Nursing Management of Endotracheal Tube

Endotracheal Tube

• Provides a patent airway, access for mechanical ventilation and easier removal of secretions
• Maintain cuff pressure between 20-25 mmHg
• Keep in place for no longer than 14-21 days, longer placement may require trachestomy

Endotracheal Tube: Injury Prevention

• Adminster warmed humidification
• Maintain adequate cuff pressure
• Suction as needed
• Maintain skin integrity
• Auscultate lung sounds
• Monitor for signs and symptoms of infection
• Administer prescribed oxygen and monitor SpO2
• Monitor for cyanosis
• Maintain adequate hydration
• Use sterile technique when suctioning

Endotracheal Tube: Placement Confirmation

• Chest X-ray to verify proper placement
• Capnography
• Check cuff pressure every 6-8 hours

Chest Tube: Nursing Management

• Promote drainage
• Maintain water seal

Mitral Stenosis: Assessment

• Valve does not completely open, blood flow reduced through the narrowed valve orifice
• Decreased ventricular filling and decreased cardiac output
• Causes right ventricular hypertrophy
• Low-pitched rumbling diastolic murmur and loud S1 sound
• Echocardiogram

### Mitral Stenosis: Clinical Manifestations

• Dyspnea on exertion
• Decreased exercise tolerance
• Dry cough or wheezing
• Significant pulmonary congestion

Mitral Regurgitation: Causes

• Blood backflows into the left atrium from the left ventricle during systole
• May result from problems with one or more leaflets, chordae tendineae, the annulus or the papillary muscles
• Conditions that can cause secondary mitral regurgitation: ineffective endocarditis, collagen vascular diseases, and cardiomyopathy
• Excess blood in the atrium causes stretching followed by hypertrophy and dilation

Mitral Regurgitation: Assessment

• Systolic murmur of mitral regurgitation is a blowing sound best heard at the apex of the heart and may radiate to the left axilla

Acute Coronary Syndrome: Assessment

• "Coronary occlusion"
• "Heart attack"
• Myocardial infarction
• Emergent situation
• Acute onset of myocardial ischemia that results in myocardial death
• Chest pain unrelieved by rest or nitro, increased JVD, elevated BP, irregular pulse
• ST segment and T wave changes
• Respiratory assessment: shortness of breath, dyspnea, tachypnea and crackles
• GI: nausea, indigestion and vomiting
• GI, skin, neurological: anxiety, restlessness and psychological fear or feeling of impending doom

Acute Coronary Syndrome: Diagnostics

• 12-lead ECG
• Q wave abnormalities
• Serial cardiac biomarkers: troponin, creatine kinase, and myoglobin

Acute Coronary Syndrome: Medical Management

• Minimize myocardial damage, preserve myocardial function and prevent complications
• Immediate intervention of MONA
• Emergent percutaneous coronary intervention
• Thrombolytics

STEMI: Identification

• ECG evidence of acute MI with characteristic changes in two contiguous leads on a 12-lead ECG.
• Significant damage to the myocardium.

STEMI: Medical Management

• Immediate cardiac catheterization lab for percutaneous coronary intervention

STEMI: Hallmark Signs or Manifestations

• Refractory hypoxemia
• Retractive breathing

### Acute Respiratory Distress Syndrome (ARDS):

• Horowitz Index PaO2/FiO2
  • Mild: >200 mmHg
  • Moderate: >100 mmHg
  • Severe < 100 mmHg
• Brain natriuretic peptide (BNP) level
  • Used to differentiate between ARDS and cardiogenic pulmonary edema
  • Higher levels of BNP are associated with a decreased odds for ARDS
  • A normal BNP is < 100 pg/mL
• P/F ratio calculation
  • PaO2/FiO2 is the equation
  • Horowitz Index PaO2/FiO2:
    • Mild >200 mmHg
    • Moderate >100 mm Hg
    • Severe < 100 mmHg

ARDS: Medical Management

• Identification and treatment of the underlying cause
• Supportive measures
  • Supplemental oxygen
  • Intubation
  • Mechanical ventilation with PEEP
  • Circulatory support
  • Prone positioning
  • Sedation
  • Paralysis
  • Nutritional therapy
  • Frequent repositioning

ARDS: COVID Considerations

• ARDS most serious and frequent cause of death
• Atypical clinical manifestations
• Same classification system
• Low-dose corticosteroids
• Prone position for 12-16 hours/day
• Neurological assessment
• Increased sedative requirements
• Airborne isolation

