401 LEC [PRELIMS] Critical Care Nursing PDF

TRANSES Subject Code: NRG 401 Mode of Class: LEC Semester: 1st Term: Prelims LESSON OUTLINE ii. Determining What f. Pharmacological...

TRANSES Subject Code: NRG 401 Mode of Class: LEC Semester: 1st Term: Prelims LESSON OUTLINE ii. Determining What f. Pharmacological Ought to Be Done Management 1. Introduction to Critical Care iii. Common Legal and g. Nursing Management Nursing Ethical Issues a. What is Critical Nursing? iv. Some Factors that 4. Pulmonary Embolism & Chest i. Goals of Critical Care Affects the Trauma Nursing (CCNAPI, Well-Being of Critical a. Pulmonary Embolism 2014) Care Nurses; i. Clinical ii. Common Cases in Resolving These Manifestations Critical Care Units Factors ii. Assessment and iii. Levels of Care v. Recommendations Diagnostic Findings (CCNAPI, 2014) iii. Prevention b. The Critical Care 2. Respiratory System: Review of iv. Medical Management Environment the Anatomy and Physiology v. Surgical Management i. Categorization of a. Introduction: Anatomy and vi. Nursing Management CCU Physiology b. Chest Trauma: Blunt Trauma ii. What to Expect in the b. The Upper Respiratory Tract i. Assessment ICU? i. Nose ii. Diagnostic Tests iii. Roles of Critical Care ii. Sinuses iii. Medical Management Nurses iii. Oral Cavity c. Chest Trauma: Sterna and iv. Competencies of iv. Pharynx Rib Fracture Critical Care Nurses v. Larynx i. Clinical c. Nursing Responsibilities c. The Lower Respiratory Tract Manifestation i. Common Concerns of i. Tracheobronchial ii. Assessment and the Critical Ill Tree Diagnostic Findings d. Essentials in Patient Care ii. Trachea (Windpipe) iii. Medical Management i. Communication iii. Bronchus iv. Nursing ii. Pain Assessment iv. Right and Left Lungs Responsibilities iii. Pain Management v. Alveoli d. Chest Trauma: Flail Chest iv. Provision of d. Ribcage i. Laboratory and Physiologic Needs e. Diaphragm Diagnostic Tests v. The Needs of ii. Medical Management Families of the 3. Respiratory Distress Syndrome Critically Ill a. Definition: Respiratory 5. Pulmonary Contusion e. The Multidisciplinary Team Distress Syndrome a. Pulmonary Contusion i. Working in Critical b. Surfactant i. Definition Care Environments c. Infant Respiratory Distress ii. Pathophysiology ii. Rapid Response Syndrome iii. Clinical Team i. Signs and Symptoms Manifestation iii. Managing the d. Diagnostic Tests iv. Assessment and Critically Ill e. Medical Management Diagnostics f. Ethical and Legal Issues in i. Surfactant v. Medical Management the Delivery of Critical Care Replacement therapy 1. Non-invasive i. Ethical Dilemma ii. Breathing support Therapies dfd  Go Back to Lesson Outline 2. Pharmacothe c. Pathophysiology Potential Complications rapy d. Clinical Manifestations f. Weaning the Patient from the 3. Invasive e. Assessment and Diagnostic Ventilator Therapies Findings i. Positive vi. Nursing Management i. Computed End-Expiratory 1. Assessment Tomography Scan Pressure 2. Possible (CT Scan) ii. Continuous Positive Diagnosis ii. Bronchoscopy Airway Pressure 3. Priorities f. Medical Management Therapy 4. Interventions i. Positive End iii. Pressure Support b. Penetrating Trauma Expiratory Pressure Ventilation (PSV) i. Definition (PEEP) iv. Inverse Ratio ii. What can be damaged ii. Chest Physiotherapy Ventilation in PT? iii. Nebulizer Treatments v. Bilevel, or Biphasic iii. Assessment and g. Surgical Management Ventilation Diagnostics i. Thoracentesis vi. Mandatory Minute iv. Medical Management ii. Cryotherapy/Laser Ventilation 1. Pharmacothe therapy vii. Proportional Assist rapy h. Nursing Management Ventilation 2. Medical/Surg i. Voluntary ical Deep-Breathing Therapies Maneuver v. Nursing Management ii. Positions & 1. Assessment Mobilization 2. Possible iii. Deep Breathing Diagnosis Exercise, Suctioning, 3. Priorities Incentive Spirometry, 4. Interventions and Postural Drainage 6. Cor Pulmonale iv. ICOUGHSM a. Definition b. Pathophysiology 8. Mechanical Ventilation c. Clinical Manifestation a. Mechanical Ventilator d. Assessment b. Classification of Ventilators e. Diagnosis/Diagnostic Exam i. Positive-Pressure f. Medical Management Ventilator ii. Controlled 7. Atelectasis Mechanical a. Definition of Atelectasis Ventilation i. Acute Atelectasis iii. Synchronized ii. Microatelectasis Intermittent iii. Macroatelectasis Mandatory iv. Obstructive and Non Ventilation Obstructive c. Planning and Goals Atelectasis d. Nursing Interventions b. Risk Factors e. Monitoring and Managing dfd  Go Back to Lesson Outline To use relevant and up-to-date knowledge, caring attitude and LESSON 1: clinical skills, supported by appropriate technology for the prevention, Introduction to Critical Care early detection and treatment of complications to facilitate recovery. To provide palliative care to the critically ill patients in situations Nursing where their health status is progressing to unavoidable death, and to help the patients and families go through their painful sufferings. What is Critical Care Nursing? Common Cases in Critical Care Units Critical Nursing is: Critical Care Units often have the following cases: Traumatic injuries from such events as automotive collisions, falls, The delivery of specialized care to critically ill patients— that is, ones gunshots. who have life-threatening illnesses or injuries. Cardiovascular disorders, such as heart failure and acute coronary To be considered critical, an illness or injury must acutely impair one syndromes (unstable angina and myocardial infarction [MI]). or more vital organ systems to such a degree that there is a high Surgeries, such as abdominal aortic aneurysm repair and carotid probability of life-threatening deterioration. endarterectomy. - Perrin and McLeod, 2018 Respiratory disorders, such as acute respiratory failure and pulmonary embolism. Critical nursing is a nursing care that: GI and hepatic disorders, such as acute pancreatitis, acute upper GI Reflects a holistic approach in caring of patients. bleeding, and acute liver failure. Places great emphasis on the caring of the Renal disorders, such as acute and chronic renal failure. bio-psycho-social-spiritual nature of human beings and their Cancers, such as lung, esophageal, and gastric cancer. responses to illnesses rather than the disease process. Shock caused by hypovolemia, sepsis, and cardiogenic events (such Helps maintain the individual patient’s identity and dignity. as after MI). The focus of caring includes preventive