Respiratory Monitoring PDF

Unit 2 Respiratory Monitoring Introduction Respiratory assessment is an essential part of emergency nursing. It is a skill that requires time to develop and therefore continual practice is essential. Respiratory assessment forms an integral part of your complete assessment. An effective respiratory...

Unit 2 Respiratory Monitoring Introduction Respiratory assessment is an essential part of emergency nursing. It is a skill that requires time to develop and therefore continual practice is essential. Respiratory assessment forms an integral part of your complete assessment. An effective respiratory assessment will highlight airway, ventilation, and gas exchange deficits, which in turn will guide nursing and medical interventions to optimise respiratory function. Learning Objectives On completion of this unit the RN will be able to: 1. Demonstrate competence in performing a respiratory assessment on a patient in the emergency department 2. Document clinical findings and initiate appropriate nursing interventions following respiratory assessment 3. Analyse patient assessment findings and select an appropriate oxygen therapy device for the patient 4. Analyse and interpret Arterial Blood Gas results Key Concepts Respiratory health assessment Pulse oximetry Oxygen therapy Maintain an artificial airway Arterial blood gas analysis Respiratory Health Assessment Health History The aim of obtaining an accurate Respiratory Assessment is to: Identify adequacy of gas exchange (tissue oxygenation and excretion of carbon dioxide) Identify recent clinical manifestations of respiratory dysfunction. [13, 14] Transition Support Program - Emergency – Fundamentals of Emergency Nursing - 16 - When obtaining a clinical history, the presence or absence of acute distress determines whether an extensive or focused history is obtained. Questions for a focused history would include: What is the major presenting problem? What factors if any initiated the problem? Any specific disease process e.g. Cardiac Failure, Asthma, Pulmonary Embolism Questions for a comprehensive history would include information relating to: Cough Sputum Dyspnoea Chest pain Patient understanding of the problem Past history, may be obtained from many sources. Primarily the patient or their family and carers, General Practitioner (GP), nursing home notes, medical record or community nursing notes. Pattern of previous illness and exacerbations may indicate the potential level of severity. Nurses need to recognise red flags for respiratory illness such as previous intensive care admissions. Physical Assessment Effective physical examination will provide baseline data, which will aid in the prompt identification of change and the determination of appropriate nursing interventions. Physical assessment includes inspection, palpation, percussion and auscultation. Regularly using a systematic format reduces potential for missing important aspects of the assessment. Inspection Inspection involves direct observation of the patient’s chest. The aim is to identify abnormalities; the nurse should pay attention to chest excursion, symmetry, skin colour and any lesions present. Palpation Palpate the patient’s neck and thorax, specifically looking for but not limited to, position of trachea, subcutaneous emphysema, palpate and compare left and right chest wall, bone tenderness or crepitus, pulsations, bulges and depressions. Percussion Percussion is used primarily to assess the density of underlying lung structures. Transition Support Program - Emergency – Fundamentals of Emergency Nursing - 17 -  Different sounds are produced on percussion if the underlying structures are air filled, fluid filled or filled with solid matter. Auscultation Auscultation involves listening and interpreting sounds using a stethoscope. A systematic approach is used, auscultating the anterior, posterior and lateral aspects of the chest. Listen throughout inspiration and expiration and compare both sides of chest. Reading Access a current critical care text and review the section on - Tactile Fermitus is felt on the chest the Vibrations assessment of the respiratory system. In your reading, note: Wall as a patient talks "sounda "boat" "com" wordsSuch - as Effective clinical history taking and barriers that impede at