Exam 2 Foundations

Respiratory Mechanics & Assessment

• Normal Breathing Stimulus: Carbon dioxide (CO2) levels typically trigger breathing.
• COPD Breathing Stimulus: In patients with Chronic Obstructive Pulmonary Disease (COPD), oxygen (O2) levels become the primary breathing trigger due to chronic CO2 retention.
• Normal Respiration Rates:
  • Adults: 12-20 breaths per minute
  • Infants: 30-60 breaths per minute
• Eupnea: Refers to normal breathing.
• Bradypnea: Slow respiratory rate.
• Inspiratory/Expiratory Ratio: A normal ratio is 1:2, indicating inspiration is shorter than expiration.
• Body Position: Upright posture facilitates easier lung expansion.
• Environmental Factors: Factors like pollution, allergens, and humidity can impact respiratory function.
• Lifestyle Habits: Smoking, drug use, and alcohol consumption negatively affect respiratory function.
• Work of Breathing (WOB): Represents the effort required to breathe; increased WOB is a key sign of respiratory distress.
• Conditions Increasing WOB:
  • Restrictive lung movement (e.g., idiopathic pulmonary fibrosis)
  • Airway obstruction (e.g., asthma, COPD)

Restrictive Lung Diseases

• Characteristics: Difficulty filling the lungs with air during inhalation, leading to shortness of breath.
• Key Features:
  • Decreased total lung volume and capacity
  • Reduced lung elasticity
  • Decreased chest wall expansion during inhalation
  • Lung stiffening (as seen in idiopathic pulmonary fibrosis)
• Pneumonia: Accumulation of pus or fluid in the alveoli due to inflammation (consolidation).
• Atelectasis: Partial or complete collapse of a lung or lobe.

Obstructive Lung Diseases

• Characteristics: Obstruction in the air passages, making exhaling difficult and increasing residual air volume.
• Airway Changes: The diameter of the airway decreases, and resistance increases.
• Asthma:
  • Bronchoconstriction
  • Inflammation
  • Mucus production
  • Airway obstruction
• COPD (Chronic Obstructive Pulmonary Disease):
  • Includes chronic bronchitis and emphysema.
  • Airways become inflamed and thickened.
  • Tissue responsible for oxygen exchange is damaged.
  • Symptoms include:
    • Shortness of breath (SOB)
    • Cough with mucus
    • Fatigue
    • Frequent lung infections

Advanced Respiratory Concepts & Interventions

• Accessory Muscle Use: Using muscles other than the diaphragm and intercostal muscles to breathe, indicating respiratory distress.
  • Accessory muscles include:
    • Sternocleidomastoid
    • Pectoralis major
    • Trapezius
    • Intercostal muscles
    • Abdominal muscles
• Tripod Position: Often adopted to facilitate breathing.
• Signs & Symptoms of Altered Respiratory Function:
  • Cough
  • SOB/dyspnea
  • Sputum production
  • Bradypnea/tachypnea/Cheyne-Stokes breathing
  • Chest pain
  • Use of accessory muscles
  • Adventitious breath sounds
• Cheyne-Stokes Breathing: Alternating periods of increased rate and depth of respirations followed by apnea (cyclic pattern)
• Stridor: High-pitched sound heard on inspiration, indicating upper airway obstruction or edema.
• Cyanosis: Bluish discoloration of the skin, lips, mucous membranes, or nail beds due to low oxygen levels.
• Clubbing: Enlargement and rounding of the fingertips, associated with chronic hypoxia in cardiac or respiratory diseases.
• Pulse Oximetry: Normal readings are 95-100%; COPD patients may have lower readings. A baseline is crucial for monitoring.
• Oxyhemoglobin Curve:
  • Left shift: Higher binding affinity of oxygen (O2)
  • Right shift: Lower binding affinity of oxygen (O2)
• Interventions to Improve Respiratory Function:
  • Hydration
  • Positioning (upright)
  • Ambulation
  • Deep breathing
  • Pursed-lip breathing
  • Stacked/huff cough
  • Incentive spirometry
• Peak flow meter: Measures peak expiratory volume with forced exhalation. Used before and after treatment.
• Spacer: Ensures the patient receives all medication from an inhaler.
• Acapella: Uses positive expiratory pressure to force air behind sputum, moving it forward.
• Nebulizer treatment: Delivers aerosolized medication directly to the lungs.
• Metered dose inhaler: Measures delivery of respiratory medication to the lungs.

