-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
1/118
Interventions forInterventions forCritically Ill PatientsCritically Ill Patientswith Respiratorywith Respiratory
ProblemsProblems
Demuel Dee L. Berto, RN, MDDemuel Dee L. Berto, RN, MD
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
2/118
Disorders of the PulmonaryDisorders of the Pulmonary
VasculatureVasculaturePulmonaryPulmonary
EmbolismEmbolism
an occlusion ofaan occlusion ofaportion of theportion of thepulmonary bloodpulmonary blood
vessels by anvessels by anembolusembolus
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
3/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
4/118
Virchows triadVirchows triad::
1.1. Venous stasisVenous stasis
2.2. Hypercoagulable stateHypercoagulable state
3.3. Vessel injuryVessel injury
EtiologyEtiology::
Sites of thrombusSites of thrombus formation:formation:
1.1. Iliofemoral venous systemIliofemoral venous system most commonmost common2.2. Prostatic veinsProstatic veins
3.3. Pelvic veinsPelvic veins
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
5/118
D/O of the Pulmonary Vasculature
Pulmonary Embolism
Precipitating factorsPrecipitating factors
::
1.1. ExerciseExercise
2.2. Straining on defecationStraining on defecation
Other sources of emboliOther sources of emboli::
1.1. TumorsTumors
2.2. Air Air
3.3. FatFat Fx of long bonesFx of long bones
4.4. Bone marrowBone marrow
5.5. IV catheterIV catheter
6. Amniotic fluid6. Amniotic fluid 8080--90%90%mortalitymortality
-- 1 per 20,001 per 20,00--30,00030,000deliveriesdeliveries
7. Septic emboli7. Septic emboli
8. Vegetations on heart8. Vegetations on heart
valvesvalves
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
6/118
D/O of the Pulmonary Vasculature
Pulmonary Embolism
Risk factorsRisk factors::
1.1. Previous surgery on the pelvis / legs.Previous surgery on the pelvis / legs.
2.2. Trauma of long bones.Trauma of long bones.
3.3. Immobility early ambulationImmobility early ambulationleg exercisesleg exercises
4.4. Obesity weight lossObesity weight loss
5.5. DVTDVTHomans sign dont massage calf areaHomans sign dont massage calf area
-- avoid restrictive clothing on legsavoid restrictive clothing on legs
-- prolonged standing / sittingprolonged standing / sitting
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
7/118
D/O of the Pulmonary Vasculature
Pulmonary Embolism
PathophysiologyPathophysiology
DVT Emboli singleor multiple
IVC RV Pulmonary artery
obstruction
o Resistance
to blood flowRelease of humoral
substancesV/Q Mismatch
Pulmonary
HPN Vasoconstriction
throughout lungs
Pulmonary
infarction
RV strain
RV failure
Lungs have 3 sources of O2: lungs, bronchial circulation, pulmonary circulationLungs have 3 sources of O2: lungs, bronchial circulation, pulmonary circulation
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
8/118
D/O of the Pulmonary Vasculature
Pulmonary Embolism
Clinical manifestations:Clinical manifestations:SymptomsSymptoms
1.1. Dyspnea at restDyspnea at rest
2.2. SyncopeSyncope w/w/ qq COCO
3.3. Pleuritic chest painPleuritic chest pain when pulmonarywhen pulmonaryinfarction occurs, stabbing, sharp duringinfarction occurs, stabbing, sharp during
inspirationinspiration4.4. CoughCough
5.5. HemoptysisHemoptysis pulmonary infarctionpulmonary infarction
6.6. Feeling of impending doomFeeling of impending doom
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
9/118
SignsSigns
Tachypnea, tachycardiaTachypnea, tachycardia
CracklesCrackles Pleural friction rubPleural friction rub
DiaphoresisDiaphoresis
Low grade feverLow grade fever
Distended neck veinsDistended neck veins
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
10/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
11/118
4. Perfusion scanning4. Perfusion scanning -- blood is labeledblood is labeledw/ radioactive tracerw/ radioactive tracer
5. Xenon ventilation scan5. Xenon ventilation scan patientpatient
inhales tracerinhales tracer
6. Pulmonary angiography6. Pulmonary angiography goldgold
standard , definitive and specificstandard , definitive and specific
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
12/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
13/118
7. Blood Coagulation Tests7. Blood Coagulation Tests
Prothrombin TimeProthrombin Time Evaluates the effectiveness of coumadin (Vit. K)Evaluates the effectiveness of coumadin (Vit. K)
1.5 to 2 times the normal or control1.5 to 2 times the normal or control
11 to 16 seconds11 to 16 seconds
