oxygen therapy

Question 1

whats the goal of oxygen therapy

Answer 1

deliver the least amount necessary

Question 2

name some low flow devices

Answer 2

Nasal Cannula
Face mask
Venturi mask
Nonrebreather

Question 3

describe acute respiratory failure

Answer 3

Inadequate gas exchange
Usually occurs secondary to another disorder
Problem with oxygenation or CO2 elimination or both
ABGs reveal hypoxemia and/or hypercapnia

Question 4

causes of respiratory failure

Answer 4

Intrapulmonary
Lower airways, alveoli, pulmonary circulation, alveolar-capillary membrane

Extrapulmonary
CNS injury, neuromuscular disorders, thorax, pleura, upper airway disorder

Question 5

treatment of respiratory failure

Answer 5

Improve oxygenation &/or ventilation
Non-invasively if possible (CPAP/BiPAP/NIV mask)
Intubation if necessary
Treat cause

Question 6

describe non-invasive ventilation and give examples

Answer 6

Uses a mask that fits tightly over the mouth and nose, or just the nose

BiPAP – Positive pressure on both inspiration AND expiration; inspiratory and expiratory pressures are different. IPAP & EPAP

CPAP – Continuous Positive Airway Pressure; inspiratory pressure and expiratory pressure is the same

Question 7

nursing considerations for NIV

Answer 7

Airway protection
Nutrition & Hydration
Oral care
Skin care
Communication

Question 8

describe intubation

Answer 8

Tube is placed in trachea - between vocal cords – can not speak
Tube is placed 2-3 cm above carina
ETCO2 monitor– color change (purple to yellow) assures correct placement ETCO2
Breath sounds heard equally bilaterally
Chest x-ray for placement
Coughing - indicates need for suctioning or inappropriate tube placement

Question 9

intubation nursing interventions

Answer 9

Ensure equipment is ready (intubation tray, ambu bag, suction)
Ensure pulse oximeter is in place, BP cuff
Administer medications (sedative, paralytic) as directed
Monitor time during each attempt–Each attempt should be limited to 30 seconds
Monitor vital signs!
Secure and note placement

Question 10

what are some goals of mechanical ventilation

Answer 10

Improve ventilation
Decrease work of breathing
Correct inadequate breathing patterns
Improve oxygenation

Question 11

what ventilator setting affect the amount of air being moved in and out of the lungs (ventilation) and what ABG values are affected

Answer 11

tidal volume: size of each breath
rate: number of breaths per minute

affect PaCO2 and indirectly pH

Question 12

name some ventilation modes

Answer 12

Assist Control (AC)
Synchronized Intermittent Mandatory Ventilation (SIMV) or (IMV)
Pressure Support Ventilation (PSV)

Question 13

describe assist control (A/C)

Answer 13

Ventilator delivers a preset tidal volume at a preset rate. The patient will never get fewer breaths than the preset rate. The patient CAN trigger an additional breath and then the ventilator kicks in and delivers the full preset tidal volume

Question 14

describe Synchronized Intermittent Mandatory Ventilation (SIMV/IMV)

Answer 14

Ventilator delivers a preset volume at a preset rate. In between mandatory breaths, the patient can breathe spontaneously, with a pressure-supported breath. However, the tidal volume of the patient-initiated breaths will only be as large as the patient is strong enough to inspire.

Question 15

advantages of SIMV

Answer 15

Helps keep respiratory muscles active and coordinated
Can be used as a weaning mode. As the patient improves, the preset rate is decreased, and the patient assumes greater responsibility for breathing on his/her own.
If the patient stops breathing for any reason, he/she will still receive the preset volume at the preset rate.

Question 16

describe pressure support

Answer 16

when on IMV or Spontaneous breathing trial, this “boost” from the ventilator increases spontaneous breath volume and makes it easier for the patient to inspire.

It is meant to overcome the increased airway resistance afforded by the ETT, so the patient does not have to work as hard to initiate a breath. This facilitates weaning, and the amount of support is gradually reduced as the patient is weaned.

Positive pressure to augment patient’s inspiratory efforts
May be used with SIMV or during breathing trial
May be used as the primary mode of ventilation
Weaning modality

Question 17

what vent settings affect oxygenation

Answer 17

FiO2 (Fraction of Inspired Oxygen)
PEEP (Positive End Expiratory Pressure)

Question 18

what is FiO2

Answer 18

Fraction of Inspired Oxygen
The percentage of oxygen delivered via the ventilator
30-100%

Question 19

what is PEEP

Answer 19

Positive pressure applied at the end of expiration of ventilator breaths
Increases oxygenation by preventing collapse of alveoli
Maximizes the number of alveoli available for gas exchange
Typically set at 5 cm H2O, can be increased as necessary

Question 20

what are some complications of PEEP

Answer 20

Hemodynamic compromise d/t decreased venous return
Volutrauma or barotrauma

Question 21

If a patient’s ABG results indicate an elevated PaCO2, what changes on the ventilator may be ordered to correct this?

Increase FiO2
Increase PEEP
Decrease TV
Increase rate

Answer 21

Increase rate

Question 22

If a patient’s ABG results indicate a low PaO2, what changes on the ventilator may be ordered to correct this?