Oxygen Therapy

• Three Principles:
  • Lowest concentration
  • Shortest duration
  • Continuous monitoring of ABGs (Arterial Blood Gases) and O2 saturation

Oxygen Delivery Systems

• Low-flow systems: Do not meet all the patient's ventilatory demands and mix with room air.
  • Nasal cannula (1-6 L = 24-60%)
  • Simple face mask (5-10 L = 40-60%)
  • Partial rebreather mask (10-15 L = 30-60%)
  • Non-rebreather mask (10-15 L = 60-90%)

Diet

• Full Liquid Diet: Includes tea, soda, Jell-O, broth, ice cream, sherbet, anything that becomes liquid at room temperature.
• Soft Diet: Includes pureed foods, foods not requiring chewing (e.g., soft pasta, pudding, applesauce, yogurt, eggs). Suitable for patients with poor dentition or difficulty swallowing.
• "As Tolerated" Diet: Determined by the patient's individual tolerance.
• Restrictive Diets: Limit certain food items. Examples include:
  • Cardiac Diet: Low sodium, low fat
  • Diabetic Diet: Low sugar, consistent carbohydrates (e.g., 60 grams/meal)
  • Obese Patient Diet: Restricted calories
  • Renal Diet: Low protein, low sodium, low potassium, fluid restriction

Nasogastric (NG) Tube

• Definition: A tube inserted through the nose into the stomach.
• Uses: Gastric decompression, gastric lavage, and gastric feeding.
• Confirmation: Placement must be confirmed by X-ray and a "ready to use" order. Auscultation with air insertion is no longer used to check placement.
• NGT Confirmation (Post-X-Ray): Assess aspirate characteristics, observe for respiratory distress, and confirm exit site markings.
• NGT Insertion: Can be performed by a provider, nurse, or nursing student.
• Checking Residual: Use a syringe to withdraw gastric contents to determine if the patient is absorbing the tube feeding. Return any residual to the stomach.
• Salem Sump: An NGT used for suctioning. The pigtail is an air filter preventing the tube from adhering to the stomach mucosa. Short-term use.
• Levine Tube: An NGT used for tube feeding.
• Percutaneous Endoscopic Gastrostomy (PEG) Tube: A surgically placed tube for long-term tube feeding, accessed through the abdomen.
• Gastrojejunostomy Tube: Similar to a PEG tube but has three lumens (compared to PEG's two), allowing for tube feeding through the jejunal port while connecting the gastric port to suction. Long-term use.

Tube Feeding

• Kangaroo (Patrol) Pump: Controls the amount and rate of tube feed administration. Use only 8 hours' worth of tube feed in a bag with this pump.
• Medication in Tube Feeding Bags: Never add medication to a tube feeding bag.
• Tube Feed Bag Changes: Every 24 hours
• Patient Positioning (Tube Feeding): Minimally semi-Fowler's (30-45 degrees)
• Holding Tube Feedings: Hold if residual is 1.5-2 times the rate.
• Hypertonic Feeding Solutions: Can cause diarrhea due to osmotic gradient drawing fluid from the body into the GI tract. Adjust feeding as needed.
• Stopcock (Lopez Valve): Allows access to NGT/PEG/GJ tubes without disconnecting the system.
• Bolus Tube Feeding: A specific amount of tube feed administered at once, rather than continuously via a pump. Hold if residual is 250-500 cc.