care, and risk factor modification and education to decrease future patient admissions to acute care facilities. Levels of Care (CCNAPI, 2014) Goals of Critical Nursing (CCNAPI, 2014) 1. Level 1: Should be capable of providing immediate resuscitation for the critically ill and short- term cardio-respiratory support Critical Care Nursing aims: because the patients are at risk of deterioration. To promote optimal delivery of safe and quality care to the critically ill Has a major role in monitoring and preventing complications patients and their families by providing highly individualized care so in “at risk” medical and surgical patients. that the physiological dysfunction as well as the psychological stress Must be capable of providing mechanical ventilation and in the ICU are under control. simple invasive cardiovascular monitoring. To care for the critically ill patients with a holistic approach, Has a formal organization of medical staff and at least one considering the patient’s biological, psychological, cultural and registered nurse. spiritual dimensions regardless of diagnosis or clinical setting. dfd  Go Back to Lesson Outline A certain number of nurses including the nurse incharge of The Critical Care Environment the unit should possess post-registration qualification in critical care or in the related clinical specialties, and The critical care environment is: Has a nurse: patient ratio of 1:1 for all critically ill patients. Also known as Intensive Care Unit (ICU) or Intensive Treatment Unit (ITU). 2. Level 2: A special department of the hospital or healthcare facility that Should be capable of providing a high standard of general provides intensive care medicine. critical care for patients who are stepping down from higher Caters to patients with severe or life- threatening illnesses and levels of care or requiring single organ support/support injuries, which require constant care, close supervision from life postoperatively. support equipment and medication to ensure normal bodily functions. Capable of providing sustainable support for mechanical Staffed by highly trained physicians, nurses, respiratory therapists ventilation, renal replacement therapy, invasive and other members of the healthcare team who specialize in caring hemodynamic monitoring, and equipment for critically ill for critically ill patients. patients of various specialties such as medicine, surgery, trauma, neurosurgery, vascular surgery. Has always a designated medical director with appropriate Categorization of CCU intensive care qualification and a duty specialist available 1. By age group: exclusively to the unit. Neonatal The nurse in-charge and a significant number of nursing staff Pediatric in the unit have critical care certification; and Adult A nurse: patient ratio is 1:1 for all critically ill patients. 2. By specialty: 3. Level 3: Medical Is a tertiary referral unit, capable of managing all aspects of Surgical critical care medicine (This does not only include the Cardio-thoracic management of patients requiring advanced respiratory Cardiac support but also patients with multi-organ failure). Respiratory Has a medical director with specialist critical / intensive care Neurosurgical qualification and a duty specialist available exclusively to the Trauma unit and medical staff with an appropriate level of experience always present in the unit. 3. By system operation: A nurse in-charge and most nursing staff have intensive care Open System – certification; and i. The admitting and other attending doctors make A nurse: patient ratio is at least 1:1 for all patients at all decisions without consulting or communicating with times. a Critical Care Specialist. Closed System – i. Patient care is provided by a dedicated ICU team that includes a critical care physician. dfd  Go Back to Lesson Outline What to expect in the ICU? In ICU, you must expect a: Critically ill patients with various attachments and monitoring devices Common equipment in an ICU include: o Mechanical ventilators to assist breathing through an endotracheal tube or a tracheostomy tube. o Cardiac monitors for monitoring Cardiac condition. o Other devices for the constant monitoring of bodily functions. o A web of intravenous lines, feeding tubes, nasogastric tubes, Roles of Critical Care Nurses suction pumps, drains, and catheters, syringe pumps. A critical care nurse is a licensed professional nurse who is responsible for o A wide array of drugs to treat the primary condition(s) of ensuring that acutely and critically ill patients and their families receive hospitalization. optimal care. 1. Staff Nurse Makes independent assessments. Plans and implements patient care. Provides direct nursing care. Makes clinical observations and executes interventions. Administers medications and treatments. Promotes activities of daily living. 2. Nurse Educator Assesses patients and families’ learning needs; plans and implements teaching strategies to meet those needs. Evaluates effectiveness of teaching. Educates peers and colleagues. Possesses excellent interpersonal skills. 3. Nurse-Manager Acts as an administrative representative of the unit. Ensures that effective and quality nursing care is provided in a timely and fiscally sound environment. 4. Case Manager Manages comprehensive care of an individual patient. Encompasses the patient’s entire illness episode, crosses all care settings, and involves the collaboration of all personnel who provide care. dfd  Go Back to Lesson Outline Is involved in discharge planning and making referrals. Identifies community and personal resources. 3. Caring Practices Arranges for equipment and supplies needed by the patient Nursing activities create a compassionate, supportive, and on discharge. therapeutic environment for patients and staff, with the aim of promoting comfort and preventing unnecessary suffering. 5. Nurse Practitioner Provides primary health care to patients and families; can 4. Advocacy and Moral Judgement function independently. Respecting and supporting the basic rights and beliefs of the May obtain history and conduct physical examinations. critically ill patient. Orders laboratory and diagnostic tests and interprets results. Diagnoses disorders. 5. Systems Thinking Treats patients. Managing the existing environmental and system resources Counsels and educates patients and families. for the benefit of patients and their families. 