Partial Thromboplastin TimePartial Thromboplastin Time Best single screening test for disorders ofBest single screening test for disorders of
coagulationcoagulation
Evaluates the effectiveness of Heparin (ProtamineEvaluates the effectiveness of Heparin (Protamine
Sulfate)Sulfate) Normal range is 60Normal range is 60 70 secs70 secs
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
14/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
15/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
16/118
Collaborative ManagementCollaborative Management
Problem: HypoxemiaProblem: Hypoxemia
O2 TherapyO2 Therapy
Nasal canula or mask, ABGs and PulseNasal canula or mask, ABGs and PulseOximetryOximetry
MonitoringMonitoring
V/S, Lung sounds, increasing DOB, NVE,V/S, Lung sounds, increasing DOB, NVE,dysrhythmias, pedal edemadysrhythmias, pedal edema
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
17/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
18/118
Surgical ManagementSurgical Management
EmbolectomyEmbolectomy removal of the embolus orremoval of the embolus oremboli from the pulmonary arteriesemboli from the pulmonary arteries
Inferior VenaCaval InterruptionInferior VenaCaval Interruption vena cavalvena cavalfilterfilter
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
19/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
20/118
Problem: Decreased Cardiac OutputProblem: Decreased Cardiac Output
IV FluidsIV Fluids crystalloidscrystalloids
Watch out for RSHFWatch out for RSHF DrugsDrugs
Positive inotropes (Dobutamine)Positive inotropes (Dobutamine)
Vasodilators (Nitroprusside)Vasodilators (Nitroprusside) MorphineMorphine for painfor pain
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
21/118
Acute Respiratory FailureAcute Respiratory Failure
CriteriaCriteria
PaO2 < 60mmHgPaO2 < 60mmHg
SaO2 < 90%
SaO2 < 90%
PaCo2 > 50mmHgPaCo2 > 50mmHg
Acidemia ( pH
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
22/118
ClassificationClassificationVentilatory FailureVentilatory Failure
Perfusion is normal but ventilation isPerfusion is normal but ventilation isinadequateinadequate
Occurs when the thoracic pressure cannot beOccurs when the thoracic pressure cannot bechanged sufficiently to permitappropriate airchanged sufficiently to permitappropriate airmovement into and out of the lungsmovement into and out of the lungs
CausesCauses
Mechanical abnormality in the lung or chest wallMechanical abnormality in the lung or chest wall Problem in the respiratory center in the brainProblem in the respiratory center in the brain
Impaired respiratory musclesImpaired respiratory muscles
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
23/118
OxygenationFailureOxygenationFailure
Lungs are able to move air sufficiently butLungs are able to move air sufficiently butcannot oxygenate the pulmonary bloodcannot oxygenate the pulmonary bloodproperlyproperly
Ventilation is normal but perfusion isVentilation is normal but perfusion isdecreaseddecreased
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
24/118
Combined Ventilatory and OxygenationCombined Ventilatory and OxygenationFailureFailure
Involves insufficient respiratory movementsInvolves insufficient respiratory movements
( hypoventilation)( hypoventilation)
Gas exchange at the alveolar capillaryGas exchange at the alveolar capillarymembrane is inadequate so that too littlemembrane is inadequate so that too little
oxygen reaches the blood and CO2 is retainedoxygen reaches the blood and CO2 is retained
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
25/118
CausesCausesVentilatory FailureVentilatory Failure
MS, MG, GBS, Polio, stroke, SCI, increasedMS, MG, GBS, Polio, stroke, SCI, increasedICP, kyphosis, sleep apnea, PEICP, kyphosis, sleep apnea, PE
OxygenationFailureOxygenationFailure Right to left shuntingRight to left shunting
Impaired diffusion of oxygenat the alveolarImpaired diffusion of oxygenat the alveolarlevelslevels
Abnormal hemoglobin levelsAbnormal hemoglobin levels
CombinationCombination
BA, Bronchitis, emphysema,BA, Bronchitis, emphysema,
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
26/118
Adult RespiratoryAdult RespiratoryDistress SyndromeDistress Syndrome
(ARDS)(ARDS) Progressive form ofProgressive form of
respiratory failurerespiratory failure
characterized bycharacterized by severe dyspneasevere dyspnea
refractory hypoxemiarefractory hypoxemia
diffuse bilateral infiltratesdiffuse bilateral infiltrates NonNon--cardiogenic bilateralcardiogenic bilateral
