Mechanical Ventilation Nursing Notes PDF

9/14/24 Mechanical Ventilation Oxygenation Santa Fe College of Nursing Megan Jo Salazar RN, BSN 1 Oxygenat...

9/14/24 Mechanical Ventilation Oxygenation Santa Fe College of Nursing Megan Jo Salazar RN, BSN 1 Oxygenation Review Respiratory system Ventilation- Inspiration is half of Normal Adult RR is Alveoli includes perfusion- V/Q ratio expiration I:E ratio 15-20 oral and nasal Responsible for 4L/min/5L/min or Example 1:2 cavities gas exchange.8 Larynx Produce Above or below.8 Trachea surfactant is called V/Q Bronchus, mismatch bronchiole, alveolar ducts and alveoli 2 Gas Exchange Arterial C02 is primary stimulus for ventilation (PaCO2) CO2 and pH will move in opposite direction in gas exchange Healthy Compensation will adjust ventilation when CO2 is not WDL Gas exchange happens in the alveoli-capillary bed. Damage to the alveoli create ventilation deficits Damage to capillaries create perfusion deficits This is referred to as V-Q mismatch 3 1  9/14/24 Acid Base Balance Cellular Regulation Cognition Concepts Related to Comfort Oxygenation Perfusion Stress and Coping *refer to chart on pg 1075-76 of your Pearson text 4 ETT Tracheostomy Types of airways Oropharyngeal and Nasopharyngeal airways 5 Negative Pressure Ventilators Iron Lung Positive Pressure Ventilators Types of Adds pressure to inhalation Ventilators Exhalation is passive Invasive or Noninvasive Noninvasive Positive Pressure Ventilation Cpap, Bipap, Hiflow Nasal Canula 6 2  9/14/24 Noninvasive Positive Pressure Ventilation CPAP (Continuous Positive Airway Pressure) BiPap (Bilevel Positive Airway Pressure) Two levels of pressure with inspiration and expiration Triggered by spontaneous breath initiated by patient Back up frequency set in case of apnea HFNC (Hi Flow Nasal Canula) Contraindicated for patients with significant decrease in LOC 7 Mechanical Ventilator 8 Parts of a ventilator 9 3  9/14/24 Ventilator settings Frequency (Respiratory Rate) Tidal Volume (Based on patients’ height and weight) PEEP (Positive end expiratory pressure) FIO2 Ventilator Modes (Mechanical vs Spontaneous) 10 Rate of Ventilations Normal RR is 12-20 Ventilator rate typically set at 10-12 breaths/min High-frequency ventilators can deliver small tidal volumes at rapid RR 11 Tidal Volume (VT) Volume of air delivered during a ventilator- 6-12 ml/kg for adult augmented breath ­ VT ® ­ risk of barotrauma & ¯ venous ¯ VT ® ­ risk of return to Rt. Side of the atelectasis heart 12 4  9/14/24 Pressure applied to the airway during ventilator exhalation (3-20 cm H2O) *** Most Common Setting: PEEP 5*** Keeps lungs partially expanded during Positive End- expiration Expiratory Pressure (PEEP) Decreases the amount of FiO2 needed Bag Valve Masks have PEEP valves 13 PEEP (Positive end expiratory pressure) 14 Oxygen (FiO2) Try to keep FiO2 < 50% to avoid oxygen toxicity Often have set order parameters to keep SpO2 > 90% & PaO2 > 60 mm Hg 15 5  9/14/24 Assist Control ACMV Preset VT Preset Rate Spontaneous breaths will be supported with set VT Can adjust the PEEP but pressure support is Ventilator automatic Modes Synchronized intermittent SIMV Preset VT Preset Rate Spontaneous breaths allowed but no support given Can adjust PEEP Can Adjust Pressure Support 16 Spontaneous All breaths initiated by patient VT determined by patient Ventilator Pressure support and PEEP are set Modes and given with each breath Breath will be given mechanically if Cont…. no breaths are taken for 20 seconds 17 Vent screen interpretation 18 6  9/14/24 19 What determines Changes in ventilator settings 20 Practice adjusting settings based on patient problem SIMV 12/5/40% ASMV 10/8/50% ABG ABG PH 7.48 PH 7.32 paO2 75 paO2 58 paCo2 30 paCo2 47 21 7  9/14/24 Troubleshooting High Pressure Alarm Low Pressure Alarm Assess patient Assess Patient alarms Look for kinked tubing Check connections Assess need for Check for leaks suctioning Is pilot balloon inflated? Is the tube in the right place? 