Albany State University NURS 2115 Respiratory Study Guide
1. Review A&P of lungs:
• Bronchioles lead to alveoli
• Alveoli lead to alveolar
... [Show More] sacs
• Alveoli: functional unit of the lungs
o 35% of gas exchange occurs here
o Surfactant formation occurs here
• Alveolar sacs: last part of the airway
o Surrounded by alveoli
o 65% of gas exchange occurs here
• Lungs:
o Right lung: 3 lobes
o Left lung: 2 lobes
2. In order to understand the more difficult content, you should have an understanding of the following basics:
• Upper and lower airways: provide defense mechanisms. Patients lose their normal
respiration defense mechanisms due to:
o Disease/illness
o Injury
o Anesthesia
o Corticosteroids
o Smoking
o Malnutrition
o Uremia
o Ethanol
o Hypoxia
o Artificial airways
• Work of breathing:
o Related to lung compliance and resistance of lungs and/or thorax
o Factors affecting lung or chest wall compliance:
▪ Flail chest
▪ Atelectasis
▪ Pneumonia
▪ Pulmonary edema
▪ Pulmonary fibrosis
▪ Pleural effusion
▪ Pneumothorax
• O2:
o SpO2 saturation: measurement of the percent of oxygen the hemoglobin is saturated with- 95-100%
▪ Non-invasive
▪ Not indicative of the amount of oxygen being let go to perfuse the tissues
• CO2: a byproduct of cellular metabolism and is transported to the lungs where it is eliminated during exhalation
o Lungs can usually rapidly eliminate CO2 from the body through rapid deep expirations (“blowing off CO2”) or retain CO2 by shallow, slow respirations
• Tidal volume: volume of air inhaled and exhaled with each breath
o Normal value: 500 ml
• Compliance: elasticity and expandability of the lungs and thoracic structures
o Allows the lung volume to increase when the pressure in between the atmosphere and thoracic cavity (pressure gradient) causes air to flow in
o Factors that affect compliance:
▪ Surface tension of alveoli
▪ Connective tissue
▪ Water content of lungs
o Normal compliance: 1 L/cm H2O
▪ Lungs and thorax easily stretch and distend when pressure is applied
o Increased compliance: lungs have lost their elastic recoil and become overdistended (emphysema)
o Decreased compliance: lungs and thorax are stiff
• FIO2: fraction of inspired oxygen the patient inhales
o Normal level/room air: 21%
o The higher the prescribed FiO2, the sicker they are
• Oxygenation: blood taken to the lungs is getting rid of CO2 and getting O2 to take back to the body
o For acidosis: increased FiO2 and decreased PEEP
o For alkalosis: decreased FiO2 and increased PEEP
• Ventilation: movement of air in and out of the airways
o How well CO2 is being removed from the blood
o Measured by PaCO2
o Requires movement of the walls of the thoracic cage and of its floor, the diaphragm
o Higher PaCO2: less CO2 is being cleared
▪ Ventilation is worse
o Lower PaCO2: more CO2 is being cleared
▪ Ventilation is better
o Respiration rate
o Tidal volume
• Effective respirations requires gas exchange in the lungs (external resp) and tissues (internal resp) and depends on the following to maintain oxygenation and acid-base balance:
o Ventilation: gas distribution into and out of the pulmonary airways
o Pulmonary perfusion: blood flow from the right side of the heart, through pulmonary circulation, and into the left side of the heart
o Diffusion: gas movement from areas or greater concentration to lesser concentration
o Internal respirations: occurs only through diffusion when the RBCs release O2 and absorb CO2
o Variable effecting O2 transport:
▪ Cardiac output
▪ PaO2
▪ Hemoglobin
▪ Metabolic demand
