, Corticosteroids, Antibiotics, Conservative fluid therapy, Enteral or parenteral nutrition ```
31
Tension pneumothorax
``` Can be side effect of PEEP, Can occur from trauma, Absence of breath sounds on one side, Asymmetry of thorax, Tracheal movement away from midline, Distended neck veins, Hypotension, Hypertympanic sound to percussion, Assess lung sounds hourly, Suction PRN ```
32
ARDS phase 1
Dyspnea & tachypnea, | Support the pt and provide O2
33
ARDS phase 2
Increasing pulmonary edema, | Use mechanical ventilation and prevention of complications
34
ARDS phase 3
``` Days 2-10: Pt has increasing hypoxemia, Deliver adequate O2, Prevent complications, Support lungs ```
35
ARDS phase 4
``` Pulmonary fibrosis with progression, Irreversible, Permanent lung damage, Prevent sepsis, pneumonia, and multi-organ dysfunction syndrome (MODS), Wean pt from vent ```
36
Mechanical ventilation
Temporary life-support technique, May be life-long, Most often used for hypoxemia and progressive alveolar hypo ventilation with resp acidosis, Pts who need vent support after surgery, Pts who expend too much energy with breathing, Pts who have general anesthesia or heavy sedation
37
Endotracheal intubation
Artificial airway, Short term basis, Passed through nose or mouth into trachea, Tip of tube rests 2 cm above the carina, Usually performed as emergency, Pt cannot talk due to inflated cuff at distal end
38
Purpose of intubation
Maintain patent airway, Provide means to remove secretions, Provide ventilation and oxygen
39
Nurse actions during intubation
Coordinates response, Monitors for changes in VS, Monitors for signs of hypoxemia, aspiration, and dysrhythmias, Ensures no attempt lasts longer than 30 sec, Provides oxygen between attempts, Suctions PRN
40
Verification of E-tube placement
``` End-tidal CO2 levels, Chest X-ray, Assess breath sounds, Assess symmetrical chest movement, Assess air moving out of ET tube, If abdomen is distended, tube is in esophagus ```
41
Nursing care for ET tube
``` Tube placement, Cuff leak, Chest wall movement, Prevent dislodgment, Respiratory status, pulse ox, ABGs, Check vent settings Q8, Check alarms, Observe PEEP setting, Empty vent tubing, Check delivered air temp (humidity), Suction PRN, Assess mouth PRN perform care Q2, Change tape PRN, Assess for GI distress, Monitor I&O, Turn pt Q2, Schedule care for rest intervals, Monitor progress, Monitor for adverse effects, Monitor readiness to wean, Provide method of communication ```
42
Types of ventilators
Pressure-cycled, Time-cycled, Volume-cycled, Microprocessor
43
Modes of ventilators: | Assist-control (AC)
Used as a resting mode; Vent takes over as needed; Responds to inspiratory effort and delivers tidal volume while pt allows rate
44
Modes of ventilators: | Synchronized intermittent mandatory ventilation (SIMV)
Allows spontaneous breathing at the pts rate and tidal volume between breaths
45
Ventilator modes: | Bi-level positive airway pressure (BiPAP)
Noninvasive pressure support ventilation by nasal mask or face mask
46
Modes of ventilators: | Peak airway pressure (PIP)
Pressure used by the ventilator to deliver a set tidal volume at a given lung compliance
47
Modes of ventilators: | Continuous positive airway pressure (CPAP)
Applies positive airway pressure throughout resp cycle for spontaneously breathing pts
48
Modes of ventilators: | Positive end expiratory pressure (PEEP)
Indicates severe gas exchange problem | Prevents alveoli from collapsing because it keeps the lungs partially inflated
49
Nursing management
Address concerns of pt and family; Explain the purpose of vent; Encourage pt and family to express concerns; "ICU psychosis" pt needs frequent repeated explanations and reassurance; Be concerned with pt first and vent second; Understand any chronic health problems
50
Monitor pt response
``` Assess vs; Listen to breath sounds every 30-60 min; Monitor resp parameters; Check ABGs; Assess breathing pattern and breath sound r/t vent cycle; Determine need for suctioning; Assess area around ET tube Q4; Pace activities; coordinate with physician; Provide communication tools; If pt goes into resp distress, remove vent, bag/mask ventilate, call for help ```
51
Manage ventilator
``` Perform and document vent checks; Respond promptly to alarms; Compare prescribed setting with actual setting; Check water level and temp; Remove condensation in tubing ```