pulmonary edemapulmonary edema
-- Decrease pul. complianceDecrease pul. compliance
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
27/118
Etiologies and RiskEtiologies and Risk
factors:factors:1.1. AspirationAspiration
2.2. Drug ingestionandDrug ingestionand
overdoseoverdose3.3. HematologicHematologic
disorderdisorder
4.4. oxygen toxicityoxygen toxicity5.5. localized infectionlocalized infection
5.5. metabolicmetabolicdisordersdisorders
6.6. shockshock7.7. traumatrauma
8.8. major surgerymajor surgery
9.9. fat/air embolismfat/air embolism10.10. sepsissepsis
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
28/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
29/118
Manifestations:Manifestations:
This stage involves dyspnea, esp onThis stage involves dyspnea, esp on
exertionexertion Respiratory and heart rates are normal toRespiratory and heart rates are normal to
highhigh
Auscultation may reveal diminished breath
Auscultation may reveal diminished breathsoundssounds
Management: O2 supportManagement: O2 support
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
30/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
31/118
Tachypnea with use ofaccessoryTachypnea with use ofaccessorymusclemuscle
Restless and apprehensiveRestless and apprehensiveDry or frothy sputum, cracklesDry or frothy sputum, crackles
Elevated heart rateElevated heart rate
Cool and clammy skinCool and clammy skin
Treatment: ET intubation, MV andTreatment: ET intubation, MV andprevent complicationsprevent complications
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
32/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
33/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
34/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
35/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
36/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
37/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
38/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
39/118
Goals of Med Mgt.:Goals of Med Mgt.:
1.1. Respiratory SupportRespiratory Support
Hook to mechanical ventilatorHook to mechanical ventilator Administer nitric oxide which dilates theAdminister nitric oxide which dilates the
capillary bed of the lungscapillary bed of the lungs
High concentrations of supplemental O2High concentrations of supplemental O2
Surfactant replacementSurfactant replacement Prone positioningProne positioning
2.2. Maintenance of hemodynamic stabilityMaintenance of hemodynamic stability
Administer diuretics
Administer diuretics Fluid restrictionFluid restriction if fluids are to be given,if fluids are to be given,
give crystalloidsgive crystalloids
Administer inotropic drugsAdminister inotropic drugs
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
40/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
41/118
Artificial AirwayArtificial Airway
Endotracheal TubeEndotracheal Tube An endotracheal tube is a long,An endotracheal tube is a long,
slender, hollow tube, inserted intoslender, hollow tube, inserted into
the trachea via the mouth or nose. Itthe trachea via the mouth or nose. Itpasses through the vocal cords, andpasses through the vocal cords, andthe distal tip is positioned justabovethe distal tip is positioned justabove
the carinathe carina
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
42/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
43/118
Major Indications for IntubationMajor Indications for Intubation
Airway protection when the client losesAirway protection when the client losesreflexes because ofanesthesia,reflexes because ofanesthesia,
medications, disease, or decreased LOCmedications, disease, or decreased LOC
To provide posiive pressure or highTo provide posiive pressure or highoxygen concentrationoxygen concentration
To bypass airway obstructionTo bypass airway obstruction Facilitating pulmonary hygieneFacilitating pulmonary hygiene
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
44/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
45/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
46/118
Tube insertionTube insertion
Secure the tube firmly with tapeSecure the tube firmly with tape
A chestXA chestX--ray may be ordered toray may be ordered toconfirm tube placementconfirm tube placement
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
47/118
ContinuationContinuation2.2. Monitoring the cuffMonitoring the cuff
Check pilot balloonand keep it inflated.Check pilot balloonand keep it inflated.