Increase FiO2
Decrease PEEP
Decrease TV
Increase rate

Answer 22

Increase FiO2

Question 23

potential complications of mechanical ventilation

Answer 23

Aspiration
Barotrauma and Pneumothorax
Ventilator-associated pneumonia
Decreased cardiac output
Decreased fluid balance
Immobility
GI problems
Muscle weakness
Self-extubation
Ventilator dependence

Question 24

whats the ABCDEF bundle

Answer 24

Assess, prevent and manage pain
Both spontaneous awakening trials and spontaneous breathing trials daily
Choice of analgesia & sedation
Delirium: Assess, prevent & manage
Early mobility and exercise
Family engagement and empowerment

Question 25

ABCDEF bundle benefits

Answer 25

Decreased ventilator time Decreased ICU length of stay Improved return to normal brain function Increased independent functional status Improved patient and family satisfaction Increased survival

Question 26

ICU Delirium Nonpharmacologic Interventions Pain:

Answer 26

Monitor and manage pain using an objective scale (e.g., FACES FLACC, CPOT, etc.)

Question 27

ICU Delirium Nonpharmacologic Interventions Orientation:

Answer 27

Convey the day, date, place, and reason for hospitalization Update the whiteboards with caregiver names Request placement of a clock and calendar in room Discuss current events

Question 28

ICU DeliriumNonpharmacologic Interventions Sensory:

Answer 28

Determine need for hearing aids and/or eye glasses Provide these for patient when appropriate

Question 29

ICU DeliriumNonpharmacologic Interventions Sleep:

Answer 29

Noise reduction strategies (e.g. minimize noise outside the room, offer white noise or earplugs) Normal day-night variation in illumination Use “time out” strategy to minimize interruptions in sleep Promote comfort and relaxation (e.g., back care, oral care, washing face/hands, and daytime bath, massage)

Question 30

VAP prevention aspiration prevention techniques

Answer 30

Maintain adequate ETT cuff pressure Check pressure q shift with a manometer HOB 30-45 degrees Use sedation as sparingly as possible Verify correct feeding tube placement Consider swallowing evaluation after prolonged intubation

Question 31

VAP prevention oral care

Answer 31

Brush teeth, gums and tongue at least twice a day using a soft toothbrush Provide oral care to oral mucosa and lips every 4 hours or PRN Daily use of chlorhexidine

Question 32

VAP prevention oropharyngeal suctioning

Answer 32

Suction oropharynx with each mouth care and before turning patient or lying flat Suction before deflating cuff

Question 33

continuous removal of subglottic secretions

Answer 33

Use an ET tube with continuous suction through a dorsal lumen above the cuff to prevent drainage accumulation (CASS tube) -10 to -20 cm of continuous suction

Question 34

VAP prevention hand washing

Answer 34

Wash hands or use an alcohol-based waterless antiseptic agent before and after: suctioning touching ventilator equipment coming into contact with respiratory secretions.

Question 35

other considerations for mechanical ventilation

Answer 35

Stress Ulcer Prophylaxis DVT Prophylaxis Communication Psychological care Caring for the family Nutrition

Question 36

troubleshooting alarms with mechanical ventilation

Answer 36

Always check connection to ETT or trach FIRST Check alarm indicators High pressure = possible obstruction Low pressure = possible leak Safety: Ensure ambu bag available

Question 37

guidelines for weaning from short-term ventilation

Answer 37

Hemodynamically stable SaO2 > 90% on FiO2 50% or less, PEEP 8 cm H20 or less ABGs within normal range (for patient) Adequate pain/anxiety/agitation management No residual neuromuscular blockade

Question 38

describe spontaneous breathing trials

Answer 38

AKA: CPAP Trials Pressure support, PEEP & FiO2 only No tidal volume given by machine Place enteral feedings on hold Minimize sedation Instruct patient/provide support/failures may occur Monitor patient response (SaO2, BP, HR, respiratory rate and pattern)

Question 39

criteria for stopping a SBT

Answer 39

RR > 35 SaO2 < 90% Decreased tidal volumes Increased work of breathing Increased anxiety and/or diaphoresis HR > 140 SBP > 180 or < 90

Question 40

extubation criteria

Answer 40

ABGs WNL for the patient Respiratory rate < 30 NIF > -20 cm water Negative Inspiratory Force (-30 is better, -10 is worse) Patient alert/following commands Adequate cough/gag reflex to protect airway Occlusion test (if concerned for tracheal swelling)

Question 41

extubation procedure

Answer 41

Elevate HOB & Instruct patient on procedure Suction ETT & Suction oropharynx Deflate cuff and remove Encourage coughing to remove sputum Suction as needed Apply oxygen Assess for laryngeal edema Assess ability to talk and swallow Monitor vital signs

Question 42

Which setting provides the patient with a tidal volume? PEEP CPAP AC Pressure support

Answer 42

AC

Question 43

Which ventilator setting will augment spontaneous breaths by decreasing resistance upon inspiration ? AC SIMV PEEP Pressure support

Answer 43

Pressure support

Question 44

Which ventilator setting can be increased to help improve oxygenation? AC SIMV PEEP Pressure Support

Answer 44

PEEP

Question 45

If a patient has an elevated PaCO2 and a normal PaO2 what vent change may be made? Increase PEEP Decrease FiO2 Increase rate Decrease TV

Answer 45

Increase rate