6. Clinical Nurse Specialist 6. Facilitator of Learning Participates in education and direct patient care. Creatively modify or develop patient/family educational Consults with patients and family members. programs and integrate family/patient education throughout Collaborates with other nurses and health care team the delivery of care. members to deliver high-quality care. 7. Response to Diversity 7. Nurse Researcher Sensitivity to recognize, appreciate, and incorporate diversity Reads current nursing literature. into the provision of care. Applies information in practice. Collects data. 8. Collaboration Conducts research studies. Working with others in a way that promotes each person’s Serves as a consultant during research study contributions toward achieving optimal and realistic implementation. patient/family goals. Competencies of Critical Care Nurses Nursing Responsibilities 1. Clinical Inquiry Standards of Care for Acute and Critical Care Nursing: Critical care nurses should be engaged in the ongoing process of questioning and evaluating practice and providing 1. Standard of Care I: Assessment informed practice. The nurse caring for acute and critically ill patients collects relevant patient health data. 2. Clinical Judgment Clinical reasoning which includes clinical decision- making, 2. Standard of Care II: Diagnosis critical thinking, and a global grasp of the situation, coupled The nurse caring for acute and critically ill patients analyzes with nursing skills acquired through a process of integrating the assessment data in determining diagnoses. formal and experiential knowledge. dfd  Go Back to Lesson Outline 3. Standard of Care III: Outcome Identification 14. Standard of Professional Practice VIII: Resource Utilization The nurse caring for acute and critically ill patients identifies The nurse caring for acute and critically ill patients considers individualized expected outcomes for the patient. factors related to safety, effectiveness, and cost in planning 4. Standard of Care IV: Planning and delivering patient care. The nurse caring for acute and critically ill patients develops a plan of care that prescribes interventions to attain Common Concerns of the Critically Ill expected outcomes. 5. Standard of Care V: Implementation Being thirsty The nurse caring for acute and critically ill patients Being in pain implements interventions identified in the plan of care. Having tubes and lines in their body that restrict their movement. 6. Standard of Care VI: Evaluation Not being able to communicate. The nurse caring for acute and critically ill patients evaluates Being unable to fulfill family roles. the patients’ progress towards attaining expected outcomes. Being unable to sleep. 7. Standard of Professional Practice I: Quality of Care Not being able to control themselves. The nurse caring for acute and critically ill patients systematically evaluates the quality and effectiveness of nursing practice. Essentials in Patient Care 8. Standard of Professional Practice II: Individual Practice Evaluation The practice of the nurse caring for acute and critically ill Essentials in Patient Care - Communication patients reflects knowledge of current professional practice 1. Sedated Patients standards, laws, and regulations. Provide orientation or translate medical information. 9. Standard of Professional Practice III: Education State procedural and task intentions. The nurse acquires and maintains current knowledge and Provide reassurance. competency in the care of acute and critically ill patients. Apologize and/or recognize discomfort. 10. Standard of Professional Practice IV: Collegiality Obtain a response. The nurse caring for acute and critically ill patients interacts Provide intentional and unintentional distractions. with and contributes to the professional development of Provide social information to colleagues. peers and other healthcare providers as colleagues. 2. Responsive Patients 11. Standard of Professional Practice V: Ethics If with limitation to verbal communication, provide The nurses’ decisions and actions on behalf of acute and communication tools such as letter boards, speaking valves, critically ill patients are determined in an ethical manner. and prosthetic larynxes. 12. Standard of Professional Practice VI: Collaboration Recognize nonverbal cues like nodding and hand The nurse caring for acute and critically ill patients movements. collaborates with the team, consisting of patient, family, and Limit the use of restraints. healthcare providers in providing care in a healing, humane, Be educated about the frustration that mechanically and caring environment. ventilated patients experience when they are attempting to 13. Standard of Professional Practice VII: Research communicate their needs and desires. The nurse caring for acute and critically ill patients uses When communicating with ventilated patients, you should – clinical inquiry in practice. dfd  Go Back to Lesson Outline o Routinely ask patients about their feelings and their Intravenous infusions of analgesics start to act immediately; state of mind. however, they will not provide significant analgesia until the infusion o Ask permission before beginning nursing care and reaches “steady state.” procedures. At the initiation of an infusion and when the infusion rate is o Evaluate patients’ understanding of the information increased, loading doses must be administered to provide immediate conveyed to them by asking simple yes/no analgesia and maintain the desired analgesia until the infusion questions. reaches a steady state. Demonstrate attention to the needs of their patients by In response to anticipated painful procedures (e.g., turning) the informing them of their surroundings, plan of care, and when patient might receive an additional bolus. they will return after leaving the bedside. Adjustment of dose as indicated (e.g., elderly patients, impaired Approach each patient with a kind, patient manner; take the renal function). time to investigate and understand what the patient is communicating; and respond to the patient’s communicated Essentials in Patient Care - Provision of Physiologic Needs needs. Sleep: Assess all intravenous lines for patency and level all transducers, Essentials in Patient Care - Pain Assessment placing the head of the bed in the desired position before the patient Patient self-report. is settled for sleep. Obtain vital signs. Search for a potential cause of a change in patient behavior. Assess