Parenteral Nutrition

• Definition: Intravenous delivery of fluids.
• Examples of Parenteral Fluids: IV fluids, electrolytes, nutrition, medication, blood products.
• Isotonic Solutions: Same osmolarity as cells (e.g., 0.9% sodium chloride, Lactated Ringer's). Used for hypovolemia.
• Hypotonic Solutions:
  • Lower osmolarity than cells (e.g., 0.45% sodium chloride).
  • Fluid shifts into cells; use cautiously to prevent fluid depletion and cardiovascular collapse.
• Hypertonic Solutions:
  • Higher osmolarity than cells (e.g., 3%, 5% sodium chloride).
  • Requires strict monitoring in ICU due to risks of circulatory overload, hypertension, and pulmonary/cerebral edema.
  • Fluid is pulled from cells into the intravascular space.
• Angiocath: Device used for venous access (peripheral IV).
• IV Tubing Preparation: Prime the tubing before use to remove air.
• Gravity Infusion Rate: Fill the drip chamber halfway; count drips for one minute (or 30 seconds x 2) to determine the drip rate.
• IV Complications:
  • Infiltration: IV fluid leaks into surrounding tissue; may present with pain, burning, soft swelling. Apply heat or cold, elevate extremity.
  • Phlebitis: Inflammation of a vein; causes redness, warmth, and hardness at the IV site. May be caused by catheter size, infusion duration, irritating fluids, or poor vein selection. Can lead to thrombophlebitis (blood clot formation).
  • Infection: Redness, pain, warmth, pus at the IV site.
  • Fluid Overload: Too much fluid infused or infused too quickly; symptoms include hypertension, edema, dyspnea, and heart issues.
  • Air Embolism: Air entering the cardiovascular system, often due to insufficiently primed IV tubing or during central line placement.
• IV Orders:
  • Maintenance Fluid: Fluid administered at a prescribed rate to maintain homeostatic fluid status.
  • Bolus: A large amount of fluid given in a short time (sometimes called a fluid challenge).
  • KVO (Keep Vein Open): 10-20 cc per hour, preventing IV clotting.
• Banana Bag/Osler Bag: Yellow in color; contains vitamins and minerals in an isotonic solution.
• Infusion Pump: Regulates IV fluid infusion.
  • Pump Occlusion (Fluid Side): Problem above the pump.
  • Pump Occlusion (Patient Side): Problem below the pump.
• Piggyback Tubing (Secondary Tubing): Connects a secondary fluid bag to the primary line.
• IV Push: Administering medication directly into a PIV or primary line via a syringe. Always flush with normal saline before and after an IV push.
• IV Push Chart Importance: Details how much of what medication can be pushed, if dilution is needed, and possible adverse effects.
• Triple Lumen Central Line: A short-term central line allowing infusion of three incompatible fluids simultaneously.
• External Jugular IV: A peripheral line, not a central line.
• Hickman and Groshong Catheters: Long-term tunneled central catheters; Groshong does not require heparin flushes to keep the line patent.
• Central Line Placement Confirmation: X-ray
• Dacron Sheath: A cuff anchoring the central line and acting as a barrier against microorganisms.
• PICC (Peripherally Inserted Central Catheter): A long-term central catheter inserted into the arm and threaded into the superior vena cava. A specially trained nurse can place this bedside, and placement is verified by X-ray.
• TPN/CPN (Total Parenteral Nutrition/Complete Parenteral Nutrition): Contains >10% dextrose and/or >5% protein. Infused through a central line. Complications include infection, fluid overload, and hyperglycemia. Use D10W if TPN/CPN needs to be stopped abruptly. Patients receive finger sticks to monitor for hyperglycemia.
• PPN (Peripheral Parenteral Nutrition/Partial Parenteral Nutrition): Contains <10% dextrose and <5% protein. Can be infused through a PIV.

Respiratory Mechanics & Assessment

• Carbon dioxide levels are the usual trigger for breathing.
• In patients with Chronic Obstructive Pulmonary Disease (COPD), oxygen levels become the main trigger due to the body's inability to eliminate carbon dioxide.
• Normal breathing rate for adults is 12-20 breaths per minute.
• Normal breathing rate for infants is 30-60 breaths per minute.
• Eupnea refers to normal breathing.
• Bradypnea refers to slow breathing.
• A normal inspiration/expiration ratio is 1:2, with inspiration shorter than expiration.
• Upright posture facilitates lung expansion.
• Pollution, allergens, and humidity can affect respiration.
• Smoking, drug use, and alcohol negatively impact respiratory function.
• The work of breathing (WOB) is the effort needed to breathe.
• Increased WOB is a key indicator of respiratory distress.
• Conditions increasing WOB include restrictive lung movement (e.g., idiopathic pulmonary fibrosis) and airway obstruction (e.g., asthma, COPD).

