RESPONSES-TO-ALTERED-VENTILATORY-FUNCTION.pdf

RESPONSES TO ALTERED VENTILATORY FUNCTION DIAGNOSTIC ASSESSMENT NON-INVASIVE 1. OXIMETRY - A noninvasive technique that measures the arterial oxyhemoglobin saturation (SpO2) of arterial blood. - A sensor, or probe, uses a beam of red and infrare...

RESPONSES TO ALTERED VENTILATORY FUNCTION DIAGNOSTIC ASSESSMENT NON-INVASIVE 1. OXIMETRY - A noninvasive technique that measures the arterial oxyhemoglobin saturation (SpO2) of arterial blood. - A sensor, or probe, uses a beam of red and infrared light that travels through tissue and blood vessels. - Oxygen saturation is determined by the amount of each light absorbed; nonoxygenated hemoglobin absorbs more red light, and oxygenated hemoglobin absorbs more infrared light. - Sensors are available for use on a finger, a toe, a foot (on infants), an earlobe, forehead, and the bridge of the nose. - A range of 95% to 100% is considered normal. - For patients with chronic lung disease, a level of 88% to 92% may be considered within normal limits. - Unreliable when vasoconstriction medications or IV dyes are used and when in SHOCK, CARDIAC ARREST, or SEVERE ANEMIA NURSING CONSIDERATIONS: Assess for the presence of health problems that may impact oxygenation. Assess the patient’s respiratory rate and depth and mental status, skin temperature and color. Assess the quality of the pulse proximal to the sensor application site. Assess for edema of the sensor site. If absent or weak signal: check vital signs and patient condition; check connections and circulation to site. If extremity is cold, cover with a warm blanket and/or use another site. If a bright light (sunlight or fluorescent light) is suspected of causing equipment malfunction, turn off light or cover the probe with a dry washcloth (bright light can interfere with operation of light sensors and cause an unreliable report). Excessive motion of the sensor probe site, such as with extremity tremors or shivering, can also interfere with obtaining an accurate reading. 2. CAPNOGRAPHY - Measures the concentration of CO2 in respiratory gas. - Delivers a more comprehensive measurement that is displayed in both graphical (waveform) and numerical form - For this reason, capnography is currently the most widely recommended method for monitoring EtCO2 (End Tidal Carbon Dioxide) - EtCO2 (NORMAL RANGE = 35-45 mmHg) ▪ Level of carbon dioxide that is released at the end of an exhaled breath ▪ Its level reflects the adequacy with which carbon dioxide (CO2) is carried in the blood back to the lungs and exhaled ▪ Abnormal Values: o EtCO2 45 mmHg = Hypoventilation/Hypercapnia or Hypercarbia INDICATIONS: Verification of artificial airway placement Assessment of pulmonary circulation and respiratory status Optimization of mechanical ventilation NURSING CONSIDERATIONS: If EtCO2 is 45 to 50 mmHg o Attempt to stimulate and arouse the patient. If patient is immediately aroused and breathing normally, monitor every 15 minutes x 1 hour. o Assess vital signs for decompensation (02 sat, BP, HR, RR, and LOC). o Check patient for normal signs of ventilation and assess for hypoventilation via assessment of RR, quality and depth.  o Reposition the device if necessary. If EtCO2 remains > 45 mmHg despite interventions o Contact physician. If EtCO2 is >50 mmHg or greater o If it does not return to normal within 5 minutes, call Rapid Response Team and notify MD immediately to report patient condition. o Consider obtaining ABG (arterial blood gas). o If the patient does not immediately arouse, evaluate the appropriateness of administering Narcan to partially OR completely reverse sedation. o Patients may be referred to an intensive care unit when nursing staff has concerns about possible respiratory compromise. INVASIVE 1. ARTERIAL BLOOD GAS (ABG) - Assess the ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH. - Obtained through an arterial puncture at the radial, brachial, or femoral artery, or through an indwelling arterial catheter NURSING CONSIDERATIONS: In most critical care units, a doctor, respiratory therapist, or specially trained critical care nurse draws ABG samples, usually from an arterial line if the patient has one. The most common site is the radial artery, but the