the patient for pain or discomfort and provide medication as Surrogate report of a patient’s pain or patient’s behavior change. needed. Observation of patient behaviors when patient self-report is not Decrease noise in the patient’s environment as much as possible. possible – Assess the patient’s normal sleep patterns and habits. Attempt to o Facial expressions duplicate as many of these as possible. o Body Movements Ensure ventilator settings are in synchrony with the patient’s o Muscle Tension breathing pattern. o Compliance with ventilation If it is necessary to disrupt the patient’s sleep, try to space o Physiologic parameters procedures so that the patient is able to obtain at least 2 to 3 hours of uninterrupted sleep at a time. Nutrition: Essentials in Patient Care - Pain Management Perform assessment and history taking. General Principles for Administration of Pain or Sedative Medications: Determine nutritional requirements. For acute pain, analgesics should be administered intravenously for Assist in feeding as necessary. Be mindful of enteral and parenteral immediate onset of action to prevent the imprinting of the painful feedings. experience on the nervous system. Coordinate nutritional care with a nutritionist/dietician. Subsequent doses may be given intravenously or orally on a regular Evaluate effectiveness of nutritional therapy. schedule around the clock. Continuous pain management is Mobility: essential since duration and efficacy of analgesic intervention may Adherence to progressive mobilization plan (turning to sides, be as important as timing for treatment of pain. passive/active ROM, movement against gravity, dangling and balancing, transferring to a chair, chair positioning, then ambulating). Collaboration with physical and occupational therapists. dfd  Go Back to Lesson Outline DATAS Report Used to report patient condition during hand-offs The Needs of Families of the Critically Ill i.e., shift-to-shift, unit-to-unit. Support Comfort Proximity Information Assurance The Multidisciplinary Team For optimum patient outcomes, critical care is delivered by a multidisciplinary team whose members trust each other and communicate and collaborate well. Stop the Line: Use CUS Words Working in Critical Care Environments Structured communication tool to flag patient safety risks Communication: Empowers everyone on the team to stop the line Optimal patient care is not possible without skilled communication, Cues everyone on the team to pay attention if these words are used and errors are frequent in situations where communication between healthcare providers and patients and their families is impaired. Use of SBAR and/or DATAS communication tools. Use of the CUS method and/or the Two-challenge Rule to resolve concern. SBAR Report Used to report findings to a physician or other members of the health Two-Challenge Rule care team about a patient’s condition. Invoked when an initial assertion is ignored... Prior to calling the physician, review the last 24 hours of progress It is your responsibility to assertively voice your concern at least two notes and always assess the patient. times to ensure that it has been heard The member being challenged must acknowledge If the outcome is still not acceptable ○ Take a stronger course of action ○ Use supervisor or chain of command How do team members stop the line now? Can patients and families stop the line? Empower any team member to "stop the line" If patient safety is at stake dfd  Go Back to Lesson Outline Collaboration: Rapid Response Team (RRT) Collaboration is a process, not a single event, and it requires that members of the healthcare team develop a pattern of sharing knowledge and responsibility for patient care. This ultimately affects Also known as the Medical Emergency Team. patient outcomes. A team of nurses and other health care professionals (respiratory therapists, pharmacists, emergency department personnel, and Building the Team: others) who bring critical care expertise to the bedside. Nurses have an important role on the multidisciplinary team in The teams may or may not include physicians. helping the team to recognize that the overall goal is related to the The key goal is to act before “failure to rescue” occurs and a patient patient’s values and quality of life preferences as well as assisting in has suffered a cardiac or respiratory arrest. the establishment of the daily patient goals and the treatment plan. Negotiating Respectfully o Nurses should contribute to teams from positions of strength Managing the Critically Ill by being innovative and by demonstrating integrity in Clinical Pathways collaboration and to achieve collaboration there must be Practice Guidelines some form of power sharing Protocols Managing Conflict Wisely Best Practices o Encountering conflict can be stressful but acknowledging it Critical Care Research and managing it well is the cornerstone to successful Evidenced-Based Care collaboration. o It is important to distinguish between emotional conflict and Ethical and Legal Issues in the Delivery of Critical Care task conflict. Ethical Dilemma A situation that gives rise to conflicting moral claims, resulting in disagreements about choice for action. Exist when there is a conflict between the duties, rights, or values of the people involved in the situation. Ethical dilemmas are usually described in terms of right or wrong, Conflict Resolution (DESC Script) duty or obligation, rights or responsibilities, and good or bad. A constructive approach for managing and resolving conflict Determining What Ought to be Done Identify significant information. Recognize what ethical reasoning you are using and identify the ethical viewpoints of those involved in the dilemma. Ask yourself – dfd  Go Back to Lesson Outline o What ethically justified goals can be identified? o What are the ethically justified alternatives for action or what are the choices? o Are there practical constraints to following any of them? o What arguments can be constructed in favor of these alternatives (this includes considering the probable consequences)? o How can these arguments be evaluated? o What ought to be done? Common Legal and Ethical Issues Informed Consent Use of Restraints End-of-Life Issues o Advance Directives o Limitation of Therapy o Withdrawal of Therapy o Euthanasia o Organ Donation Compassion Fatigue: Cultural Consideration State of tension and preoccupation with the suffering of those