### Neuromuscular Blockades: Assessment

• Used for the shortest time possible
• Vented more easily and may appear unconscious/appear they lost motor function but they are awake can feel and hear
• Examples
  • Vecuronium
  • Pancuronium
  • Rocuronium
  • Atracurium

### Neuromuscular Blockades: Nursing Management

• Train of Four Test: Assess neuromuscular blockade
  • Four consecutive stimuli being conducted along the nerves and the response of muscle is measured in order to evaluate whether or not the stimuli is effectively being blocked
  • No blockage: muscle twitches
  • Blockage present: loss of twitch and number will indicate degree of blockage
• Reassurance: This is due to medication and is only temporary
• Vent and patient alarms are on at all times
• Eye care: Patient cannot blink
• Predispose patient to VTE, muscle atrophy, foot drop, stress ulcers, and skin breakdown

### Mechanical Ventilation: Patient/Ventilator Dyssynchrony Management

### Concussion: Education

• Encephalopathy
• Worsening signs of neurological deficits

Traumatic Brain Injury: Pathophysiology

### Traumatic Brain Injury: Posturing

• Abnormal posuturing response to stimuli
• Decorticate reflection
• Decerebrate posturing

### Traumatic Brain Injury: Medical Management

• Depends on injury
• Elevation of the skull: surgical intervention
• Observation

### Skull Fractures: Types

• Linear (simple): A break in the continuity of the bone
• Comminuted: A splintered or multiple fracture line
• Depressed skull fracture: Occurs when the bones of the skull are forcefully displaced downward and can vary from a slight to splintered an embedded in the skull fracture

### Skull Fractures: Clinical Manifestations

### Spinal Cord Injury: Spinal Shock

• Sudden depression of reflex activity in the spinal cord called areflexia
• Occurs after injury. If a complete spinal cord injury, it does usually occur
• Loss of function of the autonomic nervous system
• Muscles innervated; BP decreased and bradycardia
• Reflexes that initiate bladder and bowel are affected
• Takes 4-6 weeks to resolve

### Subdural Hematoma: Clinical Manifestations

Subdural Hematoma: Assessment; Diagnostics

Subdural Hematoma: Clinical Manifestations

• (Acute vs. Chronic)
• An SDH is frequently venous in origin and is caused by a rupture of small vessels that bridge the subdural space.
• Acute symptoms: Change in LOC, pupillary signs, and hemiparesis
• Coma, increasing blood pressure, decreasing heart rate, and slowing respiratory rate are all signs of rapidly expanding mass requiring immediate intervention.
• Chronic symptoms: Can resemble other conditions such as stroke. Classical symptoms fluctuate due to clot breakdown and calcification and ossification of the clot in the brain, alternation in focal neurological signs, personality changes, mental deterioration, and focal seizures. Typically deeper than long

### Subdural Hematoma: Nursing Management

• Goal is to restore skin integrity and function while minimizing scarring and preventing infection
• Proper documentation
• Aseptic technique

Subdural Hematoma: Medical Management

• Wound cleansing: Normal saline solution, povidone-iodine
• Primary closure: Sutures and staples
• Delayed primary closure: Gauze and occlusive dressing; antibiotic agents, tetanus booster

Disaster Triage: Categories (Title, Color, Priority) and Typical Conditions

• Immediate
  • Color: Red
  • Priority: 1
  • Typical conditions: Sucking chest wound, airway obstruction secondary to mechanical cause, shock, hemothorax, tension pneumothorax, asphyxia, unstable chest and abdominal wounds, incomplete amputations, open fractures of long bones, and second/third degree burns of 15-40% total body surface area
• Delayed
  • Color: Yellow
  • Priority: 2
  • Typical conditions: Stable abdominal wounds without evidence of significant hemorrhage; soft tissue injuries; maxillofacial wounds without airway compromise; vascular injuries with adequate collateral circulation; genitourinary tract disruption; fractures requiring open reduction, débridement, and external fixation; most eye and central nervous system injuries
• Minimal
  • Color: Green
  • Priority: 3
  • Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding, behavioral disorders or psychological disturbances
• Expectant
  • Injuries are extensive and chances of survival are unlikely even with definitive care
  • Persons in this group should be separated from the other casualties, but not abandoned
  • Comfort measures should be provided when possible

This quiz covers essential aspects of managing endotracheal tubes, including placement, injury prevention, and nursing interventions. It focuses on maintaining airway patency, monitoring cuff pressure, and assessing for complications related to tube placement. Understanding these concepts is vital for effective patient care in critical settings.