WK4. Respiratory Assessment Techniques, Ventilator Management.pdf

BACHELOR OF SCIENCE IN NURSING: NCMB 418: CARE OF THE CLIENT WITH LIFE- THREATENING CONDITIONS, ACUTELY ILL / MULTI- ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION (ACUTE AND CHRONIC) COURSE MODULE COURSE UNIT WEEK 1...

BACHELOR OF SCIENCE IN NURSING: NCMB 418: CARE OF THE CLIENT WITH LIFE- THREATENING CONDITIONS, ACUTELY ILL / MULTI- ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION (ACUTE AND CHRONIC) COURSE MODULE COURSE UNIT WEEK 1 4 4 Respiratory Assessment, Techniques and Monitoring Systems ✓ Comprehend the course and unit objectives. ✓ Peruse through the study guide prior to class attendance. ✓ Analyze the required learning resources; refer to unit terminologies for jargons. ✓ Proactively participate in classroom discussions ✓ Participate in weekly discussion board (Canvas). Answer and submit course unit tasks on time. At the end of this unit, the students are expected to: 1. Perform safe and quality respiratory assessment techniques and interventions to address the client’s identified needs/ problems. 2. Offer client health education using selected and appropriate approaches of care for the sick adult client. 3. Document nursing care and services rendered and processes outcomes of the findings/ result of the client data. 4. Ensure completeness, integrity, safety, accessibility, and security of information. 5. Adhere to protocols of confidentiality in safekeeping and releasing of records and other information. Burns, S. and Delgado, S. (2019). Essentials of Critical Care Nursing, 4th ed. USA: McGraw-Hill Schumacher, L., & Chernecky, C. C. (2010). Saunders nursing survival guide: critical care & emergency nursing. St. Louis, Mo.: Elsevier Saunders. REVIEW ON THE ASSESSMENT OF RESPIRATORY FUNCTION PURPOSE OF THE RESPIRATORY SYSTEM § The lungs, in conjunction with the circulatory system, deliver oxygen to and expel carbon dioxide from the cells of the body. § The upper respiratory system warms and filters air. § The lungs accomplish gas exchange. STRUCTURES OF THE RESPIRATORY SYSTEM 1. Parts of the Upper Respiratory System § Nose § Sinuses and nasal passages § Pharynx, Tonsils and adenoids § Larynx: epiglottis, glottis, vocal cords, and cartilages Figure 1. The Upper Respiratory System The Paranasal Sinuses Cross section of Nasal Cavity 2. Parts of the Lower Respiratory System § Lungs, Pleura and mediastinum § Lobes of the lungs: Left (upper & lower); right (upper, middle, lower) § Bronchi & bronchioles and the alveoli (gas exchange) Figure 1. The Lower Respiratory System The lung lobes and the brochial tree VENTILLATION ▪ Inspiration: contraction of the diaphragm and contraction of the external intercostal muscles increases the space in the thoracic chamber (lowered intrathoracic pressure causes air to enter through the airways and inflate the lungs) ▪ Expiration: with relaxation, the diaphragm moves up and intrathoracic pressure increases (pushes air out of the lungs); expiration requires the elastic recoil of the lungs.= ▪ Inspiration = 1/3 of the respiratory cycle; expiration = 2/3 of the respiratory cycle RESPIRATION ▪ Oxygen diffuses from the air into the blood at the alveoli to be transported to the cells of the body. ▪ Carbon dioxide diffuses from the blood into the air at the alveoli to be removed form the body. ASSESSTMENT OF BREATH SOUNDS ▪ Normal breath sounds: Vesicular, Bronchovesicular, Bronchial ▪ Abnormal (adventitious) breath sounds: o Crackles o Wheezes o Friction rubs VENTILLATION PERFUSION (V/Q) RATIO ▪ Ventilation is the movement of air in and out of the lungs. ▪ Air must reach the alveoli to be available for gas exchange. ▪ Perfusion is the filling of the pulmonary capillaries with blood. ▪ Adequate gas exchange depends upon an adequate V/Q ratio, a match of ventilation and perfusion. ▪ Shunting occurs when there is an imbalance of ventilation and perfusion. This results in hypoxia. LUNG CAPACITIES ▪ Tidal volume (TV): air volume of each breath ▪ Inspiratory reserve volume (IRV): maximum volume that can be inhaled after a normal inhalation. ▪ Expiratory reserve volume (ERV): maximum volume that exhaled after a normal exhalation.  ▪ Vital capacity (VC): the maximum volume of air exhaled from a maximal inspiration, VC = TV + IRV + ERV. ▪ Forced expiratory volume (FEV): volume exhaled forcefully over time in seconds. Time is indicated as a subscript, usually 1 second. MEASUREMENT OF VOLUME AND INSPIRATORY FORCE ▪ A spirometer measures volumes of air exhaled and is used to assess lung capacities. ▪ When assessing TV, measure several breaths. TV varies from breath to breath. ▪ Pulmonary function tests assess respiratory function and determine the extent of dysfunction. ▪ Peak flow rate reflects maximal expiratory flow and is frequently done by patients using a home spirometer. INSPIRATORY FORCE ▪ Evaluates the effort of the patient in making an inspiration. ▪ A monometer which measures inspiratory effort can be attached to a mask or endotracheal tube to occlude the airway and measure pressure. ▪ Normal inspiratory pressure is approximately 100 cm H2O. ▪ Force of less than 25 cm usually requires mechanical ventilation. ARTERIAL BLOOD GAS ▪ Measurement of arterial oxygenation and carbon dioxide levels. ▪ Used to assess the adequacy of alveolar ventilation and the ability of the lungs to provide oxygen and remove carbon dioxide. ▪ Also assesses acid base balance PULSE OXIMETRY ▪ A noninvasive method to monitor the oxygen saturation of the blood. ▪ Does not replace ABGs ▪ Normal level is 95-100%. ▪ May be unreliable DIAGNOSTIC TESTS ▪ Imaging tests: Chest x-ray, CT scan, MRI, Fluoroscopic Studies and Angiography, Radioisotope procedure-lung Scans, Bronchoscopy, Thoracoscopy ▪ Pulmonary function tests ▪ Arterial blood gases ▪ Sputum tests ▪ Thoracentesis ▪ Biopsies RESPIRATORY CONDITIONS: 1. UPPER AIRWAY OBSTRUCTION ▪ Causes: Foreign bodies/materials; enlargement of tissues in the wall of airway, pressure on the walls of the airway, altered level of consciousness ASSESSMENT: ▪ Inspection (eye) ▪ Palpation (touch) ▪ Auscultation (hearing) AIRWAY MANAGEMENT 1. OROPHARYNGEAL AIRWAY (OPA) o Also known as Oral bite block o Temporary o Relieves upper airway obstruction o Tongue relaxation, secretions, seizures o Not recommended for alert clients o May trigger gag and cause vomiting Nursing Responsibility o Frequent assessment of the lips and tongue to identify pressure areas o Removed at least q 24 hours to check for pressure areas and to provide oral hygiene 2. NASOPHARYNGEAL AIRWAY o a.k.a. Nasal trumpet o Maintains airway patency o Also used to facilitate nasotracheal suctioning o Size: French 26-35 Complications o Bleeding o Sinusitis o Erosion of the mucus membranes Nursing Responsibility o Assessment of the pressure areas and occlusion due to secretions o Rotation of tube from nostril to nostril daily 3. LARYNGEAL MASK AIRWAY Laryngeal Mask Airway o An ET with a small mask on one end that can be passed orally over the larynx o Provides ventilatory assistance and prevent aspiration Combitube o Esophageal/tracheal double lumen airway o Used for difficult or emergency intubation o Permits blind placement 4. Endotracheal (ET) tube o Includes a 15mm adapter at the end for connection to life support equipment o Distance marker on the sides for placement o Inserted into the trachea through the mouth or nose Insertion of Endotracheal (ET)Tube o Using laryngoscope to visualize the upper airway o Inserted through the vocal cords into the trachea o 2-4 cm above the carina o Anchored by inflating the cuff (prevents air leakage and aspiration)  Confirm proper placement o Presence of bilateral breath sounds o Equal o Suctexcursion during inspiration o Absence of breath sounds over the stomach o PETCO2: 35-40 mmHg