being Negligence helped that is traumatizing for the helper. Standards of Care The term used to describe the combined effect of secondary traumatic stress and burnout. Some Factors That Affect the Well-Being of Critical Nurses and How They Secondary traumatic stress is primarily a response to caring for people who are suffering, whereas burnout is often a response to are Resolved other stressors such as poor morale in the work environment. Moral Distress: Signs and Symptoms: A nurse would know the right thing to do, yet institutional constraints o Intrusive thoughts or images of patients’ situations or such as lack of resources or personal authority would prevent her traumas. from doing it. o Difficulty separating work life from personal life. What can we do? o Lowered tolerance for frustration and/or outbursts of anger o Ask-Affirm-Assess-Act: The 4 As to rise above moral or rage. distress. o Dread of working with certain patients. o Conscientious refusal o Depression o Increase in ineffective and/or self-destructive self-soothing behaviors. o Hypervigilance o Decreased functioning in nonprofessional situations o Loss of hope dfd  Go Back to Lesson Outline What can we do? Strategies for enhancing professional well-being include: o Make a commitment to self-care. Balancing work and home responsibilities – devoting sufficient time o Develop strategies for letting go of work. to each without compromising the other. o Develop strategies for acquiring adequate rest and Establishing boundaries and setting limits concerning: relaxation. o Overworking o Plan strategies for practicing effective daily stress reduction. o Therapeutic/professional boundaries o Personal boundaries Job Satisfaction: o Realis when differentiating between things that one can An important component of nurses' lives that can impact on patient change and accepting things that one cannot change. safety, staff morale, productivity and performance, quality of care, Obtaining support at work from peers, supervisors, and mentors. retention and turnover, commitment to the organization and the Generating work satisfaction by noticing and remembering the joys profession with additional replacement costs and further attempts to and achievements of the work. hire and orientate new staff. Factors affecting job satisfaction: Strategies for enhancing psychological well-being include: o Working environment, policies and practice, caring Sustaining a balance between work and play. organization. Developing effective relaxation methods. o Appreciation, pay, age, promotion, feeling of belongings. Maintaining contact with nature or other soothing stimuli. What can we do? Developing methods of effective creative self-expression. o Address issues or concerns relating to the above-mentioned Maintaining effective skills for ongoing self-care such as: factors. o Assertiveness o Stress reduction o Interpersonal communication skills o Cognitive restructuring o Time management Recommendations Strategies for enhancing physical well-being include: Monitoring all parts of the body for tension and utilizing appropriate techniques to reduce tension. Utilizing health methods that induce sleep and return to sleep. Monitoring all foods and drink intake with an awareness of their implication for health and functioning. Strategies for enhancing social/interpersonal being include: Identifying at least five people who will be highly supportive when called to deliver help and will respond quickly and effectively. Knowing when and how to secure help both personally and professionally. Being involved in addressing and preventing moral harm. dfd  Go Back to Lesson Outline Turbinates also direct air upwards at the top of the nasal cavity with LESSON 2: the olfactory mucosa. Respiratory System: Review of the ○ Olfactory mucosa is a specialized area for smelling. In this area, there are a bunch of tiny nerves that collectively make Anatomy and Physiology up the Cranial I (Olfactory Nerve). These tiny little nerves pass through the school at this area to reach the cranial cavity at a special spot Introduction: Anatomy and Physiology called the olfactory bulb, which will then have attracted to the brain to process the sense of smell. Our body uses energy from the food we eat, but cells can obtain the energy from food only with the help of the vital gas oxygen (O2), which allows for cellular respiration. Sinuses The respiratory system's primary function is to transport the oxygen These cavities of air in the bones of the cranium are believed to help from the atmosphere into the bloodstream to be used by cells, in the prolongation and intensification of sound produced by the tissues, and organs for the processes necessary to sustain life. voice. Remember, during cellular respiration glucose is broken down to Not all of the sinuses exist at birth; rather, they develop as you grow make adenosine triphosphate (ATP) our body needs oxygen to and influence facial changes as you mature. sinuses also provide burn glucose such as your car needs oxygen to burn gasoline. further warming and moisturizing of inhaled air. The Upper Respiratory Tract Nose Oral Cavity Food and water passes through the oral cavity and eventually A semi rigid structure made of cartilage (anterior) and bone passes through the esophagus. But this creates a problem (posterior) because there's a space where both food and water are shared The nasal cavity is separated into right and left halves by a wall with air. called the nasal septum or septal cartilage, made of bone and Bolus is formed when food is being chewed and is held in place cartilage. by the tongue. Nasal Conchae is located at the back of the bony septum. It is ○ Soft Palate is located at the posterior area of the tongue composed of three (3) parts: Superior, Middle, Inferior. It is also and lacks bone. It acts as a flap to prevent food from known as turbinates, which helps warm air, humidify, and clean. going up into the nasal cavity. dfd  Go Back to Lesson Outline ○ Epiglottis is a flap of tissue located at the inferior base of The Lower Respiratory Tract the tongue. It serves to flap down and protect the opening to the airway as food is being swallowed. Tracheobronchial Tree Pharynx The airway network that leads to the lungs and then branches out into the various long segments resembles an upside down tree and is sometimes called the tracheobronchial tree. Trachea (Windpipe) After leaving the larynx, the inspired air enters