mechanical ventilation - exam 1 questions with answers, Exams of Nursing

Download mechanical ventilation - exam 1 questions with answers and more Exams Nursing in PDF only on Docsity! mechanical ventilation - exam 1 questions with answers Reasons for Mechanical Ventilation - ANSWER: ✔✔- Acute Respiratory Failure - Ventilatory Failure - not moving adequately but perfusing - Oxygenation Failure - moving air but perfusing inadequate - Combined Ventilatory and Oxygenation Failure Acute Respiratory Failure - ANSWER: ✔✔- Classified as blood gas abnormality - PaO2 less than 60 mm Hg (however, less than 80 is hypoxemia) - PCo2 greater than 45 mm Hg with acidosis. - Sa02 less than 90%. (pulse oximetry) - Can be caused by ventilatory failure, oxygenation failure or a combination of both. - Whatever the cause, the patient is hypoxemic. Ventilatory Failure - ANSWER: ✔✔- Can result from inadequate chest wall movement not allowing enough air movement into and out of the lungs, which causes carbon dioxide to be retained. - Muscle weakness that occurs with some neuromuscular diseases such as Myasthenia Gravis, ALS, brain stem dysfunction can cause inadequate ventilation. - Table 32-2 - Shallow resp, agonal resp, probs with brain Oxygenation Failure - ANSWER: ✔✔- Oxygenation failure results when air moves in and out the lungs without difficulty, but does not oxygenate the blood sufficiently. - Poor diffusion of oxygen at the alveolar level. - Air that is low in oxygen - Abnormal hemoglobin that fails to bind oxygen. - Table 32-3 Combined Ventilatory and Oxygenation Failure - ANSWER: ✔✔- Hypoventilation and poor gas diffusion with or without poor lung perfusion. - Examples are ARDS and combined heart failure and lung disease. - With ards, surfactant is washed away and pt will have slower breaths and lungs fdont' move adequately and lungs become stiff and as alveoli are affected , we don't have good oxygenation Clinical Manifestations (ASSESSMENT) - ANSWER: ✔✔- Dyspnea - difficulty breathing - Orthopnea - can't breathe while laying down. characterized by number of pillows it takes for pt to lay on to breath properly - Hypercarbia - too much CO2 Pallor - turning pale or grayish (later sign) - Cyanosis - turning blue or purple (later sign) Restlessness - will happen with hypoxemia (early sign) - Confusion - Labored breathing - Agonal respirations- An abnormal pattern of breathing characterized by gasping, labored breaths that are not effective. Not moving air --- Can be the result of brain injury, respiratory failure, cardiac arrest Diagnostics - ANSWER: ✔✔- Pulse Oximetry - measured on finger, earlobe, nose, forehead (SaO2 95% - 100%) - ABGs - most reliable way to tell about gas echange and oxygenation - End-Tidal Carbon Dioxide Monitoring - amount of CO2 that is exhaled (normal value is 35-45). When pt is being intubated is the most definitive way to show proper placement without x-ray - CXR - can visualize lungs and see if pt is properly intubated, if needed Pulse Oximetry (cannot replace abgs) - ANSWER: ✔✔- Noninvasive measurement of oxygen saturation (SpO2). - Measures the percentage of oxygen bound to hemoglobin (normal 97%) - Can be used for continuous monitoring or spot check. Types of Trachs - ANSWER: ✔✔- cuffed - non-cuffed - fenestrated - non-fenestrated cuffed trach - ANSWER: ✔✔creates a seal in the trachea in order for the pt to get the proper tidal volumes. has a pilot balloon and sits outside of pt to give a status of the cuff. Pilot balloon inflated, then cuff is inflated. Inflate cuff with syringe on pilot balloon with about 10 ml of air at 14-20 mmHg pressure. Too much pressure can cause tracheal damage. Underinflated cuff won't allow pt to get proper tidal volumes. will not be able to speak. If pt is making sounds, check pilot balloon to see if cuff is inflated. Will require mechanical ventilation Noncuffed trach - ANSWER: ✔✔even if nonfenestrated will allow pt to speak Fenestrated trach - ANSWER: ✔✔has holes on tube that allow air to pass over the vocal cords to allow pt to speak. If inner cannula is in, pt won't be able to speak Nonfenestated trach - ANSWER: ✔✔has no holes on tube Tracheostomy Indications - ANSWER: ✔✔- Long term ventilation - Facilitate weaning - less dead space - Patient comfort -- Et tube is much longer and placed in throat Post Op Trach Care - ANSWER: ✔✔- Focus on the AIRWAY! • Note the quality, pattern, and rate of breathing: --- Within patient's baseline? ------ Tachypnea can indicate hypoxia. ------ Dyspnea can indicate secretions in the airway. • Assess for any cyanosis, especially around the lips, which could indicate hypoxia. • Check the patient's pulse oximetry reading. • If oxygen is prescribed, is the patient receiving the correct amount, with the correct equipment and humidification? • Assess the tracheostomy site: --- Note the color, consistency, and amount of secretions in the tube or externally. --- If the tracheostomy is sutured in place, is there any redness, swelling, or drainage from suture sites? --- If the tracheostomy is secured with ties, what is the condition of the ties? Are they moist with secretions or perspiration? Are the secretions dried on the ties? Is the tie secure? --- Assess the condition of the skin around the tracheostomy and neck. Be sure to check underneath the neck for secretions that may have drained to the back. Check for any skin breakdown related to pressure from the ties or related to excess secretions. --- Assess behind the faceplate for the size of the space between the outer cannula and the patient's tissue. Are any secretions collected in this area? • If the tube is cuffed, check cuff pressure. • Auscultate the lungs. • Are a second (emergency) tracheostomy tube and obturator available? - Looking for infection - temp, drainage, redness, wbcs and differentials Trach Care overview - ANSWER: ✔✔- see hospital p/p manuals - clean q8hrs and prn - removal inner cannula - plastic trachs have disposable inner cannulas - suction prn & assess secretions (always assess need first) - not done on schedule unless prescribed by dr; suctioning can cause tissue damage and only done prn - monitor for redness, swelling, & odor - Prevent tissue damage Trach Suctioning - ANSWER: ✔✔1. Assess the need for suctioning (routine unnecessary suctioning causes mucosal damage, bleeding, and bronchospasm). 2. Wash hands. Don protective eyewear. Maintain Standard Precautions. 3. Explain to the patient that sensations such as shortness of breath and coughing are to be expected but that any discomfort will be very brief. 4. Check the suction source. Occlude the suction source, and adjust the pressure dial to between 80 and 120 mm Hg to prevent hypoxemia and trauma to the mucosa. 5. Set up a sterile field. 6. Preoxygenate the patient with 100% oxygen for 30 seconds to 3 minutes (at least three hyperinflations) to prevent hypoxemia. Keep hyperinflations synchronized with inhalation. 7. Quickly insert the suction catheter until resistance is met. Do not apply suction during insertion. 8. Withdraw the catheter 0.4 to 0.8 inch (1 to 2 cm), and begin to apply suction. Apply suction and use a twirling motion of the catheter during withdrawal. Never suction longer than 10 to 15 seconds. 9. Hyperoxygenate for 1 to 5 minutes or until the patient's baseline heart rate and oxygen saturation are within normal limits. 10. Repeat as needed for up to three total suction passes. 11. Suction mouth as needed, and provide mouth care. 12. Remove gloves, and wash hands. 13. Describe secretions, and document patient's responses. --- Succinylcholine (Anectine) - Bed flat or slight Trendelenburg - Sniffing position - nose upward Post Intubation - ANSWER: ✔✔- Inflate Cuff - End Tidal CO2 detector - to ensure proper placement - Auscultate chest bilaterally and observe for rise and fall as the pt is being ventilated - starting at the epigastric to make sure we aren't in the stomach. Should hear air in each lung field with each breath and also see symmetrical rise and fall of chest ETT tube is secured Note where (the cm marking) tube is secured at the incisor teeth/gumline Chest x-ray to visualize tip 2cm above carina Will report size of tube and cm marking; will need to assess this when seeing the pt for the first time along with how pt is breathing ** if in lungs will more likely be on right side because right lung is higher than left lung Complications of Intubation - ANSWER: ✔✔- Wall necrosis - Tracheal dilation - Tracheal stenosis - Infection Cuffs - ANSWER: ✔✔Maintain cuff pressure to reduce risk of aspiration, tracheal damage, and adequate volumes. (between 14-20 mm Hg or 20-30 of h2o (ideally 25)) this is done with a manometer. Indications for Suctioning for ET tubes and Trachs - ANSWER: ✔✔- number one is gurgling or hearing secretions - change in V/S - tachypnea, increased HR (with hypoxemia) - dyspnea - restlessness - observed mucus - high-pressure alarm - tells us that the vent is meeting resistance when trying to deliver a breath - Coughing - Adventitious breath sounds Points to Remember When suctioning Artificial Airways - ANSWER: ✔✔- Hypoxia - if there is a 5% drop from baseline, HR goes up, Premature ventricular contractions --- ***stop suctioning and hyperoxygenate pt - Tissue trauma - back up 2cm and then start suction for 10-15 seconds on removal and not going in - Infection - maintain sterility, hand hygiene, use closed system (will use clean gloves), do continuous suction as opposed to imtermitent - Vagal stimulation - bp and hr drops --- *stop suctioning and hyperoxygenate patient - Bronchospasm - coughing and wheezing -- *stop suctioning, hyperoxygenate and give bronchiole dialator immediately Advantages of Tracheostomy Over Endotracheal Intubation - ANSWER: ✔✔- Faster weaning - Comfort - Possibility of oral feedings and speech - will need to deflate cuff to do this; will work with speech therapy. Inner canula will be removed and button placed on outer cannula Disadvantages of Tracheostomy Over Endotracheal Intubation - ANSWER: ✔✔- Hemorrhage - Infection - Pneumothorax - SQ emphysema - Aspiration - use shields in shower or bath and turn away from shower head - Nerve damage - Dysphagia - difficulty swallowing MECHANICAL VENTILATION indications - ANSWER: ✔✔- Apnea or agonal breathing - Impending inability to breathe - Acute resp. failure - Severe hypoxemia - Resp. muscle fatigue - mystenis gravis, ALS MECHANICAL VENTILATION goals - ANSWER: ✔✔- maintenance alveolar ventilation (CO2 removal) - delivery of O2 (reliable) - gas under pressure (>volumes) - maintain small airways open - alveoli - reduce work of breathing Ventilator settings - ANSWER: ✔✔- Mode - assist controlled, SINV, pressure controlled, cpap - Rate - breaths vent give pt -Tidal volume - amt of volume taken into lungs with each breath - Oxygen percentage (FIO2). - Positive End Expiratory Pressure (PEEP) - delivered in exhalation in order to open the alveoli in order to promote gas exchange - Pressure Support ventilation (PSV) - used as adjunt or by itself and gives support on inhalation in order to give pt a tidal volume --- kicks in on spontaneous breaths and not ventilated breaths Modes of ventilation - ANSWER: ✔✔- Assist Control (A/C) - Also receives the Preset rate (controlled breath) - Settings: --- Mode A/C --- Rate: 12 --- Vt: 500 ml --- FIO2 40% --- PEEP: 5 cm/H20 SIMV (Synchronized Intermittent Mandatory Ventilation) "Weaning Mode" - ANSWER: ✔✔- Most commonly used - Preset rate and volume - Pt can initiate own breath at their own Tv - Settings --- Mode: SIMV --- Rate: 12 --- Vt: 500 ml --- FIO2 40% --- PEEP: 5 cm/H20 --- Pt's own Rate: 7 Pressure Support (PSV) "Weaning Mode" - ANSWER: ✔✔- Augments patient's spontaneous tidal volume. - Pressure is increased on inspiration to boost patient's efforts. - Used with other ventilator modes --- SIMV and CPAP. - Decreases the work of breathing - Can be used alone CPAP (Continuous Positive Airway Pressure) "Weaning Mode" - ANSWER: ✔✔- Continuous pressure throughout respiratory cycle - Spontaneously breathing patient - Settings: --- CPAP 10 cm H2O --- FIO2 40% --- PSV (pressure support) Noninvasive Positive Airway Pressure - ANSWER: ✔✔- CPAP - BiPAP (Bi-level Positive Airway Pressure) --- Noninvasive form of mechanical ventilation --- Spontaneously breathing patient --- Nasal mask --- Pt gets a set inspiratory pressure and set expiratory pressure ---Settings ------ IP (pressure support) 14 cm ------ EP (PEEP) 6 cm Settings with Pressure Adjuncts - ANSWER: ✔✔- A/C Rate: 12 Tv: 500 ml FIO2 40% PEEP: 5 cm/H20 - SIMV Rate: 12 Tv: 500 ml FIO2 40% PEEP: 5 cm/H20 PSV: 10 cm/H20 Pt's own Rate: 7 