Quiz 3: CNA Presentation - Mechanical Ventilation PDF

Quiz 3 CNA presentation: Mechanical Ventilation Indication -supporting cardiopulmonary gas exchange, increasing lung volume, reducing the work of breathing -reversing hypoxemia and acute respiratory acidosis, relieving respiratory distress, preventing or reversing atelectasis, reversing ventilatory...

Quiz 3 CNA presentation: Mechanical Ventilation Indication -supporting cardiopulmonary gas exchange, increasing lung volume, reducing the work of breathing -reversing hypoxemia and acute respiratory acidosis, relieving respiratory distress, preventing or reversing atelectasis, reversing ventilatory muscle fatigue, permitting sedation and/or neuromuscular blockade, decreasing systemic or myocardial oxygen consumption, reducing intracranial pressure and stabilizing the chest wall 2 types of ventilation 1. Negative pressure -applied externally to the client and decrease the atmospheric pressure surrounding the thorax to initiate inspiration -not used in critical care setting 2. Positive pressure -acute care setting -uses a mechanical drive mechanism to force air into the lungs -usually through an endotracheal tube (ETT) or tracheostomy tube -noninvasive mechanical ventilation is a new method that uses a mask, instead of an endotracheal tube, to administer positive pressure on both inspiration and expiration -nasal or facial mask and ventilator or a BiPAP machine 4 phases of ventilation (positive pressure) 1. Change from exhalation to inspiration 2. Inspiration 3. Change from inspiration to expiration 4. Exhalation 4 variables of positive pressure 1. Volume 2. Pressure 3. Flow 4. Time -these begin, sustain and terminate each of these phases -the phase variable initiates the change from exhalation to inspiration is called the trigger -breaths can be pressure-triggered or flow-triggered based on the sensitivity setting of the ventilator and the clients inspiratory effort -the phase variable that maintains inspiration is called limit or target -inspiration can be limited, flow-limited or volumed limited -the variable that ENDS inspiration is called the cycle -the variable that is CONTROLLED during exhalation is called the baseline -the client exhales to a certain baseline pressure that is set on the ventilator at ZERO (atmospheric pressure) or above atmospheric pressure (positive-end expiratory pressure or PEEP) 4 classifications of positive-pressure ventilators are based on the cycle variable 1. Volume-cycled ventilators: delivers a breath until a preset volume is delivered 2. Pressure-cycled ventilators: delivers a breath until a preset pressure is reached within the clients airways 3. Flow-cycled ventilators: delivers a breath until a preset inspiratory flow rate is achieved 4. Time-cycled ventilators: delivers a breath over a preset time interval Modes of mechanical ventilation -ventilator mode: how the machine ventilates the client; selection of a oparticular mode determines how much the client will participate in his or her own ventilation pattern 1. Assist control -ventilator is providing full ventilation for the client -tidal volume and ventilation rate is preset -delivers preset number of breaths to client if they do not initiate a breath -if client takes a breath, machine delivers the preset tidal volume (allows client to have some control over the breathing) May cause hyperventilation and respiratory alkalosis; client can require sedation to decrease respiratory rate 2. Synchronized intermittent mandatory ventilation -tidal volume and ventilator rate are preset -between ventilators breaths, client can take a spontaneous breath -helps client be weaned off of ventilator -SIMV = weaning mode (number of breaths gradually decrease as client begins breathing) may increase workload of breathing, causing respiratory fatigue Modes of mechanical ventilation 1. Positive end-expiratory pressure (PEEP) -baseline/preset pressure that prevents the client from exhaling past that pressure, during the exhalation phase -improved oxygenation by enhancing gas exchange and preventing atelectasis -keeps clients airways open at the end of expiration -prevents collapse of small airways to maximize available alveoli for ventilation 2. Continuous positive airway pressure (CPAP) -application of positive pressure during the respiratory cycle for spontaneously breathing clients -non-invasive (face mask or nasal mask) or invasive (endotracheal tube (ETT) or tracheostomy tube -obstructive sleep apnea 3. Pressure support ventilation (PSV) -positive pressure is delivered to client on inspiration -helps alleviate WOB, increases oxygenation and ventilation -helps avoid atelectasis and lower concentrations of O2 required -can be used during weaning 4. FiO2 -concentration of O2 delivered to client (goal to maintain PaO2 >60 mmHg using FiO2 of 40% or less) 5. Tidal volume -the volume of air a client