the trachea, also The pharynx is a hollow muscular structure about 2 ½ inches long, known by the lay term windpipe. lined with epithelial tissues. The trachea is the largest bronchus and can be thought of as the The pharynx begins to steer to the nasal cavities and is divided into trunk of the tracheobronchial tree. the following three sections. Larynx The larynx located in the neck is a triangular chamber inferior to the pharynx that houses the Once the trachea reaches the center of the chest approximately at important structures needed for the level of vertebrae T5, it begins its first branching, or bifurcates, speech. into bronchi (bronchus is the singular form), the right mainstem and This is commonly known as the the left mainstem. voice box, the larynx is a semi rigid structure composed of several types of cartilage connected by muscles and ligaments that provide for movement of the vocal cords to control speech. Vestibular fold = false vocal cords It terminates through the carina where it becomes the right main Vocal fold creates vocalization; thus, known as the true vocal chords. bronchus and the left main bronchus. dfd  Go Back to Lesson Outline The right lung can be further divided into three (3) lobes: Superior Bronchus lobe, Middle lobe and Inferior lobe. Two (2) parts: Right main bronchus and Left main bronchus. ○ The superior and inferior lobes are separated by an oblique The left main bronchus branches at a different angle than the right main bronchus because of the presence of the heart in the left side fissure. of the chest. ○ The superior and middle lobes are separated by a horizontal Secondary bronchi aka Lobar Bronchi fissure. ○ 3 branches on the right On the left, however, we typically only have two (2): Superior lobe ○ 2 branches on the left Tertiary bronchi aka Segmental Bronchi and Inferior lower lobe. These two lobes are separated by an oblique fissure. Right and Left Lungs A hilum is an area where vessels and other things enter and exit. The space in the lungs is called the mediastinum and contains a lot The right and left lungs are cone shaped organs; the rounded peak is called the apex of the lung. of important structures. Each lung is composed of an apex (top) and base. The apices (plural ○ Esophagus carries food through the thorax down to the of apex) of the lungs extend 1-2 inches above the clavicle. The abdomen then into the stomach. bases of the lungs resume the right and left hemidiaphragm. The ○ Trachea right lung base is a little higher than the left to accommodate the large liver lying underneath. ○ Aortic arch ○ Descending aorta PULMONARY CIRCULATION Pumping action of the right ventricles ○ Pumps blood (deoxygenated blood) through the pulmonary arteries It becomes oxygenated in the lungs. Come back as the pulmonary vein into the left atrium. The reservoir of oxygenated blood can be used for systemic circulation. HOW WE BREATHE The control center that tells us to breathe is located in the brain, specifically in the medulla oblongata. There is also another respiratory area in the pons. Inspiration is an active process of ventilation in which the main breathing muscle, the diaphragm (a dome-shaped muscle when at rest), is sent a signal via the phrenic nerve, from the cervical plexus of the spinal cord. dfd  Go Back to Lesson Outline Ventilation versus Respiration Respiration Respiration is the process of gas exchange however the are two events of respiration in your body. External Respiration - Gas exchange in the lungs occurs between the blood and the air in the external atmosphere. Internal Respiration - the oxygenated blood is transported internally via the cardiovascular system to the cells and tissues where gas exchange is happening, and oxygen moves into the cells as carbon dioxide is removed COMPLIANCE The ease by which ventilation occurs is referred to as compliance. Low compliance means that it is more difficult to expand the lungs, high compliance means that less effort is required to expand the lungs For example, this becomes clinically significant when assessing people who have a broad take diseases of the lungs that decrease compliance and make it difficult to breathe in a sufficient volume of air What makes the brain tell the lungs how rapidly or how slowly to Alveoli breathe? In a general sense, the respiratory system is a series of branching ○ When your pH is Down = aciDosis tubes called bronchi and bronchioles that transport the ○ Although we can consciously speed up or slow down our atmospheric gas deep within our lungs to the small air sacs called breathing, our breathing rate is normally controlled by the alveoli, which represent the terminal end of the respiratory system. level of carbon dioxide in our blood. If blood carbon dioxide To better visualize this system, look at a stalk of broccoli held upside levels rise, it means that not enough CO2 is being ventilated, down. The stalk and its branches represent the airways, and the So the medulla oblongata send signals to respiratory green bumpy stuff on the end is like the terminal alveoli. muscles to increase the rate and depth of breathing. dfd  Go Back to Lesson Outline INSPIRATION AND EXPIRATION ○ Inspiration Diaphragm contracts Thoracic cavity expands volume and reduces pressure Lungs expand and pulls air from the outside environment ○ Expiration Diaphragm relaxes The volume of the thoracic cavity decreases, while the pressure within it increases Ribcage Lungs contract and air is forced out The bony supports structure and protection of the pulmonary cavity. Anteriorly in the midline, we have this bone called the sternum or the breastbone. And going from superior to inferior, it's broken up into a manubrium, a body, and a xiphoid process ○ Manubrium means handle ○ Xiphoid means sword like; thus xiphoid process is the very pointy part at the very inferior edge. Attaching to the sternum laterally are these cartilages called the costal cartilages. Inferiorly, several of them merge to form the inferior border of the ribcage and is called the costal margin. There are 12 ribs on either side of the sternum. The first ribs, one (1) through seven (7) are often called true ribs because they all connect directly to the sternum via one of their costal cartilages. However, ribs eight through 12, don't; thus called false ribs. Furthermore, ribs 11 and 12 are sometimes called floating ribs because they have no attachment direct or indirect to the sternum. Diaphragm The major