brachial or femoral arteries can be used. When a radial artery is used, an Allen’s test is done before drawing the sample to determine whether the ulnar artery can provide adequate circulation to the hand, in case the radial artery is damaged. After obtaining the sample, apply pressure to the puncture site for 5 minutes and tape a gauze pad firmly in place. Regularly monitor the site for bleeding and check the arm for signs of complications, such as swelling, discoloration, pain, numbness, and tingling. Note whether the patient is breathing room air or oxygen. If the patient is on oxygen via nasal cannula document the number of liters. If the patient is receiving oxygen by mask or mechanical ventilation, document the fraction of inspired oxygen (Fio2). Examples of conditions that can interfere with test results are failure to properly heparinize the syringe before drawing a blood sample or exposing the sample to air. Venous blood in the sample may lower Pao2 levels and elevate Paco2 levels. Make sure you remove all air bubbles in the sample syringe because air bubbles also alter results. Make sure the sample of arterial blood is kept cold and delivered as soon as possible to the laboratory for analysis. 2. PULMONARY CAPILLARY WEDGE PRESSURE PLEURAL FLUID ANALYSIS - Used to assess left ventricular filling, represent left atrial pressure, and assess mitral valve function. - Measured by inserting a balloon-tipped, multi-lumen catheter (Swan-Ganz catheter) into a central vein and advancing the catheter into a branch of the pulmonary artery. - The balloon is then inflated, which occludes the branch of the pulmonary artery and then provides a pressure reading that is equivalent to the pressure of the left atrium. INDICATIONS: Differentiate between cardiogenic pulmonary edema and noncardiogenic pulmonary edema Confirm the diagnosis of pulmonary arterial hypertension Assess the severity of mitral stenosis Differentiate between different forms of shock Measure key hemodynamic parameters and assess response to therapy  NURSING CONSIDERATIONS: Site Care and Catheter Safety o A sterile dressing is placed over the insertion site and the catheter is taped in place. The insertion site should be assessed for infection and the dressing changed every 72 hours and PRN. o The placement of the catheter, stated in centimeters, should be documented and assessed every shift. o The integrity of the sterile sleeve must be maintained so the catheter can be advanced or pulled back without contamination. o The catheter tubing should be labeled and all the connections secure. The balloon should always be deflated, and the syringe closed and locked unless you are taking a PCWP measurement. Patient Activity and Positioning o Many physicians allow stable patients who have PA (pulmonary artery) catheters, such as post CABG (CORONARY ARTERY BYPASS GRAFT) patients, to get out of bed and sit. o The nurse must position the patient in a manner that avoids dislodging the catheter. Dysrhythmia Prevention o Continuous EKG monitoring is essential while the PA catheter is in place. o Do not advance the catheter unless the balloon is inflated. o Antiarrhythmic medications should be readily available to treat lethal dysrhythmias. Monitoring Hemodynamic Values for Response to Treatments o The purpose of the PA catheter is to assist healthcare team members in assessing condition the patient’s and response to treatment. Therefore, accurate documentation of values before and after treatment changes is necessary. 3. PULMONARY ANGIOGRAPHY - An imaging test that uses X-rays and a special dye to see the inside of the arteries. INDICATIONS: Blood clot (pulmonary embolism) Bulging blood vessel (aneurysm) An artery abnormally connected to a vein (arteriovenous malformation) Heart and blood vessel problems present at birth Foreign body in a blood vessel Narrowing of a blood vessel wall (stenosis)  NURSING CONSIDERATIONS: Before o Stop taking certain medicines before the procedure, if instructed by HCP. o NPO. o Have someone drive you home from the hospital. o Remove jewelry or other objects. o Empty the bladder before the procedure. o o Hair at the site of the catheter insertion in the groin or arm may be trimmed. The skin will be cleaned. A