Maintain cuff pressure at minimum.Maintain cuff pressure at minimum.(Keep it below 20 mmHg)(Keep it below 20 mmHg)
Assess patients ability to talk.Assess patients ability to talk.
Auscultate for a slight hissing sound atAuscultate for a slight hissing sound atthe peak of inspirationthe peak of inspiration
Inspect for presence of food particlesInspect for presence of food particleswhen suctioningwhen suctioning
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
48/118
3.3. SuctioningSuctioning
Assess for airway obstruction e.g.Assess for airway obstruction e.g.restlessness, increased pulse andrestlessness, increased pulse andrespiration, presence ofadventitiousrespiration, presence ofadventitious
breath sounds, visible mucus bubbling inbreath sounds, visible mucus bubbling inthe airway, cyanosisthe airway, cyanosis
Hyperoxygenate client by increasingHyperoxygenate client by increasing
flow rate; encourage deep breathingflow rate; encourage deep breathing Lubricate the suction catheter withLubricate the suction catheter with
sterile watersterile water
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
49/118
ContinuationContinuation
If tracheal suction is being used, insertIf tracheal suction is being used, insert
catheter to the end of the tubecatheter to the end of the tube(approximately 4 inches);(approximately 4 inches);
Ifnasotracheal suction is being used, insertIfnasotracheal suction is being used, insertuntil the cough reflex is induceduntil the cough reflex is induced
APPLY NOSUCTION WHILE THEAPPLY NOSUCTION WHILE THECATHETER IS BEING INSERTEDCATHETER IS BEING INSERTED
Rotate and withdraw the catheter whileRotate and withdraw the catheter whilesuction is applied; DO NOT EXCEED 10suction is applied; DO NOT EXCEED 10--1515SECONDSSECONDS
Clear the catheter with sterile solutionandClear the catheter with sterile solutionand
encourage the client to breathe deeplyencourage the client to breathe deeply
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
50/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
51/118
ContinuationContinuation
Give oxygen for a few breaths, thenGive oxygen for a few breaths, theninsertanew, sterile suction catheterinsertanew, sterile suction catheterinside the tubeinside the tube
Have the patient inhale. At peak ofHave the patient inhale. At peak ofinspiration remove the tubeinspiration remove the tube
Place on supplemental O2 therapyPlace on supplemental O2 therapy
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
52/118
NOTE: Extubation is performed withNOTE: Extubation is performed with
physician
s ordersan
d carried outphysici
ans orders
and c
arried outby health team members capableby health team members capable
of reinserting the ET tube ifof reinserting the ET tube ifnecessary!necessary!
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
53/118
Monitoring after extubation is essentialMonitoring after extubation is essential
Monitor VS every hour initially. WOF signsMonitor VS every hour initially. WOF signsof Respiratory distressof Respiratory distress
Early signs include: mild dyspnea, coughingEarly signs include: mild dyspnea, coughing
and inability to expectorate secretions,and inability to expectorate secretions,STRIDOR.STRIDOR.
Sore throatand hoarseness for a fewSore throatand hoarseness for a fewdays after extubationdays after extubation
Semi fowlers, deep breathing andSemi fowlers, deep breathing andincentive spirometryincentive spirometry
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
54/118
Artificial AirwayArtificial Airway
TracheostomyTracheostomy
Definition:Definition:
TracheotomyTracheotomy
A surgical incisionA surgical incisioninto the tracheainto the tracheathrough overlyingthrough overlying
skinand muscles forskinand muscles forairway management.airway management.
