Respiratory System: Components & Oxygen Delivery

Main Components of the Respiratory System

• Ventilation is the movement of air from the atmosphere to the alveoli
• Diffusion is the exchange of oxygen and carbon dioxide at the alveolar capillary membrane
• Perfusion is blood flow by the cardiopulmonary system into alveolar capillaries
• FiO2 is the percentage of oxygen delivered or fraction of inspired oxygen
• FiO2 is the percentage of oxygen the person will inhale from the device
• Patients receiving supplemental oxygen have a higher FiO2 than atmospheric air

Oxygen Delivery Devices

• Nasal cannulas are low flow
• Nasal cannula advantages include being safe, simple, and inexpensive
• Nasal cannulas are comfortable and decrease the likelihood of causing claustrophobia
• They readily allow for eating and drinking and avoid rebreathing CO2
• Nasal cannulas deliver oxygen concentration (FiO2 24-44%) at lower flow rates of 1-6 L/min
• Humidification is needed for flow rates of 3 min/L or more
• Nasal cannula disadvantages include dermatitis and nasal irritation
• Tubing is easily dislodged
• Nasal cannulas are suitable for low flow rates of less than 4 L/min
• Nasal cannulas are not recommended for clients with nasal obstructions such as polyps and mucosal edema
• Flow settings and the client's respiratory pattern will determine inspired oxygen concentrations as FiO2 varies with flow rate
• Nasal cannulas are less accurate in terms of percentage of oxygen delivered compared to venturi masks
• Nursing actions include assessing patency of nares
• Ensure prongs fit nares properly
• Use WATER SOLUBLE GEL to prevent dry nares
• Provide humidification for flow rates of 4 L/min and greater

Simple Face Mask

• A simple face mask is low flow
• Advantages include being inexpensive
• Can be used on mouth breathers
• FiO2 35-60% at flow rates of 5-10
• Minimum flow rate is 5 to ensure flushing of CO2
• Disadvantages may cause claustrophobia
• Not recommended for clients at risk of CO2 retention
• Flow rate of less than 5 can cause rebreathing of CO2
• Clients should be monitored, especially if they complain of n/v, at risk of aspiration/airway obstruction
• Diaphragm will close when you breathe in and expand when you breath out
• Moisture and pressure can collect under the mask and cause skin break down
• Nursing actions include assessing proper fit to ensure a secure seal over nose and mouth and ensuring the client wears NC during meals

Partial Rebreather

• Partial rebreathers are low flow
• Advantages include covering the client's nose and mouth
• Fio2 60-90% flow rates of 10-15 L/min
• A mask has a reservoir bag attached with no valve, which allows the client to rebreathe up to one third of exhaled air together with room air
• Disadvantages include complete deflation of the reservoir bag during inspiration causes CO2 buildup
• FiO2 vaires with the client's breathing pattern
• Masks are poorly tolerated by clients who have anxiety or claustrophobia
• Eating, drinking, talking impaired
• Use caution for clients who have high risk aspiration or airway obstruction
• Nursing actions include keeping the reservoir bag from deflating by adjusting the oxygen flow rate to keep it inflated
• Assess proper fit to ensure secure seal over nose and mouth
• Assess skin breakdown beneath the edges of the mask and bridge of the nose
• Ensure the client uses a nasal cannula during meals

Non-Rebreather Mask

• Non-rebreather masks are low flow
• Cover client nose and mouth
• FiO2 80-95 at flow rates of 10-15 L/min to keep reservoir bag ½ full during inspiration and expiration
• Advantages include delivering the highest O2 concentration possible except for intubation
• A one-way valve is situated between the mask and reservoir allows the client to inhale max O2 from the reservoir bag
• The two exhalation ports have flaps covering them that prevent RA from entering the mask
• Disadvantages include the valve and flap on the mask must be intact and functional during each breath
• Poorly tolerated by clients with anxiety and claustrophobia
• Eating, drinking, talking impaired
• Use with caution for clients who have high risk of aspiration or air way obstruction
• Nursing actions include performing an hourly assessment of the valve and flap to ensure patency, proper function, and flaps are not stuck
• Assess proper fit to ensure a secure seal over nose and mouth
• Assess for skin breakdown beneath the edges of the mask and bridge of the nose
• Ensure the client uses a nasal cannula during meals