muscle of breathing. A very wide flat muscle that separates the thoracic cavity from the abdominal cavity. The dome on the right is a little bit higher up because of the presence of a very large organ called the liver. Centrally, it becomes tenderness called the central tendon. dfd  Go Back to Lesson Outline LESSON 3: Infant Respiratory Distress Syndrome Respiratory Distress Syndrome Newborn after healthy delivery, normal respiration supplies the brain tissue with Respiratory Distress Syndrome a.k.a Hyaline Membrane disease oxygen-rich blood. Oxygen and carbon dioxide are A common breathing disorder that affects newborns. RDS occurs exchanged with the alveoli most often in babies born preterm, affecting nearly all newborns who during normal respiration. are born before 28 weeks of pregnancy. Less often, RDS can affect full term newborns. More common in premature newborns because their lungs are not able to make enough surfactant. Respiratory Distress following premature delivery, decreased respiration diminishes oxygen to the brain resulting in tissue death. Thickened and inflamed Surfactant alveoli reduce oxygen and carbon dioxide exchange. A foamy substance that keeps the lungs fully expanded so that newborns can breathe in air once they are born. Without enough surfactant,the lungs collapse and the newborn has to work hard to breathe. He or she might not be able to breathe in enough oxygen to support Signs and Symptoms the body’s organs. Most babies who develop RDS show signs of breathing problems and a lack of oxygen at birth or within the first Grunting sounds few hours that follow. Rapid, shallow breathing The lack of oxygen can damage the baby’s brain and other organs if Sharp pulling inward of the muscles between the ribs when breathing not treated promptly. Widening of the nostrils, or flaring, with each breath dfd  Go Back to Lesson Outline Diagnostic Tests Surfactant replacement therapy Chest X-ray - to show whether a newborn has signs of RDS. A chest It helps keep the lungs open so that a newborn can breathe in air X-ray also can detect problems, such as a collapsed lung, that may once he or she is born. require urgent treatment. Babies who have RDS get surfactant until their lungs are able to start making the substance on their own. Surfactant is usually given through a breathing tube. The tube allows the surfactant to go directly into the baby’s lungs. Surfactant often is given right after birth in the delivery room to try to prevent or treat RDS. It also may be given several times in the days that follow, until the baby is able to breathe better. Once the surfactant is given, the breathing tube is connected to a Blood tests - to see whether a newborn has enough oxygen in the ventilator, or the baby may get breathing support from NCPAP. blood. Blood tests also can help find out whether an infection is NCPAP or Nasal continuous positive airway pressure (CPAP) causing the newborn’s breathing problems. therapy is a non-surgical treatment that provides a steady flow of air to the lungs through the nose. Echocardiography (echo) - to rule out heart defects as the cause of the newborn’s breathing problems. Medical Management Treatment for RDS usually begins as soon as a newborn is born, sometimes in the delivery room. Treatments for RDS include surfactant replacement therapy, breathing support from a ventilator or nasal continuous positive airway pressure (NCPAP) machine, or other supportive treatments. dfd  Go Back to Lesson Outline 3. CALFACTANT (Infasurf) Breathing support - A natural calf lung extract containing phospholipids, fatty acids, and surfactant-associated proteins B Newborns who have RDS often need breathing support, or oxygen (260mcg/mL) and C (390mcg/mL). It is for ET use therapy, until their lungs start making enough surfactant. Until only. recently, a mechanical ventilator usually was used. The ventilator 4. LUCINACTANT (Surfaxin) was connected to a breathing tube that ran through the newborn’s - Synthetic KL4 protein (sinapultide) similar to SP-B. mouth or nose into the windpipe. Contains DPPC and palmitoyloleoyl Treatment in the NICU helps limit stress on babies and meet their phosphatidylcholine (POPG) phospholipids. basic needs of warmth, nutrition, and protection. Such treatment may include: Nursing Management 1. Checking liquid intake 2. Checking the amount of oxygen in the blood 3. Giving fluids and nutrients Maintain airway and administer oxygen. 4. Measuring blood pressure, heart rate, breathing, and Endotracheal suctioning can be done as required using strict aseptic temperature techniques. Monitor oxygen saturation while suctioning the baby. 5. Using a radiant warmer or incubator Assess the respiratory rate and general status of the neonate, O2 saturation, respiratory pattern, arterial blood gas and vital signs. Maintain a neutral thermal environment. Pharmacological Management Preterm with respiratory distress syndrome should be prevented Exogenous surfactant can be helpful in treating respiratory distress from infection by minimal handling and using aseptic technique while syndrome (RDS). It has also been used in treating newborn infants handling. with meconium aspiration syndrome, pneumonia, and pulmonary Skin care with use of water pillows, change of napkin if wet, clean hemorrhage. In RDS, after intratracheal administration of surfactant, skin folds with sterile swab and with frequent position change. surface tension is reduced, alveoli are stabilized, work of breathing is Provide comfort and other necessary care to neonate in incubator or decreased, and lung compliance is increased. ventilator as per requirements. 1. BERACTANT (Survanta) - A natural/modified bovine lung extract that lowers surface tension on alveolar surface tension on alveolar surfaces during respiration and stabilizes alveoli against collapse at resting transpulmonary pressures. For endotracheal (ET) use only. Survanta contains 10% SP-B. 2. PORACTANT (Curosurf) - Poractant lowers surface tension on alveolar surfaces during respiration and stabilizes alveoli against collapse at resting transpulmonary pressures. It is indicated to treat respiratory distress syndrome in premature infants. Poractant is for ET use only. Curosurf has an SP-B content of 30%. dfd  Go Back to Lesson Outline LESSON 4: Pulmonary Embolism: Assessment and Diagnostic FIndings Pulmonary Embolism & Chest 1. Chest X-ray Trauma Usually normal but may show infiltrates, atelectasis, elevation of the diaphragm on the affected side, Pulmonary Embolism or a pleural effusion. 