52
Potential complications with vent pt
Hypotension-avoid valsalva maneuver; Fluid retention-monitor I&O; Lung problems; Stress ulcers-antacids, sucralfate, histamine blockers, or proton-pump inhibitors may be prescribed; Paralytic ileus-parenteral support; Malnutrition-ensure balanced nutrition via diet, enteral feedings, or parenteral feedings; Infection-infection control adherence, oral care Q2, pulmonary hygiene; Muscle deconditioning-get pt out of bed; Vent dependence-attempt occasional weaning
53
Extubation
``` Hyper oxygenate pt; Suction pt; Rapidly deflate cuff; Remove tube at peak inspiration; Instruct pt to cough; Monitor VS Q5 min; Assess for resp distress; Teach pt: Semi-fowlers position; Deep breaths Q30 min; IS Q2; Limit speaking; Normal to be hoarse and have sore throat ```
54
Pulmonary contusion
Occurs most often with rapid deceleration after car crashes; Resp failure develops over time; Pt becomes hypoxemic and dyspneic; May be asymptomatic then develop resp failure; Often leads to ARDS
55
S/S of pulmonary contusion
``` Bloody sputum; Decreased breath sounds; Crackles; Wheezes; X-ray may show no abnormalities until after several days ```
56
Pulmonary contusion management
Maintenance of ventilation; Oxygenation; Monitor central venous pressure; Restrict fluid intake as needed
57
Flail chest
Inward movement of thorax during; inspiration with outward movement on expiration; Often involves one side of the chest; Results from multiple rib fractures; Can result during CPR
58
Flail chest S/S
``` Impaired gas exchange, coughing, and clearance of secretions; Paradoxic chest movement; Dyspnea; Cyanosis; Tachycardia; Hypotension; Anxious, SOB, in pain ```
59
Interventions for flail chest
Humidified O2; Pain management; Promotion of lung expansion through deep breathing; Secretion clearance by coughing and tracheal aspiration; Mechanical ventilation; monitor ABGs; Stabilized by PEEP; Monitor VS and fluid & electrolyte balance; IV fluids; Analgesics; Psychosocial support
60
Patient management with chest tube
Dressing around tube tight and intact; Assess for difficulty breathing; Assess pulse ox; Listen to breath sounds bilat; Assess skin at insertion site; Check to see if tube eyelets are visible; Assess for pain (note location and intensity); Assist pt to deep breathe, cough, perform maximal sustained inhalations, and IS; Reposition pt who reports burning in chest
61
Drainage system management of chest tubes
Do not strip the tube; Keep drainage system lower than pt chest; Keep tubing as straight as possible; avoid dependent loops; Ensure connections are secure; Bubbling in water seal chamber should only occur on expiration, coughing, and position change; Assess for tidaling; Check water levels and maintain; Clamp tube only for short periods; Assess and document fluid in collection chamber; Change system before drainage fills chamber; Draw specimen from tube after cleansing with 20 gauge needle/syringe
62
Emergency with chest tube
Tracheal deviation; Sudden onset or increased intensity of dyspnea; O2 sat70 mL/hr; Visible eyelets on chest tube; Chest tube falls out (first cover area with sterile gauze); Drainage in tube stops within first 24 hrs
63
Focused assessment for ARDS
Chest rise (symmetric?); Lung sounds; Dyspnea; Pain with breathing
64
Ventilatory failure
Chest pressure does not change enough to permit air movement (mechanics of breathing); Perfusion is normal, ventilation is inadequate; Caused by trauma, weak muscles, high spine injury, opioids...
65
Oxygenation failure
Air movement and oxygen intake are normal, but lung flow is decreased; Ventilation is normal, perfusion is inadequate
66
Tidal volume
Amount of air delivered with each breath
67
Rate
The set respiratory rate of the pt or machine
68
Mode
Method the machine uses to deliver breaths: Assist Control (AC); Synchronized Intermittent Mandatory Ventilation (SIMD); Maximum Mandatory Ventilation (MMV)
69
FiO2
Percentage of oxygen delivered by machine
70
PEEP
Positive End-Expiratory Pressure
71
When to suction?
``` PRN, not scheduled; High pressure alarm; Secretions; Coughing; Wheezing, rhonchi; Decreased O2 sat ```
72
How to suction
``` Sterile; Hyper oxygenate before and after; No more than 10-15 seconds per suction; No lavage before; Intermittent suction with withdrawal ```

Unit 1 (4 decks)

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