receives with each breath (goal 5-8 mL/kg) 6. Respiratory rate -number of breaths each minute (goal 10-12) 7. Positive end-expiratory pressure (PEEP) -adds positive pressure on expiration 8. I:E Ratio -comparison of inspiratory to expiratory time 9. Peak airway pressure -maximal pressure level achieved during a breath 10. Sensitivity -determined the inspiratory effort required to trigger a mechanical breath Complications -barotrauma, pneumothorax, subcutaneous emphysema, malnutrition, muscular deconditioning, hypotension, alterations in cardiac function, fluid retention, hemodynamic compromise, oxygen toxicity, aspiration, GI ulcer, client-ventilator asynchrony, ventilator dependence, ventilator-associated pneumonia (VAP) -VAP can be caused by use of nebulizers, NG tubes, enteral feedings and medications as well as contamination in the lower airways within 24 hours Nursing care for clients on mechanical ventilation -respiratory assessment -arterial blood gas analysis -placement of endotracheal tube and observation for subcutaneous emphysema and synchrony with the ventilator -promoting effective airway clearance, nutritional support, eye and mouth care, facilitate communication, administering medications, psychological care, troubleshooting the ventilator and weaning the client from the ventilator -pain medications Preventing VAP -elevating the HOB (30 degrees) -temporarily interrupting sedation and conducting a spontaneous breathing trial each day to assess readiness to extubate -adequate pain control -CAM assessment (delirium screening) -using oral versus nasal tubes for access to the trachea or stomach -providing oral care -hand hygiene Evaluating ability to be weaned -LOC, physiologic and hemodynamic stability, adequacy of oxygenation and ventilation, spontaneous breathing capability, respiratory rate and pattern -once established ready, a weaning trial will take place -position patient upright to facilitate breathing -airway suctioned to ensure patency -explain process to patient -assess immediately prior to trial and frequently throughout Bucking the ventilator -client is fighting the ventilator or client's respiratory rate is not in sync with the ventilator -causing a jerky movement and the increased use of abdominal muscles -leads to activation of a high pressure alarm -can lead to secretions, hypoxia, hypercapnia, inadequate minute volume, long expiratory time, inadequate sedation level, pulmonary edema Common alarms **if issue cannot be fixed immediately, ventilate patient with manual bag until resolved** 1. High pressure alarm -secretions/plugged tube (suction) -decrease in airway size: bronchospasm (meds) -ET dislodged (re-intubation) -tube kinked or obstructed (removed obstruction) -cough, gag or bite tube (suction, bite block, ready to be weaned/alter mode, extubate, sedate) -client anxious (sedate, reassure) -inappropriate alarm 2. Low pressure alarm -disconnected/leak in tube or ET cuff (reconnect, check connection, assess cuff pressure) -inappropriate alarm Class 6: Hemodialysis Acute kidney failure -develops rapidly, usually within a few days -dialysis may only be needs for a short time -causes: blood clots, meds (chemo, antibiotics, radiologic dyes), infection, post-op complication, scleroderma, tumor lysis -S&S: decreased urine output, fluid retention, SOB, fatigue, confusion, nausea, weakness, irregular HR, chest pain, seizures, coma Causes -DM -glomerulonephritis (less than 15) -HTN -polycystic kidneys -pyelonephritis -drugs/toxins **major sign: little to no urine output; patient might experience S&S of fluid overload (pitting edema, weight gain, crackles, excessive thirst, sleep interruption, restless leg syndrome) -usually attend dialysis 3x a week -2 lines, 1 takes the toxin blood out, goes through dialyzer to filter the blood, then other line brings the filtered blood back to the patient -blood and dialysis fluid never come in contact due to semipermeable membrane -filter out phosphate, creatine, potassium -dialysis corrects pH and electrolytes in blood -patients are weight prior to and post dialysis (compare their weight from beginning of this dialysis session and the weight after their last session (should be not more than 1.5kg; more than can cause hypotension; 1 kg = 1 liter of fluid)) Vascular access (fistula) -long-term, reliable, dependable and safe method for accessing the patient’s blood has been and continues to be the most difficult challenge to hemodialysis therapy -it is the lifeline of the patient -fistula (gold standard) is created surgically by vascular surgeon and lies just beneath the skin - connected vein to an artery -blood flow is increased from 20-30 ml/min in healthy radial artery to 200-300 ml/min immediately after creation and 600-1200 ml/min after maturation (2-3 months) -can’t use until after the 2-3 month mark -avoid the cephalic veins for IVs or venipuncture on all