2. ECG Sinus tachycardia, nonspecific ST-T Refers to the obstruction of the pulmonary artery or one of its wave abnormalities branches by a thrombus (or thrombi) that originates somewhere in 3. ABG the venous system or in the right side of the heart. May show hypoxemia and hypocapnia; measurements may Mechanism of Pulmonary Embolism be normal even in the presence of PE 4. Pulse Oximetry 5. Multidetector Row computed tomography angiography (MDCTA) allows for direct visualization under fluoroscopy of the arterial obstruction and accurate assessment of the perfusion deficit 6. V/Q scan Evaluates different regions of the lung (upper, middle, lower) and to examine airflow (ventilation) and blood flow (perfusion) in the lungs. The aim of the scan is to look for evidence of any blood clot in the lungs. Pulmonary Embolism: Prevention 1. Active leg exercise Pulmonary Embolism: Clinical Manifestations 2. Early ambulation 3. Use of anti-embolism Stockings 1. Dyspnea 5. Fever Pulmonary Embolism: Medical Management 2. Chest pain - pleuritic in origin; 6. Apprehension, syncope may mimic angina pectoris I. Emergency Management 3. Anxiety , Tachycardia 7. Diaphoresis a. Nasal Oxygen b. IV infusion lines 4. Cough & hemoptysis c. Vasopressor: Dobutamine, Dopamine, Norepinephrine dfd  Go Back to Lesson Outline d. Diagnostic tests: Pulse oximetry, ABG, ECG, S. electrolytes, Pulmonary Embolism: Nursing management CBC, Coagulation studies e. Indwelling urinary catheter f. Small doses of IV morphine or sedatives 1. Minimizing the risk of Pulmonary Embolism 2. Preventing thrombus formation II. Pharamacologic Therapy a. Encourage ambulation and aactive & passive leg exercise A. Anticoagulants Therapy b. Advise pt not to sit or lie in bed for prolonged periods, not to a. Low molecualr weight heparin (e.g. enoxaparin cross the legs and not to wear constrictive clothing [Lovenox]) c. Use of Intermittent pneumatic compression (IPC) b. Unfractionated heparin or Novel oral anticoagulants d. Legs should not be dangled or feet placed in a dependent (NOACs) position while the patient sits on the edge of the bed; i. Direct thrombin inhibitor (e.g., dabigatran instead, feet should rest in the floor or on a chair. [Pradaxa]) 3. Assessing for potential pulmonary embolism ii. Factor Xa inhibitor (e.g., Fondaparinux a. Careful assessment of the patient’s pain or discomfort in the [Arixtra], rivaroxaban [Xarelto], Apixaban extremities, pt’s health history, family history, and medication [Eliquis], or edoxaban [Savaysa]) record c. Warfarin (Coumadin) 4. Monitoring thrombolytic therapy B. Thrombolytic Therapy a. During thrombolytic infusion, VS q2, invasive procedures are a. Recombinant tissue plasminogen activator avoided (Activase) b. INR or PTT are performed 3 to 4 hours after the thrombolytic b. Kabikinase (Streptase) infusion (tells you how long it takes for your blood to clot) 5. Managing pain a. Chest pain: position pt in semi-fowler Pulmonary Embolism: Surgical Management b. Turn it frequently and reposition them to improve the V/Q in the lung 1. Surgical Embolectomy c. Administer opioid analgesic agents as prescribed for severe rarely performed but may be pain indicated if pt has a massive 6. Managing Oxygen Therapy PE or hemodynamic a. Pt must understand the need for continuous oxygen therapy instability or if there are b. Assess for signs of hypoxemia Contraindications to c. Deep breathing and incentive spirometry thrombolytic (fibrinolytic) d. Nebulizer therapy or percussion and postural drainage therapy 7. Relieving anxiety 2. Insertion of Inferior Vena Cava (IVC) Filter a. Encourage pt to talk about fears or concerns An umbrella filter is in place in the inferior vena cava to b. Answers the patient’s and family’s questions concisely and prevent PE. The filter (compressed within an applicator accurately, explain the therapy, and describe how to catheter) is inserted through an incision in the right internal recognize untoward effects early jugular vein. The applicator is withdrawn from the inferior 8. Monitor for complications vena cava after ejection from the applicator. 9. Post-op Nrg Care after Surgical Embolectomy a. Measure pt’s pulmonary arterial pressure and urinary output dfd  Go Back to Lesson Outline b. Assesses the insertion site of the arterial catheter for Hypocolemia form massive fluid loss from the great vessels, cardiac hematoma formation and infection rupture, or hemothorax c. Maintaining the blood pressure at a level that supports Cardiac failure from cardiac tamponade, cardiac contusion, or perfusion of vital organs increased intrathoracic pressure d. Prevention of peripheral venous stasis 10. Promoting Home, Community-Based, and Transitional Care Chest Trauma: Blunt Trauma Assessment a. Educate pt about preventing recurrence and reporting signs and symptoms 1. Assess the pt to determine the following: time elapsed since injury b. The nurse monitors the patient’s adherence to the prescribed occured, mechanism of injury, level of time elapsed since injury mgt plan and reinforces previous instructions occured, mechanism of injury, level of responsiveness, specific c. Patient is reminded about the importance of keeping injuries, estimated blood loss, recent drug or alchol use, and follow-up appointments for coagulation tests and prehospital treatment appointments with the primary provider 2. Initial assessment of thoracic injuries includes assessment of airway obstruction, tension pneumothorax, open pneumothorax, massive hemothorax, flail chest, and cardiac tamponade Chest Trauma 3. PE: inspection of the airway, thorax, neck veins, and breathing 1. Blunt Trauma difficulty 2. Sternal and Rib fracture 3. Flail Chest Chest Trauma: Blunt Trauma Diagnostic Tests Chest Trauma: Blunt Trauma 1. Chest x-ray Also known as blunt force trauma or non-penetrating trauma 2. CT scan 3. CBC, clotting studies, blood typing and cross-matching Common Causes: 4. Electrolytes Motor vehicle crashes (trauma from steering wheel, seat belt) 5. Oxygen saturation, ABG Falls 6. ECG Bicycle crashes (Trauma from handlebars) Types of Blunt Trauma Chest Trauma: Blunt Trauma Medical Management Chest wall fractures, dislocations, and barotrauma (including diaphragmatic injuries) 1. Establishment of airway: oxygen support, endotracheal intubation Injuries of the peura, lungs, and aerodigestive tracts and ventilator support Blunt injurie