Restrictive Lung Diseases

• These diseases make inhaling difficult due to decreased lung capacity.
• Restrictive lung diseases are characterized by:
  • decreased total lung volume and capacity,
  • decreased elasticity of the lungs,
  • decreased chest wall expansion during inhalation,
  • stiffening of the lungs, as seen in idiopathic pulmonary fibrosis.
• Pneumonia is an inflammation of the alveoli caused by pus or fluid accumulation.
• Atelectasis is a partial or complete collapse of a lung or lung lobe.

Obstructive Lung Diseases

• These diseases make exhaling difficult due to airway obstruction, increasing residual air volume.
• Obstructive lung diseases are characterized by:
  • decreasing airway diameter,
  • increasing airway resistance.
• Asthma is characterized by:
  • bronchoconstriction.
  • inflammation.
  • mucus production.
  • airway obstruction.
• Chronic Obstructive Pulmonary Disease (COPD) is characterized by:
  • chronic bronchitis and emphysema.
  • inflamed and thickened airways.
  • damaged lung tissue responsible for oxygen exchange.
• COPD symptoms include:
  • shortness of breath,
  • cough with mucus,
  • fatigue,
  • frequent lung infections.

Advanced Respiratory Concepts & Interventions

• Accessory muscle use is a sign of respiratory distress, where the body uses muscles beyond the diaphragm and intercostal muscles to breathe.
• These muscles include:
  • the sternocleidomastoid,
  • the pectoralis major,
  • the trapezius,
  • the intercostal muscles,
  • the abdominal muscles.
• The tripod position is often adopted to facilitate breathing.
• Signs and symptoms of altered respiratory function include:
  • cough,
  • shortness of breath (SOB) or dyspnea,
  • sputum production,
  • bradypnea, tachypnea, or Cheyne-Stokes breathing,
  • chest pain,
  • use of accessory muscles,
  • adventitious breath sounds.
• Cheyne-Stokes breathing is a cyclic breathing pattern alternating periods of increased rate and depth of respirations followed by apnea.
• Stridor is a high-pitched sound heard during inspiration, indicating upper airway obstruction or edema.
• Cyanosis is a bluish discoloration of the skin, lips, mucous membranes, or nail beds due to low oxygen levels.
• Clubbing is enlargement and rounding of the fingertips, associated with chronic hypoxia in cardiac or respiratory diseases.
• Normal pulse oximetry readings are 95-100%, but COPD patients may have lower readings.
• It is crucial to establish a baseline for pulse oximetry monitoring.
• The oxyhemoglobin curve describes the relationship between oxygen saturation and partial pressure of oxygen.
  • A left shift indicates higher binding affinity of oxygen (LOVING).
  • A right shift indicates a lesser binding affinity of oxygen.
• Interventions to improve respiratory function include:
  • hydration,
  • positioning (upright),
  • ambulation,
  • deep breathing,
  • pursed-lip breathing,
  • stacked/huff cough,
  • incentive spirometry.
• A peak flow meter measures the peak expiratory volume with forced exhalation, used before and after therapy.
• A spacer ensures the patient receives all medication from an inhaler.
• An Acapella device uses positive expiratory pressure to force air behind sputum, helping to move it forward.
• Nebulizer treatment delivers aerosolized medication directly to the lungs.
• A metered-dose inhaler measures the delivery of respiratory medication to the lungs.
• Oxygen therapy follows three principles:
  • lowest concentration,
  • shortest duration,
  • continuous monitoring of ABGs and O2 saturation.
• Oxygen delivery systems can be low-flow or high-flow:
  • Low-flow systems mix with room air and do not meet all the patient's ventilatory demands:
    • Nasal cannula (1-6L = 24-60%)
    • Simple face mask (5-10L = 40-60%)
    • Partial rebreather mask (10-15L = 30-60%)
    • Non-rebreather mask (10-15L = 55-90%)
  • High-flow systems provide a precise FiO2 and meet all the patient's ventilatory demands:
    • High-flow nasal cannula (60l/min), increases flow of oxygen air.
    • Venturi mask (colored valves 24-60%), meets demands of COPD patients.
    • Tracheostomy collar (28-98%), high humidity.
    • Oxygen hood/tent (greater than 60%), high humidity.