numbing medicine (local anesthetic) will be injected During o Supine on the X-ray table. o An intravenous (IV) line will be put in your arm or hand. o Small sticky pads (electrodes) will be put on the chest. (They will connect with wires to a machine (ECG) that records the electrical activity of your heart. Your heart rate, blood pressure, and breathing will be watched during the procedure) into the area. Hematoma at the site. o A thin, flexible tube (catheter) will be put in the groin or arm. The catheter will be gently guided through the vein to the right side of the heart. Fluoroscopy may be used during this process to help get the catheter to the right place. o Contrast dye will be injected into your IV line. You may feel some effects when this is done. These effects may include a flushing sensation, a salty or metallic taste in the mouth, a brief headache, nausea, or vomiting. These effects usually last for a few moments. o Tell the radiologist if you feel any trouble breathing, sweating, numbness, or heart palpitations. o After the contrast dye is injected, a series of X-ray images will be taken. o The groin or arm catheter will be removed. Pressure will be applied over the area to stop bleeding. o A dressing will be applied to the site. A small, soft weight may be placed over the site for a period. This is to prevent more bleeding or a hematoma at the site. After o Lie flat in a recovery room for 1 – 2 hours. o Monitor the V/S. o Monitor the groin or arm puncture site for bleeding. You will need to keep your leg or arm straight. o Give pain medication as needed. At home o Patients can go back to their normal diet and activities if instructed by the HCP o Increase oral fluids to flush out the contrast dye from the body o Refrain from doing strenuous physical activity for a few days. o No hot bath or shower for a day or two. ***Check the puncture site in your groin or arm several times a day. Check for bleeding, pain, swelling, change in color, or change in temperature. A small bruise is normal. A small amount of blood is also normal. When to call HCP? o Fever of 100.4°F (38°C) or higher o Redness or swelling of the groin or arm site o A lot of blood at the groin or arm site o Pain, coolness, numbness, tingling, or loss of function in your arm or leg 4. Ventilation-Perfusion (V/Q) Scan - A V scan is used to: o Evaluate V mismatch o Detect pulmonary emboli o Evaluate pulmonary function, especially in patient’s marginal lung reserves. o Although it’s less reliable than pulmonary angiography, V scanning carries fewer risks. o V scan has two (2) parts ❖ During the ventilation portion of the test, the patient inhales the contrast medium gas; ventilation patterns and adequacy of ventilation are noted on the scan. (radioactive gas through mask) ❖ During the perfusion scan, the contrast medium is injected I.V. and the pulmonary blood flow to the lungs is visualized (radioactive albumin) o V scans aren’t commonly used for patients on mechanical ventilators because the ventilation portion of the test is difficult to perform. o (Pulmonary angiography is the preferred test for a critically ill patient with a suspected pulmonary embolus.) NURSING CONSIDERATIONS: Explain the test to the patient and his family, telling them who performs the test and where it’s done. Like pulmonary angiography, a V scan requires the injection of a contrast medium. Confirm that the patient doesn’t have an allergy to the contrast medium. Explain to the patient that the test has two parts. During, the ventilation portion, a mask is placed over his mouth and nose and the patient breathes in the contrast medium gas mixed with air while the scanner takes pictures of his lungs. For the perfusion portion, the patient is placed in a supine position on a movable table as the contrast medium is injected into the I.V. line while the scanner again takes pictures of the lungs. After the procedure, maintain bed rest as ordered and monitor the patient’s vital signs, oxygen saturation levels, and heart rhythm. Monitor for adverse reactions to the contrast medium, which may include restlessness, tachypnea respiratory distress, and tachycardia, urticaria, and nausea and vomiting. Keep emergency equipment nearby in case of a reaction.