renal patients as these are commonly the site for native arteriovenous fistulas creations -radiocephalic or brachiocephalic are common sites -lower infection risk and less complications -fistulas can be difficult to create in someone with PVD, DM, prolonged drug use -is has been suggested that complications such as stenosis may originate from such IV’s Graft -a piece of tubing is surgically inserted under the skin to connect an artery and a vein -used when patient’s blood vessels are so fragile that a fistula cannot be created -ready to use within 2-3 weeks to mature -self healing -infection in a graft can spread to body External vascular access central venous catheters -temporary and permanent -permanent (tunneled) placed in internal jugular in radiology -entrance suture x 7 days and exit suture x 14 days -advantage: can be used immediately -1 lumen is where they remove the blood to the dialyzer and the other returns the filtered blood -these central lines which are for dialysis should ONLY be used for dialysis -subclavian is associated with pneumothorax -internal jugular is preferred Care of fistula -no blood pressure, IV and venipuncture in access arm -sign posted in visible location as reminder (above patient’s bed) indicating the type and location of the access -assess daily and after hypotensive episodes by: 1. Listening (whooshing or pulsating sound) with a stethoscope and notify nephrologist if bruit sound is diminished or absent - should hear it 2. Feeling for thrill - vibration or pulse due to increased blood flow in fistula (stronger = more mature fistula) 3. Looking for S&S of infection (redness, swelling and drainage) and decreased circulation (pallor and slow capillary refill) Preparing for treatment -report to dialysis nurse should include  -any changes in patient’s condition and/or medications -if patient has had any invasive procedure or surgery for accurate assessment of bleeding risk and heparinization during dialysis -send patient’s chart, medication kardex and medications (if applicable) -eating during treatment is discouraged… hold meal trays patient’s room -if patient is diabetic -insulin can be given during treatment -ideally should not be scheduled around meal times -1 kg of weight = 1 L of fluid -monitor VS every 30-60 minutes while on dialysis -sit in recliners to elevate feet if hypotensive -dialysis usually takes 3-5 hours Care of patient needing dialysis -send blood requisitions to dialysis unit with patient -communicate with physicians to order blood work on dialysis days to avoid unnecessary needle sticks -results in less trauma to patient’s veins -blood work routinely done monthly on stable dialysis patients (unstable may have blood work pre and post dialysis) Blood work -increased creatinine (also increased with muscle breakdown) and urea -increased potassium and sodium (potassium may be up to 5-6 prior to dialysis then as low as 3 post dialysis, then increase once they eat) (will have sodium and potassium restricted diet) -metabolic acidosis -anemic (decreased erythropoietin), decreased serum ferritin (usually need iron supplementation) -increased phosphorus -decreased calcium (pulled out of bone) Post-dialysis -bleeding (platelet disruption) -hypotension -exhausted Post hemodialysis treatment -report given by dialysis nurse to include -vital signs, medications given or held, and analysis of untoward events that occurred during dialysis -avoid intramuscular injections 2-4 hours post as prolonged bleeding or hematoma can occur if patient heparinized on dialysis -observe the patient for hypotension -monitor blood pressure -have patient lie down -several liters of fluid may have been removed and takes time for fluid to shift back to the vascular compartment from the extravascular compartment -restlessness, headache, jerking, confusion, seizures, coma, death = disequilibrium syndrome (happens if they remove fluid too quickly) Care of fistula post treatment -two needles inserted for dialysis and removed immediately post -patient remains in unit until the sites stop bleeding with constant pressure for 10 minutes -tipstop bandage and/or gauze and cling applied once hemostasis is achieve -tipstop bandages must be removed after four hours Bleeding from fistula/graft -remove all bandages and dressings -apply firm direct pressure at least 10 minutes -while applying pressure continue to assess and maintain blood flow through fistula -using bulky pressure dressing will not stop bleeding and excessive pressure could occlude the access -reapply needle site dressing when hemostasis achieved being careful not to occlude blood flow through fistula Care of CVCs -ultimate goal is to keep the catheter patent, secure and infection free -check catheter exit site for S&S infection and ensure catheter dressing is clean and intact every shift Diet… fluid restriction -do not keep pitcher of water at bedside -give ice chips -IV never exceed 1000 mls/24 hours -KVO (keep vein open)- plugged -IV solutions should be NS as other fluids will disturb electrolytes balance Renal diet -restricted potassium and phosphorus intake -no added salt -high protein as dialysis removes protein -diabetic diet (if applicable) -wide fluctuations in their electrolytes between treatment and must follow strict diet -excessive potassium = cardiac arrhythmias and arrest -excessive phosphorus = demineralization of bones -excessive salt = thirst, weight gain, HTN -dietician invaluable in helping patients with this challenge Meds -erythropoietin (EPO) - to stimulate RBC production -eprex, aranesp -stimulates RBC production -usually given IV during dialysis -very costly but covered while in hospital -must be kept refrigerated -anemia therapy also includes iron replacement (usually given IV during dialysis) Antihypertensives -check orders carefully and when in doubt call nephrologists -ask patients as hemodialysis patients are often knowledgeable about the regimen that works best for them -as fluid removed during dialysis patients often become hypotensive -normal physiological response to low BP may be suppressed by certain antihypertensives -may be a lower dose than usual Phosphate binders -important as controlling both phosphorus and calcium by diet alone very challenging -goal to increase calcium and decrease phosphorus thus calcium-based binders used -food high in calcium tend also to be high in phosphorus (dietary products i.e. cheese, milk) -important to take with meals as medication needs to bind with food to facilitate its excretion -can be constipating Vitamins -most patients prescribed water soluble vitamins post-dialysis -they are dialyzable -dietary restrictions of fruits and vegetables to control hyperkalemia makes to difficult for patient to receive the recommended vitamins through diet alone  -vitamin preparations (B and C) are available specifically designed for dialysis patients (replavite) Analgesics -pain control usually achieved with morphine and codeine -demerol (meperidine) usually avoided as metabolites can accumulate causing seizures -narcotics generally not removed by dialysis -acetaminophen is drug of choice for non-narcotics -acetylsalicylic acid usually avoided as patients predisposed to gastric ulcers Seminar 3: Deteriorating condition & Opioid Overdose Clinical deterioration -a dynamic state experiences by a patient compromising hemodynamic stability, marked by physiological decompensation accompanied by subjective or objective findings -change in pulse quality (threading and weak) -dizzy -syncope -nausea -chest pain -increased RR and WOB -exhaustion -change in breathing pattern -LOC -skin color changes -urinary output Why is it important? -failure to recognize and respond to acutely unwell and deteriorating patients in a timely manner is a global safety concern. All hospitalized patients may be at risk of clinical deterioration -avoidable high mortality/morbidity events (i.e. in hospital cardiac arrest and unplanned ICU admissions) are still occuring; failure to recognize and respond to acute deterioration in an effective and timely manner (failure to rescue) -early warning signs of deteriorating condition are often unrecognized, leading to devastating results. Research shows that virtually all critical inpatient events are preceded by warning signs that occur approximately 6.5 hours in advance -clinical deterioration requiring an emergency response, and delays in/lack of appropriate response are associated with a significantly increased risk of death in hospital -hesitancy to call doctor, incorrect documentation of vital signs, warning signs are not picked up, lack of time to do vital signs, not completing vital signs during night shift, not checking blood results, difficulty getting ahold of doctor, not completing respiratory assessment adequate -RNs need solid assessment and intervention skills to manage these situations Contributing factors: failure to rescue -lack of awareness of S&S -lack of continuity of care -VS not monitored consistently -VS not monitored accurately -inexperience -ineffective communication -subtle changes not picked up on -unsure of how to escalate care -lack of confidence -confirmation bias - saying that abnormal findings are “normal” -distractions -increased workload risks/causes -risk increased if -pre-existing conditions, comorbidities (heart disease, DM, chronic illness) -immune compromised -causes -postop complications (infection, hemodynamic issue, fluid imbalance) -sepsis (TIME acronym) -temp -infection S&S -mental decline (confused, sleepy, difficult to rouse) -extremely ill (severe pain, discomfort, SOB) 10 warning signs of a rapidly deteriorating patient 1. Body temp is too high or low, report temperatures below 36 or above 38 2. Heart rate or respiratory rate changes 3. Blood pressure out