Verification: CXR o Anchor with tape or ET fixation device o Centimeter marking at the lip is documented during each shift o 10-14 days of intubation: tracheostomy is usually indicated Complications: o Laryngeal and tracheal damage o Laryngospasm o Aspiration o Infection and discomfort o Vocal cord paralysis (should not be used longer than 3 week) MECHANICAL VENTILLATION A form of assisted ventilation; takes over all part of the work performed by the respiratory muscles and organs Indication: impaired patient’s ability to oxygenate and exchange carbon dioxide Main goal: to support gas exchange until the disease process is resolved POSITIVE PRESSURE VENTILLATION (PPV) Most common form of mechanical ventilation used in the acute care setting Forces oxygen into the lungs with each breath through an endotracheal tube or tracheostomy tube Volume-cycled modes (deliver breath until preset tidal volume is reached with each breath) Pressured-cycled modes (deliver breath until a preset pressure is achieved within the airway) MODES OF VENTILLATION Ways in which ventilation is triggered, allowing the patient partial or complete control over their breathing Factors affecting selection of ventilator modes: Underlying pulmonary status Oxygenation Presence of spontaneous breathing Assist-control Ventilation (ACV) Delivers a preset volume at a preset rate and whenever the patient initiates a breath (i.e. if the patient does not initiate a breath within a preset time, the ventilator will deliver a breath) Used in patients with weak respiratory muscles Synchronized Intermittent Mandatory Ventilation (SIMV) Delivers a preset volume at a preset rate and is synchronized with the patient’s effort Allows spontaneous breathing between ventilated breaths Prevents competition between patient and ventilator Common mode for patients requiring minimal ventilation Used for WEANING for ventilator support Pressure-controlled ventilation (PCV) Delivers positive-pressure breath until a maximum amount of airway pressure is reached, then the inspiratory phase of the breath stops Maximum inspiratory pressure limit is preset to help minimize ventilator-induced lung injury (VILI) Settings are adjusted to achieve a goal tidal volume designated by physician Tidal volume goal: based on patient’s weight and pulmonary status Pressure-regulated volume control (PRVC) A type of PCV in which the ventilator makes pressure adjustments to aim for a predetermined tidal volume Using this mode, the ventilator senses any changes in lung compliance (ex. Increase in peak inspiratory pressure) and reduces the tidal volume until airway pressures are back within normal range ADDITIONAL VENTILATORY MODES Positive end-expiratory pressure (PEEP) Holds positive pressure in the alveoli during expiration Frequently used as a supplement to most modes of ventilation Advantages: Prevents alveoli from collapsing at end-expiration improves oxygenation Increases functional residual capacity Range: 2 to 24 cmH2O pressure Disadvantage: PEEP greater than 10 cmH2 Increased intrathoracic pressure that causes decreased venous return and decreased cardiac output (HYPOTENSION) Increase preload with fluids or vasopressors HIGH LEVELS OF PEEP Increased airway pressure VILI, hypotension, increased ICP, alveolar ventilation-perfusion mismatch Constant Positive Airway Pressure (CPAP) Similar to PEEP but provides positive pressure during spontaneous breaths Increases oxygenation by preventing closure of alveoli at end-expiration thereby maximizing functional residual capacity (FRC)  General range: 5-10 cmH2O; more than 10cmH20 = hypotension/pneumothorax Frequently used to wean patients as a non-invasive method Pressure Support Ventilation (PSV) Augments the tidal volume of spontaneous breaths by delivering a preset positive pressure during inspiration Can be added to SIMV and CPAP for weaning Range: 8-20 cmH20 Increases patient comfort by