Venturi Mask

• Venturi masks are high flow
• Venturi Masks provide a precise amount of O2
• FiO2 24-60 at flow rates of 10-15 L/min via different sizes of adapters which allow specific amounts of air to mix with oxygen
• Venturi barrels can be exchanged to deliver various concentrations
• Reduces rebreathing of exhaled air
• Works independently of client breathing factors and flow of oxygen
• If the rate of flow is increased, the concentration of oxygen remains the same
• Delivers the most precise oxygen concentration without intubation
• Humidification is not required
• Best suited for clients with chronic lung disease
• Disadvantages include being expensive, noisy, and can feel claustrophobic
• Interferes with eating and drinking
• Nursing actions: Assess frequently to ensure accurate flow rate
• Make sure tubing is free of kinks
• Assess for skin breakdown beneath the edges of the mask, particularly on nares
• Ensure client wears NC during meals

Aerosol Mask, Face Tent, Trach

• Aerosol masks, face tents, and trach are high flow
• Face tents fit loosely around the face and neck
• Trach has a small mask that covers surgically created opening in the trachea
• FiO2 24-100% at flow rates of at least 10 L/mim
• Provide high humidification with oxygen delivery
• Advantages include being good for clients who do not tolerate masks well and useful for clients who have facial trauma, burns, and thick secretions
• Disadvantages include high humidification requires frequent monitoring
• Nursing actions include emptying condensation from tubing often
• Ensure that there is water in the humidification canister
• Ensure aerosol mist leaves from vent during inspiration and expiration
• Make sure tubing does not pull on trach

Acute Respiratory Failure (ARF)

• ARF is a sudden life-threatening deterioration of gas exchange
• Hypoxemic patients should receive oxygen
• Hypercapnic patients exhibit either breathing too much or too little
• Systemic blood vessels dilate, pulmonary blood vessels constrict, blood isn't coming back to the right side of the heart because its pooled, having trouble returning blood to the right side of heart
• Common causes of ventilatory failure: COPD, pulmonary embolism, pneumothorax, flail chest, ARDS, asthma, pulmonary embolism, fibrosis of lung tissue, neuro disorders (MS, GB syndrome), spinal cord injuries, CVA that impair client rate and depth of respiration, elevated ICP from closed head injuries cerebral edema hemorrhagic stroke
• Oxygenation failure includes Pneumonia, hypoventilation, hypovolemic shock, pulmonary edema, pulmonary embolism, ARDS, low hemoglobin, low concentrations of oxygen in blood (carbon monoxide poisoning, high altitude, smoke inhalation)
• Combined vent and oxygen failure is Decreased gas exchange results in poor diffusion of oxygen into arterial blood with carbon dioxide retention
• Hypoventilation (poor respiratory movement), chronic bronchitis, asthma attack, emphysema, cardiac failure
• Decreased respiratory drive occurs from TBI, brainstem injury, CNS depressant medications, and metabolic disorders
• Chest wall dysfunction caused by Chest wall trauma, neuromuscular d/o, musculoskeletal d/o, and spinal cord injury
• Dysfunction of lung parenchyma caused by Pleural effusion (fluid where it should not be), hemo/pneumothorax, atelectasis, PNA, PE, COPD, and ARDS
• Other causes: Post op hypoventilation d/t meds, pain not using IS, coughing and deep breathing
• Diseased lungs can cause ventilation and oxygenation issues
• Asthma, emphysema, and cystic fibrosis can cause oxygenation failure and increased work of breathing, eventually resulting in respiratory muscle fatigue and ventilatory failure
• Combined failure leads to more profound hypoxemia than either ventilatory failure or oxygenation alone
• Criteria for acute respiratory failure are based on ABG values
• Early clinical manifestations of acute respiratory failure include restlessness, fatigue, HA, dyspnea, air hunger, mild tachycardia/tachypnea, and increased BP
• Late signs may be more overt confusion, lethargy, cyanosis, diaphoresis, and respiratory arrest
• Central signs are more with cardiac/pulmonary issues
• Nail beds/peripheral is circulation issues from occlusions, being cold which causes vasoconstriction in the peripheral