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
55/118
DefinitionDefinition
TracheostomyTracheostomy A surgical creation ofA surgical creation ofan opening or stoma,an opening or stoma,into the tracheainto the trachea
through which anthrough which anindwelling tube isindwelling tube isinsertedinserted
Best route for longBest route for long--term airwayterm airwaymaintenancemaintenance
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
56/118
Indication for tracheostomy:Indication for tracheostomy:
Relief ofacute or chronic upper airwayRelief ofacute or chronic upper airwayobstructionobstruction
Access for continuous mechanicalAccess for continuous mechanical
ventilationventilation Prevention ofaspirationPrevention ofaspiration
Promotion of pulmonary hygienePromotion of pulmonary hygiene
Bilateral vocal cord paralysisBilateral vocal cord paralysis Prolonged endotracheal tube insertionProlonged endotracheal tube insertion
resulting in erosion or painresulting in erosion or pain
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
57/118
Potential ComplicationsPotential Complications::
Tracheal wall necrosisTracheal wall necrosis
Tracheal dilationTracheal dilation
Tracheal stenosisTracheal stenosis
Airway obstructionAirway obstruction
InfectionInfection
Accidental decannulation
Accidental decannulation
SubcutaneousSubcutaneousemphysemaemphysema
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
58/118
Nursing Responsibilities:Nursing Responsibilities:
1.1. Assess for adequate gas exchangeAssess for adequate gas exchange
2.2. Monitor patency ofairwayMonitor patency ofairway
3.3. Monitor cuff of tubeMonitor cuff of tube4.4. Provide tracheostomy careProvide tracheostomy care
5.5. Perform suctioningPerform suctioning
6.6. Provide adequate hydrationProvide adequate hydration
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
59/118
ContinuationContinuation
7.7. Secure tubeSecure tube
properlyproperly
8.8. Prevent orPrevent or
assess for infectionassess for infection
9.9. Prevent aspirationPrevent aspiration
10.10. Avoid constipationAvoid constipation
11.11. Provide alternative means ofProvide alternative means ofcommunicationcommunication
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
60/118
Mechanical Ventilation
Mechanical ventilation is use of a
mechanical device to instill amixture of air and oxygen into the
lungs
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
61/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
62/118
Indications:
Low PaO2 levels Individuals incapable of
spontaneous breathing
Individuals with inadequate
ventilation
Individuals with difficulty of
expelling CO2
Individuals with persistently high
blood pH
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
63/118
Goals of mechanical ventilation:
Maintain adequate ventilation
Deliver precise concentrations of
FiO2 Deliver adequate tidal volumes to
obtain an adequate oxygenation
Lessen the work of breathing inclients who can not sustain
adequate ventilation on their own.
Modes of Mechanical Ventilation
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
64/118
Modes of Mechanical Ventilation
Continuous Mechanical Ventilation(CMV)
Ventilators deliver preset volume of
air during inspiration (tidal volume) Takes full control of respiration
Does not allow spontaneous
breathing
Modes of Mechanical Ventilation
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
65/118
Assist / Control Ventilation (A/C)
Pt starts ventilation but ventilatorcompletes it
Ventilator delivers preset volume of airduring inspiration when client initiates it.
Respiratory rate is controlled by theclients ability to initiate breathing
Has a back up mechanism. If the client
does not initiate breathing or inspiratoryeffort is less than a preset number in aminute, the ventilator takes charge ofbreathing until the ability to initiate breath
returns
Modes of Mechanical Ventilation
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
66/118
Modes of Mechanical Ventilation
Intermittent Mandatory Ventilation
(IMV)
Ventilator delivers preset tidal
volume and respiratory rate Allows spontaneous unassisted
breathing between the preset
breath
Commonly use in respiratory
weaning
Modes of Mechanical Ventilation
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
67/118
Modes of Mechanical Ventilation
Positive End-Expiratory Pressure
(PEEP)
Preset amount of pressure stays in
the lungs at the end of exhalation
which keeps the alveoli open
Use in combination with CMV, A/C,
and IMV
Modes of Mechanical Ventilation
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
68/118
Modes of Mechanical Ventilation
Continuous Positive Airway Pressure(CPAP)
Similar to PEEP. Preset amount of
pressure stays in the lungs at the endof exhalation which keeps the alveoli
open
Use in clients who can breathe on theirown
Nursing Management
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
69/118
Nursing Management
Monitoring patients response
Monitor VS Auscultate BS every 30 to 60 minutes
initially
Observe secretions and suction promptly
Assess area around ET tube or
tracheostomy site q 4 hours for color,
tenderness , skin irritation and drainage
Psychological support
Continuation
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
70/118
Observe for signs of respiratory
insufficiency, such as tachypnea,cyanosis, and changes in sensorium
Ascertain blood gases as ordered to
determine effectiveness of
ventilation
Establish a means of
communication because client will
be unable to speak while on aventilator
Evaluate clients response to
procedure; revise plan as necessary
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
71/118
Managing the VentilatorSystem
Maintain ventilator settings TV, FiO2,mode of ventilation etc.