PSV Settings: Used as a Mode - ANSWER: ✔✔PSV : 10cm FIO2: 40% PEEP: +5 cm Spontaneously breathing patient Complications of Mechanical Ventilation - ANSWER: ✔✔- Barotrauma - pnemothorax - Intubation of right bronchus - Tracheal damage - Aspiration - hob at 30 or higher, check residual with tube feeders, cuff inflated, give ppi or h2 antagonists - Pneumonia - VAP (ventilator associated pneumonia), do good oral care at least twice a day and more often will have better results, wash hands, turn q2h to help decrease - Complications of Immobility - pressure ulcers (turn q 2h), DVTs (scds, ted hose, passive rom, lovenox, early ambulation[sit them up, dangle feet on side of bed, get them to stand and maybe even walking. *must have person in there to help prevent et tube from moving]), contractures (passive rom), constipation (stool softeners) - Muscle weakness - give adequate protein with enteral nutrition in order to keep that gut going, parenteral put them a higher risk for infection; low carbs because they break down to CO2 ABGs - ANSWER: ✔✔- pH- 7.35-7.45: determine if normal, acidic or alkalotic - PaCO2- 35-45: determines respiratory acidity or alkalinity nursing care with nutrition - ANSWER: ✔✔- important to prevent muscle wasting - Muscles need energy to work - Muscle fatigue from lack of nutrition - Metabolic needs are higher - Enteral feedings preferred to keep GI tract moving - Weigh daily - High protein, low carb nursing care with eye care - ANSWER: ✔✔Keep eyes clean and lubricated - esp for pts whose eyes cannot close all the way nursing care with psychosocial needs - ANSWER: ✔✔- Communication - white boards and communication boards; better than squeezes and blinks because they can just be reflexes - Family visits - EBP says liberal visitation is best - Comfort measures - always anticipate pt's needs like pain level (use adult nonverbal scale if pt is sedated) nursing care with mobility - ANSWER: ✔✔- ROM - TEDS - SCDs - Low molecular weigh heparin - Assess skin q 4 - Early ambulation health promotion and maintenance - ANSWER: ✔✔- Monitor RR q hr. if on vent or CO2 is high (high levels depress resp center in the brain) - Use aspiration precautions (elevate hob, check residual, maintain adequate cuff pressures, ppi and h2 antagonists down) - Teach patient and family to perform trach care (shield over trach, turn back to shower head, teach how to perform trach care) safety with vents and trachs - ANSWER: ✔✔- Securely stabilize ETT - securement device is secure - Note cm line of ETT at the teeth or gumline - Sedate per protocol - will do sedation vacation and turn sedation off to do neuro checks once a day - Restrain per protocol - must meet protocol and do least invasive first (comfort, oral care, someone with pt) - X-ray daily to note position of the ETT (2 cm above the carina, at 2nd intercostal space) - Keep emergency equipment functional (suction, trach set, and obturator at bedside) - Check cuff pressure and keep 14- 20 mm Hg - Perform vent checks - main thing we're doing is making sure the settings on the vent match the drs orders, make sure that we empty condensation in the line to prevent breeding infections, check water in humidifier bottle, filter is good and not wet Ventilator-associated pneumonia (VAP) - ANSWER: ✔✔is defined as nosocomial pneumonia in a patient on mechanical ventilatory support (by endotracheal tube or tracheostomy) goals to reduce colonization of VAP - ANSWER: ✔✔- Handwashing - Use gloves when suctioning - Oral and nasal hygiene - Positioning - Suctioning - Prevent aspiration - h2 antoagonist and ppi --- NGT - check placement with each assessment along with residual --- HOB elevated --- Aspirate tube feeding q4 hours for residuals Safe & Effective Care with vents and trachs - ANSWER: ✔✔- Never allow water to buildup in the vent tube system - Use sterile technique when suctioning - Inspect oral mucous membranes each shift - Keep trach tube and obturator at bedside - Never use oral suctioning in an artificial airway Troubleshooting alarms - ANSWER: ✔✔High pressure alarms: - Patient coughing - Needs suctioning - Circuit kinked - Patient biting on tube - Tension pneumothorax Low pressure alarms: - Disconnected circuit