Medications Assessment

• Physical, vital signs, monitoring SpO2, and ABG interpretation
• Lab tests: ABGs to confirm and monitor, PaO2 less than 60 and Ox sats less than 90 on RA, PaCO2 greater than 50 and pH less than 7.35 (hypoxemia, hypercapnia)
• Diagnostics include Chest x ray
• Results can include: pulmonary edema, cardiomegaly and Ct scan to rule out cardiac involvement
• Maintain patent airway and monitor respiratory status every hour or more often as needed
• Monitor for ECG changes involving hypoxemia
• Mechanical ventilation is often required with PEEP or CPAP
• Monitor for pneumothorax be high PEEP can cause it
• Oxygenation before suctioning secretions to prevent further hypoxemia
• Suction as needed (especially if coarse crackles heard over trachea)
• Assist with intubation as needed
• Communicate with patient and family
• Benzos = The ams
• Reduce anxiety and resistance to ventilation and decrease oxygen consumption
• Nursing actions: Monitor respirations, blood pressure, SaO2, opioid conjuncts

Propofol

• Induce anesthesia and sedates clients for ventilation
• Contraindicated for clients with hyperlipidemia and egg allergies
• Only given to intubated or vented patients
• Slow drip to assess neuro status
• Monitor for hypotension
• Titrate to desired sedation
• No analgesic actions

Corticosteroids

• Methylprednisone and dexamethasone
• Reduces WBC migration and decreases inflammation
• Decrease med gradually
• Administer antiulcer med to prevent peptic ulcer formation
• Monitor weight and BP
• Monitor glucose and electrolytes
• Take with food and avoid stopping the med suddenly

Neuromuscular Blocking Agents

• Includes oNiums
• Facilitates vent and decreases oxygen consumption
• Used with painful vents
• Administer only to clients who are intubated and vent
• Monitor ecg, bp, muscle strength

Acute Respiratory Distress Syndrome (ARDS)

• ARDS is Sudden and progressive pulmonary edema (non-cardiac)
• Increasing bilateral infiltrates on CXR
• Refractory hypoxemia (not responsive to supplemental oxygen)
• ARDS has Reduced lung compliance and high mortality rates and will typically progress to multi-system organ failure and is caused by tissue injury vs arf which is caused by ventilation or oxygenation issues

Causes of ARDS

• Direct injury is Injury to lung parenchyma itself like pna
• Indirect injury is a Systematic injury that causes an inflammatory response
• Pancreatitis → enzymes, inflammatory cytokines inflames lungs + Sepsis + DIC, aspiration, pulmonary emboli, pna/pulmonary infections, sepsis, near drowning, trauma, multiple blood transfusions, damage to CNS, smoke inhalation, drug ingestion, COVID
• Initial injury: Direct/indirect injury → initiation of inflammatory-immune response activation of neutrophils, macrophages, platelets release of chemical mediators → damage alveolo-capillary membrane
• Exudative phase: Chemical mediators increase pulmonary capillary permeability, microthrombi, and pulmonary arterial pressure → leakage of fluid (protein, blood cells, fibrin, mediators) into pulmonary interstitium
• (decreased diffusion) → fluid is forced from the interstitial space into alveoli (lymphatic overwhelmed) alveolar edema → damage to type 1 alveolar cells decrease surfactant production resulting in collapse of alveoli, decreased lung compliance and REFRACTORY HYPOXEMIA
• Proliferative phase has decreased surfactant results in the collapse of alveoli and decreased lung compliance → compression, collapse, edema of alveoli and small airways results in pulmonary shunting/hypoxemia → increased airway resistance, decreased lung compliance, increased work of breathing, increased patient fatigue results in hypoventilation → hypoventilation and increased alveolar dead space (dead space is where there is oxygen but no contact with blood) results in worsening hypoxemia → pulmonary HTN increased right ventricular afterload results in RHF decreased CO

Fibrotic Phase

• Cellular granulation and collagen deposition within alveolo-capillary membrane pulmonary fibrosis → structural and vascular remodeling → further stiffening of lungs increased pulmonary HTN and worsening hypoxemia resulting in MODS → recovery resolution and restoration of alveolo-capillary membrane
• ABGs: hypercania/worsening hypoxemia; increased HR, decreased BP, decreased UO, deteriorating mental status