Clinical Scenarios & Case Studies

• During the assessment of patients:
  • Identify key signs and symptoms,
  • monitor respiratory rate,
  • measure oxygen saturation levels,
  • consider other relevant data.
• Choose the appropriate low-flow or high-flow oxygen delivery system based on the patient's condition.
• Weaning from oxygen should be gradual and closely monitored for patient response.
• Tracheal suctioning aims to remove secretions and maintain a patent airway.

Tracheal Suctioning

• The purpose of tracheal suctioning is to remove secretions through a tracheostomy tube or other airway access device.
• Assess the need for suctioning by:
  • listening for adventitious breath sounds,
  • monitoring oxygen saturation and respiratory rate,
  • assessing for signs of respiratory distress.
• The tracheal suctioning procedure includes:
  • Suctioning only when withdrawing the catheter.
  • Suctioning to the end of the tracheostomy tube, max 1 cm below.
  • Using intermittent suction.
  • Rotating the catheter.
  • Limiting suctioning to 10-15 seconds.
  • Hyperoxygenating the patient before and between suction passes.
  • Limiting suction passes to 3 per session.
  • Monitoring for complications.
• Complications of tracheal suctioning include:
  • edema,
  • obstruction,
  • hypoxia/bronchospasms,
  • expulsion of the tracheostomy tube,
  • infection,
  • hemorrhage,
  • skin breakdown.

Enteral Nutrition

• Enteral nutrition refers to feeding through the gastrointestinal system.
• "NPO" stands for "nil per os" and indicates nothing by mouth.
• Clear liquid diet includes tea, soda, light-colored Jell-O, and clear broth.
• Full liquid diet includes tea, soda, Jell-O, broth, ice cream, sherbet, and anything that becomes liquid at room temperature.
• Soft diet consists of pureed foods and foods not requiring chewing, suitable for patients with poor dentition or difficulty swallowing.
• "As tolerated" diet is determined by the patient's individual tolerance.
• Restrictive diets limit certain food items, such as:
  • Cardiac diet: low sodium, low fat.
  • Diabetic diet: low sugar, consistent carbohydrates.
  • Obese patient diet: restricted calories.
  • Renal diet: low protein, low sodium, low potassium, and fluid restriction.
• A nasogastric tube (NGT) is inserted through the nose into the stomach.
• Uses for NGT include gastric decompression, gastric lavage, and gastric feeding.
• NGT placement must be confirmed by an X-ray and a "ready to use" order.
• Auscultation with air insertion is no longer used to check NGT placement.
• Post-X-ray confirmation of NGT placement involves assessing aspirate characteristics, observing for respiratory distress, and confirming exit site markings.
• NGT insertion can be performed by a provider, nurse, or nursing student.
• Checking residual involves withdrawing gastric contents using a syringe to determine absorption of tube feedings. Return any residual to the stomach.
• A Salem Sump is an NGT used for suctioning. The pigtail functions as an air filter, preventing the tube from adhering to the stomach mucosa. It is used short-term.
• A Levine tube is an NGT used for tube feedings.
• A percutaneous endoscopic gastrostomy (PEG) tube is surgically placed for long-term tube feedings, accessed through the abdomen.
• A gastrojejunostomy tube (GJ) is similar to a PEG tube but has three lumens, allowing for tube feeding through the jejunal port while connecting the gastric port to suction. It is used long-term.
• A Kangaroo (Patrol) pump controls the amount and rate of tube feeding administration. Only an 8-hour supply of tube feed should be placed in the bag with this pump.
• Never add medication to a tube feeding bag.
• Change tube feed bags every 24 hours.
• For tube feeding, a minimally semi-Fowler's positioning (30-45 degrees) is recommended.
• Hold tube feedings if residual is 1.5-2 times the rate.
• Hypertonic feeding solutions can cause diarrhea due to osmotic gradient drawing fluid from the body into the GI tract. Adjust feeding as needed.
• Stopcock (Lopez Valve) allows access to NGT/PEG/GJ tubes without disconnecting the system.
• Bolus tube feeding is a specific amount of tube feed administered at once, rather than continuously via a pump.
• Hold bolus feeding if residual is 250-500 cc.