o Variables affecting consumption of O2 by the cells:
▪ Increased work of breathing
▪ Hyperthermia
▪ Trauma
▪ Sepsis
▪ Anxiety
▪ Hyperthyroidism
▪ Seizures
• Ventilation and perfusion balance and imbalance:
o Adequate gas exchange depends on adequate ventilation-perfusion ration (V/Q)
o Normal V/Q ratio
o Low V/Q ration: shunt
o High V/Q ratio: dead space
o Absence of ventilation and perfusion: silent unit
3. Review clinical manifestations, nursing assessment and interventions, and patient teaching for the following:
• ARDS: sudden and progressive form of acute respiratory failure in which the capillary
membrane is damaged and more permeable to intravascular fluid
o Pathology:
▪ Noncardiac pulmonary edema
▪ Alveoli fill with fluid and the fluid blocks surfactant
▪ Phase 1: injury or exudative phase- inflammation
▪ Phase 2: reparative or proliferative phase- this phase is complete when
the diseased lung is dense, fibrous tissue
▪ Phase 3: fibrotic can occur in 2-3 weeks, late or chronic phase- scarring, gas exchange is very limited
▪ Causes:
❖ Trauma
❖ Pulmonary infection/aspiration
❖ Prolonged cardiopulmonary bypass
❖ Shock
❖ Fat emboli
❖ Sepsis
o Clinical manifestations:
▪ Noncardiac pulmonary edema
❖ Capillaries leaking
▪ Early stages:
❖ Slight elevation of RR
❖ Tachypnea, tachycardia
• My heart is racing and I can’t catch my breath
❖ Dyspnea
❖ PaO2 on room air is 90 mmHg and dropping
❖ Early respiratory alkalosis and hypoxemia
• Hypoxemia determined by ABG
▪ Progresses to:
❖ Refractory hypoxemia despite high levels of FiO2 delivery
• Shunting blood from right side to left without gas
exchange
❖ Chest xray whited out (fluid in lungs)
❖ Breathing becomes labored: mechanically ventilate
❖ Reduced lung (pulmonary) compliance
❖ Retractions
❖ Fibrosis
❖ Acidotic
• Could be metabolic depending on if RR is elevated
o Nursing assessment:
▪ ABGs
▪ Chest xray: usually shows diffuse bilateral and rapidly progressing
interstitial or alveolar infiltrates
❖ Whited out
▪ ECG
o Nursing interventions:
▪ ET intubation, mechanical ventilation, PEEP
▪ Nutrition on vent:
❖ TPN vs enteral
❖ Increase protein
❖ Decrease carbs
❖ Increase calories
▪ Hemodynamic monitoring: provides precise measures for effectiveness
of interventions
❖ Swans catheter: right atrium pressure, CO, mixed venous oxygen saturation
▪ Perfusion? Check urine output
▪ Vent:
❖ 100% FiO2
❖ Increase levels of PEEP
❖ Sedation: calms patient and decreases demand for O2
• Fentanyl, propofol
❖ Paralytic agents: pavulon, norcuron, tracrium, zemuron
▪ Place in prone position
▪ Treat underlying cause, does not occur on its own
▪ Don’t give fluids
o Treatment:
▪ Prevent sepsis-MODS
▪ Early detection
▪ ET intubation, mechanical vent, PEEP
▪ Antibiotics
▪ Steroids: controversial
o Complications:
▪ Cardiac dysrhythmias
▪ Renal failure
▪ O2 toxicity
▪ Thrombocytopenia
▪ GI bleed
▪ Sepsis and DIC
o Patient teaching:
• Respiratory failure: sudden and life-threatening deterioration of the gas exchange function of the lung and indicates failure of the lungs to provide adequate oxygenation
or ventilation for the blood. Decrease in PaO2 to < 60 mmHg and an increase in CO2 to
>50 mmHg with a pH of less than 7.35
o Causes of hypercapnic (too much CO2) ARF:
▪ CNS depression
❖ Drug over doses: opioid, heroin
▪ Neuromuscular disease
▪ Acute asthma
▪ COPD
▪ Chest trauma
▪ High spinal cord injury
o Causes of hypoxemic ARF:
▪ Pneumonia
▪ Pulmonary edema
▪ Pulmonary emboli
▪ HF
o Clinical manifestations:
▪ Hypoxemic: PaO2 < 60 mmHg when the patient is receiving FiO2 >60%
▪ Hypercapnic: can’t effectively remove CO2