Diagnosis of ARDS

• Based on berlin criteria, onset occurs within seven days of initial respiratory distress event
• Noncardiac origin, imaging indicating bilateral lung infiltrates and abnormal oxygenation
• PaO/FiO ratio LESS THAN 300, Mild 200-300, Moderate 100-199, Severe less than 100

Assessment of ARDS

• Initially all good → breath sounds clear + clinical overall: Dyspnea, bilateral pulmonary edema, reduced lung compliance, dense patchy bilateral pulmonary infiltrates, severe hypoxemia despite admin of 100% oxygen, cyanosis, pallor, intercostal and substernal retractions
• Exudative phase has a May see increase WOB, fine crackles, dyspnea, tachypnea, while the Proliferative: Increasing respiratory distress, fatigue, crackles, refractory hypoxemia, white out CXR
• Fibrotic: Right sided heart failure, coarse crackles, refractory hypoxemia, worsening V/Q mismatch d/t intrapulmonary shunting

Nursing Care for ARDS

• ABGs, BNP, chest x-rays (Pulmonary edema, diffuse infiltrates and white out), ECG to r/o cardiac involvement, and Hemodynamic and pulmonary capillary wedge pressure with ARDs which is usually low or within an expected reference range of 4-12
• Continue monitoring hemodynamics for fluid management
• Controlled vent support: set inspired oxygen concentration to the lowest level to facilitate oxygenation, low tidal volume + admin and manage sedation
• Conservative fluid replacement with diuretics and nutritional support
• Prone positioning 12 hours a day and has been shown to reduce mortality if initiated early on
• High PEEP → assess lungs frequently bc can cause tension pneumo, increase intrathoracic pressure which can cause decrease in blood return to the heart/decreased CO/hypotension + decreased CO can activate RAAS system leading to fluid retention/decreased UO; tell client to avoid valsalva movement bc it can increase intrathoracic pressure
• ECMO: Heat and lung bypass equipment, same meds as ARF
• High PEEP levels are indicated and patients may fight vent or breathe asynchronously
• Nursing considerations will include admin for sedation and neuromuscular blocking agents
• If patients are on neuromuscular blocking agents, must ensure adequate sedation and pain management
• Passive ROM, skin assessment, DVT prevention

Pulmonary Embolism (PE)

• PE is a Obstruction of the pulmonary artery or one of its branches by thrombus/thrombi that originates in the venous system or right side of the heart
• PE can be solid, gaseous, or liquid is the 3rd leading cause of death in hospitalized patients
• PEs are Often associated with trauma, ortho surgeries, afib, major surgeries, immobility, and hypercoagulable states
• VTE associated emboli are most common followed by fat, air, and septic (d/t bacterial invasion of thrombus), and amniotic fluid
• Risk factors depend on long term immobility, oral contraceptive use and estrogen therapy, pregnancy, tobacco use, hypercoagulability/elevated platelet count, obesity, surgery, CVC, HF, afib, long bone fractures, hemolytic/sickle cell anemia, cancer, trauma, septicemia, and advanced age
• Expected findings include anxiety, impending doom, sudden onset chest pressure, pain upon inspiration, chest wall tenderness, dyspnea, air hunger, cough, and less common hemoptysis
• Clinical manifestations may vary based on size of thrombus and area of occlusion
• Dyspnea, chest pain, cough, palpitations, and hemoptysis are first signs; chest discomfort, agitation, and dizziness are also notable
• Late signs include severe chest pain and impending doom and death which can occur within hours of symptom onset, important to recognize early and treat promptly
• Tachypnea, crackles, tachycardia, s4 heard d/t extra pressure placed on the right ventricle, s/s dvt closely associated, pleurisy, pleural friction rub, cough, diaphoresis, decreased oxygen saturation, petechiae over chest and axillae, distended neck veins, syncope, and cyanosis
• PaCO2 levels low d/t initial hyperventilation
• As hypoxemia progresses, respiratory acidosis occurs + further progression leads to metabolic acidosis d/t buildup of lactic acid from tissue hypoxia
• Diagnostic tools: D-dimer used to rule out not confirm → positive d-dimer (what breaks down clots, lots in blood means clotting issue) tells clot forming
• Cxr to rule out other concerns like COPD, PNA