Parenteral Nutrition

• Parenteral nutrition refers to intravenous delivery of fluids including:
  • IV fluids,
  • electrolytes,
  • nutrition,
  • medication,
  • blood products.
• Isotonic solutions have the same osmolarity as cells, used for hypovolemia.
• Hypotonic solutions have a lower osmolarity than cells, used cautiously to prevent fluid depletion and cardiovascular collapse.
• Hypertonic solutions have a higher osmolarity than cells, requiring strict monitoring in ICU due to risks of circulatory overload, hypertension, and pulmonary/cerebral edema.
• An angiocath is a device used for venous access (peripheral IV).
• Prime IV tubing before use to remove air.
• For gravity infusion rate, fill the drip chamber halfway and count drops per minute to determine the drip rate.
• Potential IV complications include:
  • Infiltration: IV fluid leaks into surrounding tissue.
  • Phlebitis: inflammation of a vein.
  • Infection.
  • Fluid overload.
  • Air embolism.
• IV orders can include:
  • Maintenance fluid: fluid administered at a prescribed rate.
  • Bolus: a large amount of fluid given in a short time.
  • KVO (Keep Vein Open): 10-20 cc per hour, preventing IV clotting.

Respiratory Mechanics & Assessment

• Normal Respiration Rates:
  • Adults: 12-20 breaths/minute
  • Infants: 30-60 breaths/minute
• Eupnea: Normal breathing.
• Bradypnea: Slow respiratory rate.
• Inspiratory/Expiratory Ratio:
  • A 1:2 ratio (inspiration shorter than expiration) is normal.
• Work of Breathing (WOB):
  • The effort required to breathe.
  • Increased WOB indicates respiratory distress.
• Conditions Increasing WOB:
  • Restrictive lung movement (e.g., idiopathic pulmonary fibrosis)
  • Airway obstruction (e.g., asthma, COPD)

Restrictive Lung Diseases

• Characteristics: Difficulty filling the lungs with air during inhalation, leading to shortness of breath.
• Key Features:
  • Decreased total lung volume and capacity
  • Decreased elasticity of the lungs
  • Decreased chest wall expansion during inhalation
  • Stiffening of the lungs (as seen in idiopathic pulmonary fibrosis).
• Pneumonia: Accumulation of pus or fluid in the alveoli due to inflammation (consolidation).
• Atelectasis: Partial or complete collapse of a lung or lobe.

Obstructive Lung Diseases

• Characteristics: Obstruction in the air passages, making exhaling difficult and increasing residual air volume.
• Asthma:
  • Bronchoconstriction
  • Inflammation
  • Mucus production
  • Airway obstruction
• COPD (Chronic Obstructive Pulmonary Disease):
  • Chronic bronchitis and emphysema
  • Airways become inflamed and thickened
  • Tissue where oxygen exchange occurs is damaged
  • Symptoms:
    • Shortness of breath (SOB)
    • Cough with mucus
    • Fatigue
    • Frequent lung infections