Check water temperature and
humidification
Interventions for various causes of
ventilator alarms
Suctioning
Presence of secretions Increased peak airway pressure
Presence of rhonchi and wheezes
Decreased breath sounds
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
72/118
Preventing Complications
Cardiac hypotension and fluid retention Avoid valsalva, adequate humidification,
monitorI and O, weight hydration and signs of
hypovolemia
Lungs barotrauma (due to positivepressure) and volutrauma (due to excess
volume delivered to one lung over the
other) and AB abnormalities
Adjust ventilator settings as ordered, monitorresponse of patient to MV, adjust fluids and
correct electrolyte imbalances
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
73/118
GI and Nutritional Complications
stress ulcers antacids, PPIs , H2 receptorblockers, TPN,
Low Carbohydrate and High fat diet
especially for COPD patients
Electrolyte replacement K, Ca, Mg, phos
Infection
Strict handwashing
Oral care and pulmonary hygiene
Chest physiotherapy and postural drainage Muscular Complications
Due to immobility
Passive ROM while on ventilation
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
74/118
Ventilator Dependence
Can be psychological or physiologic The longer on ventilator the move difficult it
is to wean because the respiratory muscle
fatigue and cannot assume breathing
Techniques
Synchronus Intermittent Mandatory Ventilation
T Piece Technique
Pressure Support Ventilation
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
75/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
76/118
CHEST TRAUMACHEST TRAUMA
PneumothoraxPneumothorax life threatening situation whereinairlife threatening situation whereinair
enters the pleural cavity causing a lung toenters the pleural cavity causing a lung tocollapse partially or completely on thecollapse partially or completely on theaffected side, resulting ina reduction inaffected side, resulting ina reduction intidal volume and gastidal volume and gas
Types:Types:
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
77/118
Types:Types:
1.1. SpontaneousSpontaneous
most common type of closedmost common type of closedpneumothoraxpneumothorax
Air accumulates within the pleural spaceAir accumulates within the pleural space
withoutan obvious cause.withoutan obvious cause. Rupture ofa small bleb on the visceralRupture ofa small bleb on the visceral
pleura most frequently produces this typepleura most frequently produces this type
of pneumothoraxof pneumothorax
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
78/118
2.2. TraumaticTraumatic
Open Pneumothorax: Laceration in theOpen Pneumothorax: Laceration in theparietal pleura thatallows atmosphericparietal pleura thatallows atmosphericair to enter inside.air to enter inside.
Closed PneumothoraxClosed Pneumothorax-- Laceration inLaceration inthe visceral thatallows air in the lungthe visceral thatallows air in the lungto enter the pleural space.to enter the pleural space.
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
79/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
80/118
AssessmentFindingsAssessmentFindings
Diminished breath sounds onauscultationDiminished breath sounds onauscultation
Hyperresonance on percussionHyperresonance on percussion
Prominence of the involved side of theProminence of the involved side of thechest, which moves poorly withchest, which moves poorly withrespirationsrespirations
Deviation of the tracheaaway fromDeviation of the tracheaaway from(closed) or toward (open) the affected(closed) or toward (open) the affectedsideside
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
81/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
82/118
Pleuritic chest painPleuritic chest pain
TachypneaTachypnea
Subcutaneous emphysema
Subcutaneous emphysema
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
83/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
84/118
3.3. TensionTension--
Air enters the pleuralAir enters the pleuralspace with eachspace with eachinspiration but cannotinspiration but cannotescapeescape
Causes increasedCauses increasedintrathoracic pressureintrathoracic pressureand shifting of theand shifting of themediastinal contentsmediastinal contentsto the unaffected sideto the unaffected side(mediastinal shift)(mediastinal shift)
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
85/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
86/118
AssessmentAssessment
Asymmetry of the thoraxAsymmetry of the thorax
Tracheal deviation to the unaffected sideTracheal deviation to the unaffected side
Respiratory distressRespiratory distress
Absence of breath sounds on one sideAbsence of breath sounds on one side
Distended neck veinsDistended neck veins
CyanosisCyanosis
Hypertympanic sound on percussion overHypertympanic sound on percussion overthe effected sidethe effected side
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
87/118
Etiology/ Classification:Etiology/ Classification:
1.1. PenetratingPenetrating common cause of opencommon cause of openpneumothoraxpneumothorax
2.2. Blunt chest traumaBlunt chest trauma-- common cause ofcommon cause of
close pneumothoraxclose pneumothorax3.3. Rupture ofalveoliRupture ofalveoli
4.4. Medical procedureMedical procedure
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
88/118
Lab. And Dx. Test:Lab. And Dx. Test:
Chest xChest x--rayray
Med. Mgt.Med. Mgt.