Treatments for PE

• CTPA (computed tomographic pulmonary angiography) → number 1 choice; v/q scan SECOND CHOICE (ventilation perfusion scan); pulmonary angiography is super risky choice
• Oxygen at high fowler's, anticoagulants: heparin/Lovenox, some oral anticoagulants like apixiban, Contra include active bleeding, peptic ulcer, stroke, recent trauma, Monitor bleeding time PT/INR for warfarin and PTT for heparin and monitor for thrombocytopenia, anemia, and hemorrhage
• Xa inhibitor/Rivaroxaban, apixaban, fondaparinux, bind with active center of actor xa inhibiting production of thrombin
• Assess for bleeding, hold the med for 18 hr prior and 6 hr after removal of epidural catheter
• Thrombolytics for hemodynamically unstable patients- Alteplase, reteplase, tenecteplase
• Surgical intervention: Embolectomy → in severe cases to reduce RHF, IVC filters (filter in inferior vena cava that prevents clots from going to the right side of the heart) used in high risk patients who cannot have anticoagulant therapies
• Nursing interventions for prevention: AmbulationAssess respiratory status at least every 30 min, and
• Assess cardiac status
• Compare BP in both arms, pulse quality, dysrhythmias, distended neck veins, and petechiae, monitor changes in LOC, scds/compression stockings and close monitoring and changing of IV sites + particularly PICC lines - encourage frequent ROM
• Smoking cessation, encourage a healthy weight, encourage a healthy diet/exercise, and avoid sitting for long periods
• Admin anticoags, antithrombos. Manage pain, Maintain adequate oxygenation and relieve anxiety
• Client education: Weekly blood draws if homebound, portable oxygen for severer dyspnea, no vitamin K foods if taking warfarin, regular blood draws to monitor PT/INR, increased risk of bruising and bleeding, check mouth and skin for bleeding/bruising, electric shavers, soft bristle toothbrushes, no nose blowing, if nose bleed occurs,apply gentle pressure
• Traveling: Arise from a sitting position for 5 min out of every hour, wear support stockings, drink plenty of fluids, and perform ROM when sitting

Chest Trauma Types and Risk Factors

• Blunt chest trauma results from MVC, crushing injury, bike accident (handlebars to chest)
• Severity: can be life threatening and result in hypoxemia, hypovolemia, and cardiac failure (from tamponade, contusion, increased intrathoracic pressure)
• Penetrating trauma is brought by a Gunshot/stab wound
• Timely assessment is crucial, with Advanced trauma life support, CABDE (Circulation, airway, breathing, disability, and environment)
• Complications of trauma results in Pneumothorax, tension resulting in mediastinal shift (late sign), and is spontaneous
• Occurs when air enters the pleural space during inspiration through a one-way valve and is not able to exit upon expiration; excess pressure in the pleural space causes the lung to collapse and increased pressure also compresses blood vessels and limits venous return leading to a decrease in CO
• Risk factors include blunt/penetrating chest trauma, close/occluded chest tube, decreased pulmonary reserves, and COPD
• Anxious clients report pleuritic pain
• Assessment findings in the form of respiratory distress: tachypnea, tachycardia, hypoxia, cyanosis, dyspnea, and accessory muscles