▪ Change in LOC:
❖ Restless, confused, lethargic
▪ Tachycardia
▪ Tachypnea (hypoxemic)
▪ Bradypnea (hypercarbia)
▪ Orthopnea
▪ HTN
▪ Late sign: cyanosis
▪ Signs of deterioration:
❖ Tripod position
❖ Inability to speak
❖ Muscle retractions
❖ Use of refractory muscles
❖ Work of breathing
❖ Crackles/rhonchi
❖ Absent/diminished breath sounds
o Nursing assessment:
▪ Cause related to inflammation, infarction
▪ Labs:
❖ ABGs: determines extent of hypoxemia and course of action
❖ Chest xray: determine cause
❖ CBC: potential cause
• Elevated WBC: infection
❖ CMP: electrolyte imbalances and kidney function
❖ Sputum/blood cultures: determine microorganism for antibiotic
❖ EKG: if client has any underlying cardiac issue
o Nursing interventions:
▪ Maintain adequate oxygenation and ventilation
▪ O2 admin
▪ Mobilize pulmonary secretions:
❖ Effective coughing
❖ Adequate hydration and humidification
❖ Chest physical therapy
• Postural drainage
• Tracheal suctioning
• Breathing exercises: purse lipped breathing, incentive
spirometer
▪ Decrease anxiety: breathing techniques, calm voice
▪ Bronchodilators: reverse bronchospasms
▪ Corticosteroids: decrease inflammation
▪ Diuretics, nitroglycerin, opioids: decrease pulmonary congestion
❖ Heart failure
▪ Antibiotics: if infection is present
▪ Sedation and analgesics: decrease anxiety, agitation, and pain
▪ Mechanical ventilation:
❖ Invasive: ET intubation
❖ Noninvasive: BiPAP
o Patient teaching:
▪ Use of incentive spirometer
• Pulmonary embolism: collection of matter in venous circulation and lodges in
pulmonary vessels
o Clinical manifestations:
▪ Anxiety*
▪ Impending sense of doom*
▪ SOB*
▪ Chest pain*
▪ Respiratory alkalosis*
▪ Tachycardia, tachypnea
▪ Hypotension
▪ Fever
▪ Cough
▪ Pleural friction rub
▪ Petechial over chest and axillae
▪ Hemoptysis
▪ Altered mental status
❖ Apprehension, restlessness, decreased LOC
▪ Diaphoresis
▪ VQ mismatch
▪ Decreased PaO2
▪ Reduced oxygenation
o Nursing assessment:
▪ Pulmonary angiography*: show us the clot
▪ Ventilation-perfusion scan: admin contrast agent, evaluates different
regions of the lung (upper, middle, lower) and always comparison of VQ
in each area
▪ CT
▪ ABGs
❖ Decreased PCO2 and PO2
❖ Increased pH
▪ Assess the patient’s respiratory status by monitoring the level of
responsiveness, ABG, pulse ox, and vitals
▪ Assess the entire respiratory system and implement strategies to prevent complications
o Treatment:
▪ Emergency:
❖ Nasal oxygen to relieve hypoxemia, respiratory distress, and
central cyanosis
❖ IV infusion line for meds or fluids needed
❖ Hypotension that doesn’t resolve with IV fluids, prompt
vasopressor therapy
❖ ECG monitored for dysrhythmias and right ventricular failure
❖ Blood draw for electrolytes, CBC, and coag studies
❖ Urinary cath
❖ Small doses of morphine or sedatives for pain and anxiety
▪ General:
❖ Treat underlying cause and restore adequate gas exchange in lungs
❖ Oxygen for hypoxemia, relieve vasoconstriction and reduce pH
❖ Antiembolic stocking or intermittent pneumatic leg compression
devices reduce hemostasis
❖ Elevate legs above level of heart
▪ Anticoagulants and thrombolytics:
❖ Patients with proven PE and hemodynamically stable:
• LMWH: enoxaparin (lovenox)
• Unfractionated heparin
• NOAC: dabigatran (Pradaxal)
• Factor Xa inhibitor: fondaparinux (Arixtra), rivaroxaban
(Xarelto) apixalban (Eliquis), or edoxaban (Savaysal)
❖ Long-term treatment:
• Warfarin (coumadin)
• NOACs
❖ Thrombolytic:
• Recombination with tissue plasminogen activator
(Activase) or others like kabikinase (Streptase)