of range 4. Changes in mental state 5. Changes in urine output or appearance 6. The patient doesn't look right to the family or advocate 7. SOB or having a tight feeling or discomfort in the chest (sign of heart attack and pulmonary embolism) 8. Acute pain especially in abdomen (could be sign of infection, intestinal obstruction, perforated ulcer) 9. The patient states there is something wrong with them 10. Very pale appearance of the skin or breaking out in cold sweats (could be sign of internal bleeding, shock, infection, heart attack) Management 1. Recognize -use ABCDE to assess (look, listen, feel) -airway (increased WOB, use of accessory muscles, wheezing, color changes)  -breathing (lung issues, CNS depression, adventitious sounds, equal on each side, crackles) -circulation (cap refill, signs of bleeding, pale, mottled, cold, clammy, listen to heart) -disability (altered LOC, compromised airway, lose control, decreased gag and cough reflex (risk for aspiration), appear confused, facial asymmetry (stroke), seizure, unequal pupils/sluggish/unresponsive to light (urgent) -exposure (focus on area of concern, output from drains) -AVPU assessment (are they alert, respond to voice, respond to pain, unresponsive) -take full vital signs and compare with prior readings and look for deteriorating trends -blood pressure (trends) -RR -temperature (hypo or hyper) -O2 sat (>93, decreased perfusion can alter results) -cap refill (perfusion) -HR -LOC (glascow coma scale, AVPU) 2. Manage -get help (call MD, RT, RRT) -collect more information (gather data for charts) -position the patient -hypotensive: lie flat and raise legs -unconscious: recovery position -acute coronary syndrome: sit upright -consider oxygen therapy (COPD [watch respirations with O2, body doesn't respond to O2 as well >94%], 1.5 L in non rebreather for shock, acute hypoxemia) -prepare equipment -handover using ISBAR I: identify who you are where you are and the patient information S: situation B: background of patients history A: assessment of what you think the problem may be R: recommendation (can you come see patient) Early warning scores -score tools developed to facilitate early detection and deterioration based on physiological parameters (vital signs) -the escalation pathway outlines actions required for timely review by appropriate team members -provides standardization of assessment, monitoring and tracking of acutely ill patients Components of EWS -6 physiological parameters (vital signs) 1. Temp 2. Heart rate 3. Respiratory rate 4. Systolic BP 5. Oxygen saturation 6. LOC -important to ensure accurate vital signs are obtained Opioid crisis defined -the upsurge in opioid-related harms underscores the critical need for coordinated, evidence-based approaches to prevention, treatment and harm reduction to address this national public health emergency S&S -difficulty -walking -talking -staying awake -blue lips or nails -very small pupils -cold and clammy skin -dizziness and confusion -extreme drowsiness -choking, gurgling or snoring sounds -slow, weak or no breathing -inability to wake up, even when shaken or shouted at Management of opioid OD -follow the SAVE ME steps below -stimulate -airway 1 breath every 5 seconds -ventilate -evaluate -muscular injection of 1 mL of naloxone -evaluate (2nd dose needed?) Naloxone (opioid antagonist) -can temporarily reverse opioid overdose and is available in injectable and “intranasal” formulation -can quickly reverse the effects of opioids by binding to the same receptors in the brain as opioids. When naloxone is given, it pushes the opioid from the receptor to restore a normal breathing rate -can reverse slowed breathing within 3-5 minutes. A second dose may be needed if normal breathing is not restored -effects last 20-90 minutes, after is wears off, the opioid may linger and bind again to its receptors, causing breathing to slow down again, those the OD can return requiring another dose of naloxone -thus very important to seek medical help ASAP and be prepared with a second dose Inpatient management of opioid OD -quick assessment of ABCs -get help -do sternal rub to assess LOC -give O2 2L NP -put on cardiac monitor and pulse oximeter -assess IV access for naloxone (need dr or NP to order) -once naloxone administered, patient may become aggressive and/or combative within a few minutes (because their high is taken away and pain is back) -possibly page security in advance -give lorazepam or diazepam for sedation PRN (need dr or NP order) -consult to psych or MG nurse for addictions -if patient doesn't respond to naloxone, assess for probable other street drug Follow up -will need further monitoring -insert foley, get IV, give fluids -admission is prudent to observe for risk of respiratory depression and other complications -assess for other drugs ingested/possible risks -assess for other conditions, history and physical