Closed Chest DrainageClosed Chest Drainage
Insertion of large bore needle at the 2Insertion of large bore needle at the 2ndnd
ICS MCL of the affected sideICS MCL of the affected side
Chest Tube
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
89/118
Use of tubes and suction to return
negative pressure to the intrapleuralspace and to drain air from theintrapleural space,
To maintain negative pressure, the chest
tube is placed in the second or thirdintercostal space
To drain blood or fluid, the catheter
would be placed at a lower site, usuallythe eighth or ninth intercostal space
Also called closed thoracotomy tube(CTT), chest tube drainage
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
90/118
Types of drainage:
One-chambersystem
one bottle serves
both as a waterseal and drainage
bottle
Types of drainage:
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
91/118
Two-chamber
system
1st bottle isfor drainage
2nd bottle is a
water seal
Types of drainage:
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
92/118
Three-chamber system
1st bottle is for drainage
2nd bottle is a water seal
3rd bottle is for suction
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
93/118
Types of drainage:
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
94/118
Commerciallyprepared plastic
unit
e.g. Pleur-Evac
Combines the
features of the
other systems
and may or maynot be attached
to suction
Nursing Responsibilities:
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
95/118
Collection chamber
Monitor drainage, report if greater than100ml per hour or if bright red or
increases suddenly
Mark chest tube drainage at 1-4 hour
intervals using a tape
Water seal
Monitor for fluctuation of the fluid level
in the water seal chamber Fluctuation stops in obstruction,
looping, suction not working properly or
if the lung has re-expanded
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
96/118
In pneumothorax patients intermittent
bubbling in the water seal chamber isexpected but continuous bubbling
indicates an air leak in the system
Assess respiratory status and lung
sounds
Keep drainage below the level of the
chest and the tubes free of kinks or
obstructions
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
97/118
Encourage coughing and deep
breathing Do not strip or milk a chest tube
unless directed by a physician
Keep a clamp and sterile occlusivedressing at bedside at all times
Never clamp a chest tube without
written orders from the physician
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
98/118
If the drainage system cracks or
breaks, insert the chest tube into abottle of sterile water, remove the
cracked or broken system and
replace it
If the chest tube is pulled out
accidentally pinch the skin opening
together, apply an occlusive sterile
dressing, cover the dressing withoverlapping pieces of tape and call
the physician
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
99/118
When the chest tube is removed , the
client is asked to take a deep breathand hold it and the tube is removed; a
dry sterile dressing, petroleum gauze
dressing is taped in place
During removal of tube, deep breath ,
exhale and bear down
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
100/118
Pulmonary ContusionPulmonary Contusion
Frequently follows injuries caused by rapidFrequently follows injuries caused by rapiddeceleration during vehicular accidentsdeceleration during vehicular accidents
Most common manifestation of blunt chestMost common manifestation of blunt chesttraumatrauma
Interstitial hemorrhage accompaniesInterstitial hemorrhage accompaniespulmonary contusion which results inpulmonary contusion which results in
pulmonary edema that would lead topulmonary edema that would lead todecreased lung compliance and gasdecreased lung compliance and gasexchangeexchange
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
101/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
102/118
AssessmentAssessment
HemoptysisHemoptysis
Decreased breath soundsDecreased breath sounds
Crackles
Crackles
WheezesWheezes
Hazy opacity in the lobes or parenchymaHazy opacity in the lobes or parenchyma
I iI i
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
103/118
InterventionsInterventions
Monitor CVPMonitor CVP
Monitor I and OMonitor I and O