Chest Trauma Indicators and Treatment

• Tracheal deviations to the unaffected side indicate tension pneumo
• Absent or reduced breathing sounds on affected side
• Asymmetrical chest wall movement + Hyperresonance on percussion d/t trapped air + SQ emphysema ABG indicates hypoxemia PaO2 < 80
• Dx: Cxr to confirm
• Nursing care is made of O2 therapy, auscultate heart and lung sounds Q4, vent setting hourly, semilfowler's position, meds: Benzos for anxiety, opioids for pain + Hemothorax (Blood in thoracic cavity), dull percussion on assessment and Thoracentesis to confirm Client will lean over the bedside table will remain still during procedure, will feel pressure not pain
• The nurse will need administer and may need to assist with a flail chest (broken ribs on the front and back side of ribs), resulting In free floating ribs going in on inhalation and out on exhalation
• Risk factors result from multiple rib fractures from blunt chest trauma
• Findings are unequal chest expansion, paradoxical chest movement, tachycardia, hypotension, dyspnea,cyanosis, anxiety, and chest pain
• Nursing care involves Humidified 02, review PFT, cxr, abgs, and promote lung expansion with deep breathing and proper positioning + mechanical ventilation, suction trachea and ET tube as needed, admin pain med with PCA
• Chest tube: Disposable three-chamber system with the first chamber for drainage collection and the second chamber as a water seal + the third is a chamber of suction control (wet or dry)
• The Nurse must Ensure all chest-tube lines and connection points remain air-tight
• Water seal creates a seal that allows fluid/air to exit during exhalation and prevents it from going back up during inhalation

Chest Tubes

• Created by adding sterile fluid to a chamber up to the 2 cm line
• Allows air to exit from the pleural space on exhalation and stops air from entering lungs with inhalation
• To maintain keep chamber upright and chest tube below insertion site at all times; monitor water level d/t evaporation; add fluid prn
• Wet suction: height of sterile fluid indicates amount of suction into pleural space; -20 cm is common; a system attached to the suction source
• Initiated suction until gentle bubbling begins
• Dry suction: provider prescribes level of suction -20
• Tidaling/movement of fluid level with respiration is expected in the water seal; with spontaneous respirations, the fluid level will rise with inspiration and fall with expiration; with positive pressure mechanical vent, opposite Cessation of tidaling signals lung re-expansion of obstruction in system
• Continuous bubbling indicates leakage; intermittent suction is expected during exhalation, sneezing, coughing
• If entered into the mediastinal space, bubbling/tidaling are ont expected + insertion: Into pleural space to drain fluid, blood air; reestablish negative pressure, facilitate lung expansion, restore normal intrapleural pressure
• Bubbles in wet or dry apparatus means leakage
• do not Don't close unless air leak, drainage change, discontinuity or damage
• Always look at the insertion site and note that the tube is sutured in then look for holes + Expect gentle constant bubbling in the suction chamber + In terms of Nursing Considerations, Monitor for air leak (continuous bubbling) and keep dressing changed to avoid infection
• Output more than 70 mL/hr → call provider and if the tube is accidentally removed, place sterile gauze over the insertion site
• Notify provider if sao2 drops below 90, eyelets of the chest tube are visible, drainage is above prescribed amount or stops in 24 hrs

Ventilation Methods

• CPAP → continuous positive airway pressure (most effective for sleep apnea because positive pressure acts as splint to keep upper airway and trachea open during sleep), provides positive pressure to keep airway open and improve gas exchange, single air pressure, keeps airways through the respiratory cycle open and improves gas exchange in alveoli
• BIPAP → bi-level positive airway pressure (Higher inspiratory pressure setting than expiratory pressure, often used for COPD patients - can help treat hypercapnia, and used for sleep Apnea = Bipap is for two air pressures one from inhalation and other for exhalation

Nursing Actions

• Assist with procedure and Administer sedation and neuromuscular blockers ordered. NOTE: The diaphragm will become paralyzed
• Do not let go of unsecured ET tube
• Protect airway & Monitor VS and notify provider of changes
• Ensure correct placement X-ray is completed
• Give them 30 seconds to intubate, otherwise, timeout to reoxygenate and ventilate
• Confirm placement in a specific location to confirm that
• Gold standard is CO2 monitor, cxr verifies placement and secure ET by cuff which must be in place and checked every 1-2 hrs for an air pressure between 20-30 cm H20 with proper placement (confirmed by an Xray
• Complications: High cuff pressure can erode or perforates tracheal wall and low cuff pressure can allows aspiration and if suction is not performed, that can allow aspiration pneumonia
• Endotracheal intubation for more than 7 days should result in consideration to trach due to Hypoxemia that can result from multiple insertion attempts, as well as a risk for to discomfort and Potential for infection