22 Complications Ventilator Associated Pneumonia VAP Barotrauma Pneumothorax Cardiovascular effects GI effects 23 Ventilator Associated Pneumonia (VAP) ¡Develops within 2 days after endotracheal intubation ¡Longer hospitalizations ¡Higher costs of care ¡Higher mortality rates ***Nursing Sensitive Quality Indicator*** 24 8  9/14/24 Quality Indicators Prevention VAP: HOB 30 degrees or higher EET with subglottic suction (intubations greater than 72 hrs ) RASS +1 to -1 Daily Sedation vacation Delirium tool Daily weaning assessments Frequent, stringent oral care 25 Barotrauma (volutrauma) Caused by over inflation of the lungs and positive pressure ventilation Positive pressure- alveolar rupture and air into the pulmonary interstitial, mediastinum, and pleural spaces COPD and ARDS at greatest risk 26 Pneumothorax Abnormal collections of air in the pleural space between the lung and chest wall that restricts chest expansion S/S (signs and symptoms): Unequal chest expansion Decreased/absent breath sounds on the affected side Reduced arterial oxygenation Difficulty breathing 27 9  9/14/24 Pneumomediastinum Presence of air in the mediastinum S/S (signs and symptoms): Severe chest pain shortness of breath subcutaneous emphysema “crunching” sound during cardiac cycle 28 Cardiovascular Complications INCREASES IN THORACIC DECREASES CARDIAC OUTPUT PEEP: INCREASE MEAN THORACIC PRESSURE DECREASES VENOUS PRESSURES AND FURTHER RETURN DECREASE CARDIAC OUTPUT 29 GI Complications STRESS ULCERS OPIOIDS FOR SEDATION (BLEEDING) CAUSE CONSTIPATION 30 10  9/14/24 Goals of Care Maintain Patent Airway Promote Spontaneous Ventilation Enhance Cardiac Output Relieve Anxiety Monitor for poor ventilatory weaning response 31 Assessment Previous respiratory alterations Respiratory rate and WOB, auscultate lungs, Physical assessment peripheral perfusion, LOC and vitals How are you going to communicate with this Communication Assessment patient? Sedation Assessment How much sedation does this patient need? Monitoring for S/S of complications 32 Medication Neurom uscular blockers Succinylcholine Rocuronium Vecuronium Sedation Etomidate Propofol Ketamine Dexmedetomidine- Precedex Pain Medications Fentanyl Morphine PPI’s Pantoprazole 33 11  9/14/24 Richmond Agitation- Sedation Scale RASS 34 Confusion Assessment https://www.mdcalc.com/calc/1 870/confusion-assessment- Method for method-icu-cam-icu the ICU (CAM-ICU) 35 Restraints ICU intubated patients need orders for soft restraints. Q2 restraint assessments Communication about use of restraints 36 12  9/14/24 Nursing Diagnosis Impaired Risk for Ineffective Inadequate Airway confusion breathing gas exchange Clearance (ICU delirium) pattern Decreased Fluid Volume Nutrition Risk for Cardiac excess deficits Infection Output Anxiety and Acute Pain PTSD 37 Planning Care Oriented to person, place and time. Norm al breath sounds Maintain adequate hem oglobin and hem atocrit Maintain adequate oxygenation Maintain patent airway Maintain norm al tem p and W BC Maintain norm al vitals Maintain sufficient cardiac output Maintain norm al ABG’s Provide adequate nutritional support Provide adequate pain control 38 Implementation Assess neuro status Q4 Auscultate lungs Q2 Suction as needed (book states Q2) Monitor O2 sats and ABG’s Observe for WOB Reposition Q2- HOB always above 30 degrees Assess cardiac and peripheral vascular system Q2 39 13  9/14/24 Educate patient and family on what to expect Consider weaning to noninvasive pressure Weaning from Ventilator Hospital Protocol will define weaning parameters Ex. Shand's- RSBI (rapid shallow breathing index) less than 65 (R/Vt) and a cuff leak NG and Dobhoffs may get dislodged on extubating (be prepared) 40 Terminal Weaning Withdrawal of care- End of life Educate patients and family on steps that will be taken Medicate for comfort To leave tube in place or not is family's decision Provide privacy Keep tissues in room Provide seating for family Butterfly bundle 41 14