Advanced Respiratory Concepts & Interventions

• Accessory Muscle Use: Using muscles other than the diaphragm and intercostal muscles to breathe, indicating respiratory distress.
  • Accessory muscles include:
    • Sternocleidomastoid
    • Pectoralis major
    • Trapezius
    • Intercostal muscles
    • Abdominal muscles.
• Tripod Position: Often adopted to facilitate breathing
• Signs & Symptoms of Altered Respiratory Function:
  • Cough
  • SOB/dyspnea
  • Sputum production
  • Bradypnea/tachypnea/Cheyne-Stokes breathing
  • Chest pain
  • Use of accessory muscles
  • Adventitious breath sounds
• Cheyne-Stokes Breathing: Alternating periods of increased rate and depth of respirations followed by apnea (cyclic pattern)
• Stridor: High-pitched sound heard on inspiration, indicating upper airway obstruction or edema.
• Cyanosis: Bluish discoloration of the skin, lips, mucous membranes, or nail beds due to low oxygen levels.
• Clubbing: Enlargement and rounding of the fingertips, associated with chronic hypoxia in cardiac or respiratory diseases.
• Pulse Oximetry: Normal readings are 95-100%, but COPD patients may have lower readings.
• Oxyhemoglobin Curve:
  • Left shift - LOVING, higher binding affinity of O2
  • Right shift - lesser binding affinity of O2
• Interventions to Improve Respiratory Function:
  • Hydration, positioning (upright), ambulation, deep breathing, pursed-lip breathing, stacked/huff cough, incentive spirometry.
  • Peak flow meter: measures the peak expiratory volume with forced exhalation.
    • BEFORE AND AFTER TREATMENT
  • Spacer: ensures patient receives all medication from inhaler
  • Acapella: uses positive expiratory pressure to force air behind the sputum and move it forward
  • Nebulizer treatment: delivers aerosolized medication directly to the lungs
  • Metered dose inhaler: measures delivery of respiratory medication to the lungs
• Oxygen Therapy:
  • Three principles:
    • Lowest concentration
    • Shortest duration
    • Continuous monitoring of ABGs and O2 saturation.
• Oxygen Delivery Systems:
  • Low-flow:
    • These systems do not meet all the patient's ventilatory demands and mix with room air.
    • 1.Nasal cannula (1-6 L = 24-60%)
    • 2.Simple face mask (5-10L = 40-60%)
    • 3.Partial rebreather mask (10-15L = 30-60%)
    • 4.Non-rebreather mask (10-15L = 55-90%)
  • High-flow:
    • These systems provide a precise FiO2 and meet all the patient's ventilatory demands.
    • 1.High-flow nasal cannula (60l/min)
      • Increases flow of O2, premixed air, heated and humitified
    • 2.Venturi mask colored valves (24-60%)
      • Meets demands of COPD patients
      • Requires humidification, precise and accurate
    • 3.Tracheostomy collar (28-98%)
      • High humidity
    • 4.Oxygen hood/tent (GREATER THAN 60%)
      • High humidity

Clinical Scenarios & Case Studies

• Patient Assessment:
  • Identify the key signs and symptoms, respiratory rates, oxygen saturation levels, and other relevant data.
• Oxygen Delivery System Selection:
  • Choose the appropriate low-flow or high-flow oxygen delivery system based on the patient's condition and needs.
• Weaning from Oxygen:
  • The process should be incremental, with close monitoring of the patient's response.
• Tracheal Suctioning:
  • This procedure aims to clear secretions and maintain a patent airway.

Tracheal Suctioning

• Purpose: Remove secretions through a tracheostomy tube or other airway access device.
• Assessment for Need:
  • Listen for adventitious breath sounds (like gurgling or wheezing)
  • Monitor oxygen saturation and respiratory rate
  • Assess for signs of respiratory distress such as increased work of breathing, retractions, or cyanosis
• Procedure:
  • Suction only on the way out of the airway
  • Suction to the end of the tracheostomy tube, maximum 1 cm below
  • Use intermittent suction
  • Rotate the catheter
  • Do not suction longer than 10-15 seconds
  • Hyperoxygenate the patient before and between passes
  • Limit to 3 passes per session
  • Monitor for complications
• Complications: Edema, obstruction, hypoxia/bronchospasms, expulsion of the tracheostomy tube, infection, hemorrhage, and skin breakdown.