the - Normal vibrations are greatest be towards bases should Apex and ↓ , Inspection – tongue and mucous membrane, chest wall even on bot sides. - ↓ Vibration can be due to pleural configuration, respiratory effort, general observation effusion , pneumothorax, ↑ mucsle mass. Obesity or (COPD Astuma) Hyperinflahon Palpation – abnormalities from inspection, chest wall, trachea , be from ↑ vibrations - can https://www.osmosis.org/ Ateletsis consolidation. position, respiratory expansion, tactile fremitusanswers/tactile-fremitus Pneumonia , , -> ↑ density of long tissue = ↑ Percussion – resonance, hyperresonance, tympani, dullness, conduction of vibrations flatness Auscultation – crackles, wheezes. Activity 1 Go to YouTube and find a video that provides both a description and example of the sound for the following: Normal Breath Sound Bronchial Bronchovesicular Vesicular Abnormal Breath Sound I of fluid alveoli snapping open Rales through small space or Crackles Akt , caused by the movement secretions caused by air moving over /inflammation by plural rubbing In large air ways sound caused Pleural Friction Rub grating obstructed away Stridor High - Pitched Audible noise caused by partially Wheeze by airflow through airways narrow - caused Transition Support Program - Emergency – Fundamentals of Emergency Nursing - 18 - Activity 2 With your clinical support person, complete a respiratory assessment on a patient in your ED. Document and discuss your findings including: Clinical history of the patient General observation – inspection and palpation findings Auscultation findings The respiratory assessment skills of inspection, palpation, percussion and auscultation require practice to master. Complete this activity regularly so that you become more comfortable and confident with these essential skills. Diagnostic Data A range of diagnostic data provides additional information to the respiratory health assessment. Examples include: Pulse oximetry Arterial blood gases Chest x-ray Pulmonary function tests Capnography [13, 14] Pulse Oximetry Pulse oximetry is a rapid, non-invasive method to continuously measure arterial oxygen (O2) saturation (SpO2). Pulse oximeters measure the pulse variations in red and infrared light transmitted through a tissue bed. Data averaged over several arterial pulse cycles are then presented as oxygen saturation as measured using pulse oximetry (SpO2). SpO2 is the amount of O2 transported by haemoglobin. Indications for use of pulse oximetry include: General monitoring During transport During procedures While oxygen therapy and mechanical ventilation are in use For patients with sleep disorders Monitoring perfusion distal to a limb injury. Pulse oximetry involves the placement of a probe on a translucent body part with a pulsatile vascular bed. These sites include: Transition Support Program - Emergency – Fundamentals of Emergency Nursing - 19 -  Finger Toe Earlobe Bridge of the nose. It is important that you apply the probe correctly, identify sources of inaccuracy, and intervene to eliminate or minimise these problems where possible. Limitations of Pulse Oximetry Nail polish potentially affects accuracy Poor peripheral perfusion or peripheral vasoconstriction will contribute to inaccuracy In the anaemic patient the readings will be unreliable and is not a good indicator if tissue oxygenation Pulse oximetry does not differentiate between carboxyhaemoglobin and oxyhaemoglobin. Pulse oximetry will not accurately reflect oxygen saturation especially in patients with suspected carbon monoxide poisoning Movement affects the level of transmitted light affecting accuracy Reading Access a current critical care text and review the section on pulse oximetry. Focus your reading on the following: What pulse oximetry measures Appropriate application of probe Sources of inaccuracy Measures to rectify or minimise inaccuracies Plethysmographic waveform Alarm parameters Oxygen Therapy Oxygen therapy has long been one of the mainstays of emergency management. There is emerging evidence to suggest otherwise. For many years the detrimental effects of oxygen therapy have been known in the chronic obstructive pulmonary disease (COPD) patients. Evidence indicates the use of oxygen in patients experiencing myocardial infarction may increase infarct size and