Additional Nursing Cares

• Prevent infection by using proper hand hygiene, suctioning, and oral care to address problems like "Inability to verbally communicate" and/or a risk for aspiration pneumonia due to suppressed/absent Cough reflex, as well as "Secretions becoming viscous" and Swallowing is suppressed" to to address "Trauma to trachea and bronchial structures"
• Alter position of ET tube & Check positioning every 1-2 hours to maintain cuff pressure between 20-30 cm H2O (Assess lung sounds, SaO2, and chest movement each time client is moved, transferred, turned) Secure endotracheal tube and document level of it
• The nursing goal is to secure and document air movement in the lungs and note where those measurements occur
• Positive pressure: used with all ET tubes, delivers all air to the lungs under pressure throughout inspiration to keep alveoli open and prevent alveolar collapse during expiration
• Benefits: Includes forced/enhanced lung expansion leading to Improved gas exchange which in turn Decreases workload for breathing

Mechanical Ventilation and Methods

• AC, ventilator takes over every breath for the patient & SIMV assists the patient but allows for assisted breathing
• inverse ratio ventilation: used for hypoxemia refractory to PEEP but can cause lung injury
• Adjunct: - positive end expiratory pressure/peep=Preset pressure delivered during expiration; added to prescribed settings to treat hypoxemia; improves oxygenation by enhancing gas exchange and preventing atelectasis; 5-15 cm used Pressure support PS
• Spontaneous mode: used for weaning off ventilator and keeps the Avoli open
• volume support VS:
• must Have spontaneous breathing,
• Continuous positive airway pressure CPAP
• select mode: ac, simv - select mode: ac, simv and set your RR 12-20 bpm with a a Tidal volume 5-7 with an average of 500, and set your
• FiO2 & Inspiratory pressure limit 15-20 & set the- PEED
• Set PEEP at approximately 5-10 with and a nurse should differentiate between spontaneous vs manual breaths
• Complications of Mechanical Ventilation involve ventilator-Associated pnuemonia. CV compromise, barotrauma/pneumothorax & Mucus Plugs
• Care for a patient on the vent also calls to Assess frequently, prepare for unintended/self extubation. and assess and prevent pressure injuries
• Use ROM to combat Restraints, assess and prevent pressure injuries, note the tube positioning and prevent pressure ulcers.
• Check and admin the proper medications as noted by the ABGs and notify the team. Administer sedatives as well, being wary about sedation.
• Move ET to opposite side of mouth every 24 & Turn q 2 and maintain family communications.

Assessment For Weaning Patients

• Assess Frequently & Be prepared for self-extubation/unintended
• restriants=ROM & Work with RT to ensure adequate function and change tubings pRN
• Assess for pressure injury around tube & Note tube position (look at the teeth or nare if nasal) and provide adequate and often oral care. Perform frequent ABG"ss and medicate carefully. - -
• If they have any alarms, Check 1st for biting ET tube, then any Kinked tubing as well as secretions: Suctioning Coughhing and
• Make sure to unblock he ET tube.
• If the patient is not tolerating those well-ventilating methods may no longer applicable

Weaning From Ventilator.

• Evaluate them before the procedure:Are they alert, stable, and able to follow commands?
• Assess vitality, max capacity, and
• If they have a tidal volume: amount of air exhaled and inhaled in a normal breath & Minute ventilation (Total amount of air inhaled and exhaled in a minute)

Tracheostomy Placement Indications

• Used for surgical placement of the airway directly into the trachea to bypass the the upper obstruction to allow removal of tracheobronchial secretions
• Prevent oral and gastric aspiration in paralyzed patients
• • Typically need the patients to has been on vent for7+days

Shock States

• What is shock?: Life-threatening condition of circulatory failure, causing inadequate oxygen delivery to meet cellular metabolic needs and oxygen consumption requirements, producing cellular and tissue hypoxia
• if not corrected, tissue hypoxia and injury will progress to cellular necrosis and tissue death

Causes and Types of Shock:

• Pump failure: Cardiogenic shock- MI, CHF, dysrhythmias and Obstructive shock: Tension pneumothorax, Cardiac tamponade, Pulmonary embolism
• Poor Vessels Functioning: Distributive shock: Septic shock, neurogenic shock, anaphylactic shock
• Low Flud: Hypovolemic shock: Hemorrhagic shock & non-hemorrhagic shock

Stages of Shock:

• Initial: Minimal changed on the cellular level + Compensated , the body is doing measures to increase CO to restore tissue profusion and oxygenation
• Compensatory/Pre-Shock: Body will attempt to bring up normal VS's such as BP, RR and O2 states
• Assessment findings: near-normal assessment, anxiety will occurs
• Late findings: BP start to slip + Labs : Elevated : Lactate/metabolic acidosis & Decreased the urine output
• Progressive worsening includes Confusion progressing to loss of consciousness & Excessive diaphoresis & Pale mottled skin processing to cyanide color progression

Shock + Organ Failure:

• Irreversible shock: The body's organ malfunctions due to shock and the medical interventions are failing
• MODS assessment/Multiorgan Damage is occuring

Brain: Weakness, faintness, fatigue; drowsy or loss of consciousness; difficulty concentrating/confusion, MODs=Provide comfort as client transitions towards death in the future with limited life expectancy to less than 1 year.

Hypoveoleimc Shock, Nursing Actions and Treatments

• Decreased I's and O's can imply hemorrhage and indicate the need to stop bleed at all costs!
• Education: Eat, drink, and prevent
• Cardiogenic shock: Intracardiac dysfunction resulting in the heart working properly + Treatment include maximizing the heart function and minimizing the workload.
• Nitroglycerin: decrease afterload and workload
• Fluid balance: careful admin (< 250 m) or diuretics Assessments/Interventions depends on the types of the shocks patients are having

Obstructive Shock & Distributive Shock

• Obstructive: increased JVD, cold cold + treatment focuses on correcting the pressure
• Distributive Shock: (Sepsis) Systemic inflammatory response to infection triggered by the body's extreme reaction to infection
• Nursing intervention involve:
• Lactate levels: measure lactate level, remeasure lactate if initial is elevated over 2, which is an indicator of low level of fluid in the blood
• Admin Antibiotics properly to prevent the spread of infection
• Give 2 large of fluids and maintain MAP, and educate the patients properly

Anaphylic Shock

• Anaphylactic" happens second and is a massive flood of chemicals resulting in severe shock, as well blood in the stools and swelling.
• Ensure the access and administer new meds slowly to prevent any allergic rxn, and educate patients properly with what to do if anything feels side-effect
• Neurogenic shock is the loss stemming from all the issues with the spinal cord and the treatment are to improve fluids, O2 the perfusion with volume.
• Causes expression of procoagulant factors, the body becomes hypoxic and creates the anaerabic metabolism and causes the clots
• Treatment: provide PT/FT.

Immediate Actions,Remember stop drop roll ,Pull Aim Squeeze Sweep and Extinguish flames

Extent Of Burn Injury

• The burned of TBSA (Total body system area) determines the area and treatment of fluids
• Burns greater than 60% of total surface area leads to death and 20% or more is major with inhalation injury
• Cardiovasuclar(Burns Shock) - the most importnat step is Fluid management, but hyponertima and hypocalemia can happen.

Burn Care:

1. Assess ABC's = Circulation First!
2. Check for Carbon Monoxide levels and heath
3. Analgesia for comfort & Assess area, depth and TBSA
4. Keep patient hydrated, adminster tetnaus shot
5. Cover, and clean area/dress area and use clean cloth to prevent contamination
6. Assess for any allergies:
7. Ensure proper diet/followups /wound dressing is available.
8. Eschar tissue can turn you, assess the area properly.
9. SJS Is fatal, treat them as burns and give fluids as needed.
10. -Infections control and pain controls.
11. 1.-If the patient is renal failure

ParkLand Formula and SHCOK Care

• The body gets dehydrated and need to provide potassium, shock care, and burn is severe
• TOPICAL EPIDERMAL NECROLYSIS AND SJS (shocks) cause complications, especially if not caught quickly
• Potentially fatal disorders triggered by medication rxn & Increased risk in elderly d/t polypharm to support and treat burns is the goal.
• Supportive care is critical- to prevent Sepsis, electrolyte imbalance and skin breakdown
• Treat and support, especially on skin and airway.
• Interventions can include d/c all non essential medications, ophthalmic care to prevent side effects or blindness. Provide proper infection, check for allergies, and educate on medications "