Enteral Nutrition

• Enteral Nutrition Definition: Nutrition delivered through the GI system.
• NPO Diet: Nothing by mouth (Nil per os).
• Clear Liquid Diet: Tea, soda, light-colored Jell-O, clear broth.
• Full Liquid Diet: Tea, soda, Jell-O, broth, ice cream, sherbet, anything that becomes liquid at room temperature.
• Soft Diet: Pureed foods, foods not requiring chewing (e.g., soft pasta, pudding, applesauce, yogurt, eggs). Suitable for patients with poor dentition or difficulty swallowing.
• "As Tolerated" Diet: Determined by the patient's individual tolerance.
• Restrictive Diets: Limit certain food items. Examples include:
  • Cardiac Diet: Low sodium, low fat.
  • Diabetic Diet: Low sugar, consistent carbohydrates (e.g., 60 grams/meal).
  • Obese Patient Diet: Restricted calories.
  • Renal Diet: Low protein, low sodium, low potassium, fluid restriction.
• Nasogastric Tube (NGT): A tube inserted through the nose into the stomach.
  • Uses include gastric decompression, gastric lavage, and gastric feeding.
  • Placement must be confirmed by X-ray and a "ready to use" order.
  • Auscultation with air insertion is no longer used to check placement.
• NGT Confirmation (Post-X-Ray): Assess aspirate characteristics, observe for respiratory distress, and confirm exit site markings.
• NGT Insertion: Can be performed by a provider, nurse, or nursing student.
• Checking Residual: Use a syringe to withdraw gastric contents to determine if the patient is absorbing the tube feeding. Return any residual to the stomach.
• Salem Sump:
  • An NGT used for suctioning.
  • The pigtail is an air filter preventing the tube from adhering to the stomach mucosa.
  • Short-term use.
• Levine Tube:
  • An NGT used for tube feeding.
• Percutaneous Endoscopic Gastrostomy (PEG) Tube:
  • A surgically placed tube for long-term tube feeding, accessed through the abdomen.
• Gastrojejunostomy Tube:
  • Similar to a PEG tube but has three lumens (compared to PEG's two), allowing for tube feeding through the jejunal port while connecting the gastric port to suction.
  • Long-term use.
• Kangaroo (Patrol) Pump: Controls the amount and rate of tube feed administration. Use only 8 hours' worth of tube feed in a bag with this pump.
• Medication in Tube Feeding Bags: Never add medication to a tube feeding bag.
• Tube Feed Bag Changes: Every 24 hours.
• Patient Positioning (Tube Feeding):
  • Minimally semi-Fowler's (30-45 degrees).
• Holding Tube Feedings:
  • Hold if residual is 1.5-2 times the rate.
• Hypertonic Feeding Solutions: Can cause diarrhea due to osmotic gradient drawing fluid from the body into the GI tract. Adjust feeding as needed.
• Stopcock (Lopez Valve): Allows access to NGT/PEG/GJ tubes without disconnecting the system.
• Bolus Tube Feeding:
  • A specific amount of tube feed administered at once, rather than continuously via a pump.
  • Hold if residual is 250-500 cc.

Parenteral Nutrition

• Parenteral Nutrition Definition: Intravenous delivery of fluids.
• Examples of Parenteral Fluids: IV fluids, electrolytes, nutrition, medication, blood products.
• Isotonic Solutions: Same osmolarity as cells (e.g., 0.9% sodium chloride, Lactated Ringer's). Used for hypovolemia.
• Hypotonic Solutions:
  • Lower osmolarity than cells (e.g., 0.45% sodium chloride).
  • Fluid shifts into cells; use cautiously to prevent fluid depletion and cardiovascular collapse.
• Hypertonic Solutions:
  • Higher osmolarity than cells (e.g., 3%, 5% sodium chloride).
  • Requires strict monitoring in ICU due to risks of circulatory overload, hypertension, and pulmonary/cerebral edema.
  • Fluid is pulled from cells into the intravascular space.
• Angiocath: Device used for venous access (peripheral IV).
• IV Tubing Preparation: Prime the tubing before use to remove air.
• Gravity Infusion Rate: Fill the drip chamber halfway; count drips for one minute (or 30 seconds x 2) to determine the drip rate.
• IV Complications:
  • Infiltration: IV fluid leaks into surrounding tissue; may present with pain, burning, soft swelling. Apply heat or cold, elevate extremity.
  • Phlebitis: Inflammation of a vein; causes redness, warmth, and hardness at the IV site. May be caused by catheter size, infusion duration, irritating fluids, or poor vein selection. Can lead to thrombophlebitis (blood clot formation).
  • Infection: Redness, pain, warmth, pus at the IV site.
  • Fluid Overload: Too much fluid infused or infused too quickly; symptoms include hypertension, edema, dyspnea, and heart issues.
  • Air Embolism: Air entering the cardiovascular system, often due to insufficiently primed IV tubing or during central line placement.
• IV Orders:
  • Maintenance Fluid: Fluid administered at a prescribed rate to maintain homeostatic fluid status.
  • Bolus: A large amount of fluid given in a short time (sometimes called a fluid challenge).
  • KVO (Keep Vein Open): 10-20 cc per hour, preventing IV clotting.