mortality. High concentration oxygen induces vasoconstriction, which has been shown to reduce Transition Support Program - Emergency – Fundamentals of Emergency Nursing - 20 - cerebral blood flow and worsen outcomes in some neurological emergencies, including stroke severity and one year survival. The use of oxygen should be guided by true hypoxia and pulse oximetry. Patients including those with COPD should receive sufficient oxygen therapy to reverse hypoxia. Oxygen must be titrated to individual patient requirements. Supplemental oxygen (O2) is indicated when the patient has: Hypoxaemia Decreased O2 carrying capacity, for example anaemia. It is important to recognise the signs and symptoms of hypoxaemia. These include: Confusion, agitation Tachycardia Hypertension Dyspnoea Tachypnoea Shallow and or laboured breathing Cool, clammy skin. Oxygen therapy aims to provide supplemental oxygen to the body, thus preventing the adverse effects of hypoxaemia. Oxygen therapy can be delivered by a variety of different devices. Low or high flow is unrelated to the concentration of O2: that is high flow does not mean high concentration. Low flow oxygen devices: deliver supplemental oxygen at gas flows of less than or equal to eight litres/minute. Because this flow will not be sufficient to meet the patient’s total inspiratory requirements, the oxygen is mixed with room air. This result in variable oxygen concentrations delivered to the patient, depending on their minute volume. Nasal cannula and simple face masks are examples of low flow systems. High flow oxygen devices: deliver gas at flows sufficient to meet the patient’s inspiratory requirements regardless of the patient’s inspiratory pattern. Therefore the oxygen concentration delivered is more accurate. The venturi mask is an example of a high flow device. Reservoir systems are devices with the capacity to store oxygen between breaths. Oxygen in the reservoir can be used if the patient’s inspiratory requirement is greater than the oxygen flow. Partial re-breather masks are an example of a reservoir system. When a delivery system is chosen, consideration must be given to: Transition Support Program - Emergency – Fundamentals of Emergency Nursing - 21 -  The amount of oxygen required by the patient Advantages and disadvantages of each system Fraction of inspired O2 (FiO2) limits of each system Suitability for the patient (for example tolerance of a mask). The use of Humidified high flow nasal cannula (HHFNC) in emergency departments is increasing. HHFNC is used on the spontaneously breathing patient as a means of delivering supplemental oxygen to patients who have an oxygen requirement. The flow of HHFNC exceeds the patient’s own inspiratory demands. This reduces anatomical dead space; carbon dioxide is flushed from the upper airways creating a reservoir of fresh oxygen. The increased flow may increase airway pressure, thereby providing a small amount of positive end expiratory pressure (PEEP). Emerging evidence suggest an improvement in oxygenation when using HHFNC. It appears that HHFNC is an effective method to improve oxygenation in a patient with respiratory failure. Activity 3 Locate the oxygen delivery devices used in your ED. Discuss the advantages and disadvantages of these devices with your clinical support person. Arterial Blood Gas Analysis Arterial blood gases (ABG) is one of the most commonly performed laboratory tests in the critical care and emergency setting. ABG analysis is an important clinical skill. Analysis of arterial blood provides information on: Oxygenation (partial pressure of oxygen - PaO2 and O2 saturation - SaO2) Presence or absence of acidosis or alkalosis (acid base status - pH) Respiratory component of acid base status (partial pressure of carbon dioxide - PaCO2) Metabolic component acid base status - (level of bicarbonate - HCO3) Reading Access a current critical care text. Review the steps on arterial blood gas analysis. In this unit exclude the step on determining compensation. Transition Support Program - Emergency – Fundamentals of Emergency Nursing - 22 - Activity 4 With your clinical support person access your ED’s procedure or guideline on arterial blood gas collection. Discuss and demonstrate: Collection Labelling Transport Processing of arterial blood gas sample. Note: discuss and demonstrate only what is applicable for your ED Interpretation of ABGs is difficult to grasp for the novice nurse. This unit covers the steps required in ABG analysis. There are different methods for arterial blood gas analysis. Whichever method you choose, you should apply the same process each time. 6 Step Analysis ABG 1. Determine if the pH is normal (7.35-7.45), acid 7.45 2. Analyse PaCO2 (respiratory component of blood gas) normal 35-45mmHg. Low PaCO2 (45) this results in respiratory acidosis 3. Analyse HCO3. Normal 22-26mmols/L. Acid is < 22mmols/L Alkali is >26mmol/L 4. Match the PaCO2 or HCO3 with the pH If PaCO2 is high (acid) and pH is low (acid)= respiratory acidosis If PaCO2 is low (alkali) and pH is high (alkali) = respiratory alkalosis If HCO3 is low (acid) and pH is low (acid) = metabolic acidosis If HCO3 is high (alkali) and pH is high (alkali) = metabolic alkalosis 5. If PaCO2 or HCO3 move in opposite directions, this indicates a degree of compensation. Compensation is the body attempting to return the pH to normal values. The respiratory system begins compensation immediately, whereas the metabolic compensation may take many hours or days. 6. Analyse the PaO2 and SaO2 for hypoxaemia. The normal range for PaO2 is 80- 100mmHg on room air. Once over the age of 60, PaO2 decreases by 10mmHg for every 10 years of age. A patient on high levels of supplemental O2 with a normal PaO2 is likely to have serious pulmonary pathology. Transition Support Program - Emergency – Fundamentals of Emergency Nursing - 23 -  Immediate Respiratory compensation - Metabolic = No Metabolic compensation Acute Respiratory = : (by hidneys) days - after couple Compensation a Metabolic Chronic= +CO2 = T RR.: Activity 5 Analyse the following arterial blood gases. In the comment section, determine the oxygenation and acid base status. 1. Result Comment (acid, normal, alkali) pH 7.20 acid PaCO2 50mmHg acid HCO3 25mmol/L Normal PaO2 70 ↓ ↓ SaO2 90% ↓ Respiratory Acidosis Interpretation:…………………………………………………………………………………… ……...…………………………………………………………………………………………… (Hypoventilation) 2. Result Comment (acid, normal, alkali) pH 7.50 Alkali PaCO2 30mmHg Alkali HCO3 24mmol/L Normal PaO2 80 Normal SaO2 95% Normal Respiratory Alkalosis Interpretation: …………………………………………………………………………………… CHyperventilation) …………………………………………………………………………………………………… Transition Support Program - Emergency – Fundamentals of Emergency Nursing - 24 - 3. Result Comment (acid, normal, alkali) pH 7.20 acid PaCO2 38mmHg Normal HCO3 19mmol/L acid PaO2 85 Normal SaO2 96% Normal Metabolic acidosis - ↑ Hr Interpretation:……………………………………………………………………………………. ……..……………………………………………………………………………………………… Osmosis - A Better Way To Learn - Metabolic acidosis https://osmosis.org/learn/Metabolic_acidosis Chest X-Ray The chest x-ray gives information about the patient’s lung fields as well as correct placement of various invasive lines and tubes. It is a critical diagnostic tool used for pulmonary examination. Common abnormalities can be detected by chest x-rays which include: Atelectasis langApicies clavicle Barotrauma Trachea Pleural effusion artic arch bifurcation Pulmonary oedema Traceal o 2) pulmonary Pulmonary embolism Pneumonia or consolidation 18 Pneumothorax Hearorder Rib fractures Heart cardiophrenic Diaphragm Angle gastin R costophrenic Practice Tip Angle The interpretation of chest x-rays is an acquired skill that will develop throughout your progression of the program and experience in ED. It is suggested that you begin to look at your patient’s chest x-ray and discuss this with your peers. The subject of chest x-ray interpretation will be further discussed in the Respiratory Emergencies unit in the Adult Emergencies module. Transition Support Program - Emergency – Fundamentals of Emergency Nursing - 25 - Summary This concludes the Respiratory Monitoring unit. The key points covered were respiratory assessment; oxygen therapy, pulse oximetry and introduction to ABG analysis. To improve your skills, regular practice and application of the concepts outlined in this unit is required. If you had difficulty with any of the concepts presented, you should review the material and seek assistance from your clinical support person. Transition Support Program - Emergency – Fundamentals of Emergency Nursing - 26 -