Mechanical ventilation with PEEP ( inflateMechanical ventilation with PEEP ( inflatethe lungs)the lungs)
WOFARDSWOFARDS
Rib F tRib F t
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
104/118
Rib FractureRib Fracture
Result from direct blunt trauma to theResult from direct blunt trauma to thechest usually with involvement of the fifthchest usually with involvement of the fifththrough ninth ribsthrough ninth ribs
Fractured ribs can drive the bone endsFractured ribs can drive the bone endsinto the thorax leading to pneumothoraxinto the thorax leading to pneumothorax
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
105/118
T t tT t t
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
106/118
TreatmentTreatment
For uncomplicated rib fractures no specificFor uncomplicated rib fractures no specifictreatment because the fractured ribs unitetreatment because the fractured ribs unitespontaneouslyspontaneously
No splinting should be doneNo splinting should be done Pain medsPain meds most important so thatmost important so thatadequate ventilation is maintainedadequate ventilation is maintained
Intercostal nerve bloack for severe painIntercostal nerve bloack for severe pain Avoid analgesics that depress theAvoid analgesics that depress the
respiratory system ( morphine)respiratory system ( morphine)
Fl il Ch tFl il Ch t
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
107/118
Flail ChestFlail Chest
Paradoxical respirationParadoxical respiration
Inward movement of the thorax duringInward movement of the thorax duringinspiration, with outward movementinspiration, with outward movement
during expirationduring expiration
Usually involves one hemithorax andUsually involves one hemithorax andresults from multiple ribs fracturesresults from multiple ribs fractures
Occurs during high speed vehicularOccurs during high speed vehicularaccidents and CPRaccidents and CPR
A tA t
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
108/118
AssessmentAssessment
Paradoxic chest movementParadoxic chest movement
DyspneaDyspnea
CyanosisCyanosis
TachycardiaTachycardia
HypotensionHypotension
PainPain
I t tiI t ti
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
109/118
InterventionsInterventions
Humidified O2Humidified O2
AnalgesicsAnalgesics
Deep breathingDeep breathing
PositioningPositioning Secretion clearance by coughing and trachealSecretion clearance by coughing and trachealaspirationaspiration
MV for respiratory failureMV for respiratory failure
Positive pressure ventilationPositive pressure ventilation SurgerySurgery
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
110/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
111/118
Monitor VSMonitor VS
Fluid and electrolytesFluid and electrolytes
Monitor I and Oand s/sx of shockMonitor I and Oand s/sx of shock
Psychological supportPsychological support
H thH th
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
112/118
HemothoraxHemothorax
SimpleSimple blood loss of less than 1500 mlblood loss of less than 1500 mlinto the thoracic cavityinto the thoracic cavity
MassiveMassive more than 1500 mlmore than 1500 ml
Due to traumaDue to trauma
AssessmentAssessment
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
113/118
AssessmentAssessment
If smallIf small asymptomaticasymptomatic
If largeIf large respiratory distressrespiratory distress
Decreased breath soundsDecreased breath sounds
Dull upon percussionDull upon percussion
CXRCXR
ThoracentesisThoracentesis
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
114/118
InterventionsInterventions
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
115/118
InterventionsInterventions
Insertion if chest tubesInsertion if chest tubes
If initial drainage is 1500ml to 200ml ofIf initial drainage is 1500ml to 200ml ofbloo then open thoracotomy or persistentbloo then open thoracotomy or persistent
bleeding at the rate of 200ml/hr over 3bleeding at the rate of 200ml/hr over 3hourshours
Monitor VS, blood loss, I and OMonitor VS, blood loss, I and O
Monitor chest tubes and drainageMonitor chest tubes and drainage
IVF , blood transfusion (autotranfusion)IVF , blood transfusion (autotranfusion)
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
116/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
117/118
-
8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture
118/118
THE ENDTHE END