decreasing the amount of work required in each spontaneous breath VENTILLATOR SETTINGS Individualized settings Adjustments are based on ABG measurements and Arterial Oxygen saturations (SaO2) Vt (Tidal Volume) Amount of oxygen delivered to a patient with each preset ventilated breath; 5-15 mL/kg (average: 10mL/kg) Back up rate (BUR) or Respiratory rate Number of breaths per minute that ventilator is set to deliver; 4-20 breaths/minute Fraction of inspired oxygen (FiO2) Percentage of oxygen delivered by ventilator with each breath 21 - 100% Inspiratory to Expiratory ratio (I:E Ratio) Number of breaths per minute that ventilator is set to deliver 1;2 Sensitivity Determines amount of effort patient must generate before ventilator will give a breath Too low: patient works harder to obtain a breath Too high: patient’s respiratory effort may compete with ventilator Flow rate Determines how fast Vt will be delivered during inspiration High – increase airway pressure Low – decrease airway pressure Pressure limit Regulates maximum amount of pressure the ventilator will generate to deliver preset Vt Ventilated breath will stop when pressure limit is reached VENTILATION TERMINOLOGIES Compliance Elasticity of the lung tissue Decreased compliance = increased resistance to breath Peak Inspiratory Pressure (PIP) Airway pressure at maximum inspiration A.K.A. peak airway pressure Low pressure alarms LEAK or DISCONNECTION in ventilator circuit Patient not receiving adequate ventilation High pressure alarms PIP has exceeded a safe limit Patient at risk of VILI Volutrauma Injury to the lung tissue from over distension of alveoli Barotrauma Injury to the lung tissue from too much pressure on the airway Atelectrauma VILI from a low intra-alveolar pressure causing collapse of alveoli MECHANICAL VENTILLATION COMPLICATIONS: VENTILLATOR - ASSOCIATED PNEUMONIA (VAP) BUNDLES OF CARE Elevation of the head of the bed (HOB) Daily sedation vacations and assessment of readiness to extubate Peptic ulcer disease prophylaxis Deep vein thrombosis (DVT) prophylaxis Daily oral care with chlorhexidine (added in 2010) WEANING PATIENT FROM MECHANICAL VENTILLATION: METHODS OF MEANING: 1. Assist-Control (A/C) ventilation Control rate is decreased, patient strengthens respiratory muscle by triggering more progressive respirations Nursing Management: o WOF: rapid or shallow breathing, use of accessory muscles, decrease in LOC, increase in CO2 levels, decrease O2 saturation and tachycardia 2. Synchronized Intermittent mandatory Ventilation (SIMV) Indicated for patients who satisfied weaning criteria but cannot sustain adequate spontaneous ventilation for long periods As respiratory muscles strengthen, the pressure is decreased 3. T-piece Usually used when patient is awake and alert, breathing without difficulty, and has good gag and cough reflex Maintained on oxygen level on the same or greater than oxygen concentration the patient is receiving in mech vent  WOF: respiratory distress and hypoxia Respiration – the process of gas exchange between atmospheric air and the blood at the alveoli, and between the blood cells and the cells of the body; exchange of gases occurs due to differences in partial pressures. Ventilation – the movement of air in and out of the lungs Hinkle, J. and Cheever, K. (2017). Brunner & Suddharth’s Textbook of Medical-Surgical Nursing, 14th ed. USA: Wolters Kluwer Search, read, and understand journals / research articles from Science Direct and EBSCO on the common causes of ventilator-induced trauma / injuries and management. List them down and then develop a plan on how you can prevent these from occurring as future nurses to your future patients. Submit this via Canvas as a 200–300-word essay. Burns, S. (2018) AACN Essentials of Critical Care Nursing. Mc Graw Hill Education. Schumacher L. (2012) Saunder’s Nursing survival guide: Critical Care and Emergency Nursing. Elsevier