▪ Surgical:
❖ Surgical embolectomy
❖ IVC filter may be inserted
o Nursing interventions:
▪ Oxygen:
❖ Assess for signs of hypoxemia and pulse ox
❖ Deep breathing and incentive spirometry
▪ Assisting with intubation and maintaining mechanical ventilation
▪ Implement turning schedule, mouth care, skin, care, and ROM of
extremities to prevent complications
▪ Prevent thrombus formation:
❖ Ambulation and active and passive leg exercises
❖ IPC devices
▪ Monitor thrombolytic therapy:
❖ Vitals every 2 hours
❖ Invasive procedures avoided
❖ INR and PTT 3-4 hrs after infusion is started
▪ Managing pain:
❖ Semi-fowlers position
❖ Turn patient frequently and reposition to improve V/Q in the
lung
❖ Opioids analgesics for severe pain
o Patient teaching:
▪ Move legs in “pumping” exercise
▪ Do not sit or lie in bed for prolonged periods
▪ Do not cross legs
▪ Do not wear restrictive clothing
▪ Lifestyle change necessary to restore health
▪ Name, dose, side effects, frequency and schedule for meds
▪ Avoid and prevent bleeding:
❖ No sharp objects
❖ Toothbrush with soft bristle
❖ Avoid laxatives
❖ Report black, tarry stool
❖ Wear ID bracelet
▪ Drink fluids, especially traveling and in warm weather
▪ Tell s/sp of lower circulatory compromise:
❖ Calf/leg pain, swelling, pedal edemal
▪ Tell s/sp of pe:
❖ Dyspnea, chest pain, anxiety, fever, tachycardia, apprehension,
cough, diaphoresis, syncope, hemoptysis
• Pneumothorax/hemothorax: partial/complete collapse of lung due to accumulation of air/fluid in pleural space
o Types:
▪ Spontaneous pneumo: ruptured blebs (COPD, emphysema, asthma)
▪ Open pneumo
▪ Tension pneumo
▪ Hemothorax
o Causes:
▪ Thoracentesis
▪ Trauma
▪ Secondary infection
o Clinical manifestations:
▪ Sudden sharp pain
▪ Dyspnea
▪ Diminished/absent breath sound
▪ Decreased respiratory excursion
▪ Hyperresonance: sounds hollow
❖ pneumo
▪ Decreased vocal fremitus
▪ Dullness
❖ Hemothorax
▪ Unequal chest expansion
▪ Tracheal shift to opposite side:
❖ Tension pneumo
▪ Weak rapid pulse
▪ Anxiety
o Nursing assessment:
▪ Chest xray
▪ PCO2 elevated
▪ PO2 and pH decreased
o Nursing interventions:
▪ ETT
▪ Suctioning
▪ Monitor mechanical vent
▪ Restore function:
❖ Thoracentesis:
❖ Insertion of chest tube:
❖ Provide pain relief
❖ Position in high fowler’s
o Patient teaching:
• Pulmonary contusion:
o Clinical manifestations:
o Nursing assessment:
o Nursing interventions:
o Patient teaching:
• Oxygen toxicity: O2 concentrations of > 50% for extended periods of time (> 48 hours but can occur in hours) can lead to overproduction of free radicals which can severely
damage cells leading to pulmonary edema and progressing to cell death
o Clinical manifestations:
▪ Substernal discomfort
▪ Paresthesia
▪ Dyspnea
▪ Restlessness
▪ Fatigue
▪ Malaise
▪ Progressive respiratory difficulty
▪ Refractory hypoxemia
▪ Alveolar atelectasis
▪ Alveolar infiltrates on chest x-rays
o Nursing assessment:
o Nursing interventions:
▪ Using lowest amount of O2 to maintain an acceptable PaO2 level and treating the underlying condition aids in prevention of O2 toxicity
▪ PEEP applied to the end of expiration of ventilator breaths or CPAP
reverses or prevents
o Patient teaching:
• Chest tubes: catheter placed into the intrapleural space to drain air and/or fluid
o Cath is connected to a 3 chamber drainage system consisting of a drainage,
water seal, and suction chamber
▪ Water seal makes chest tube function
o Clinical manifestations:
▪ Drain fluid, blood, air
▪ Establishes negative pressure
▪ Chest expansion
o Nursing assessment:
▪ Tidaling: movement with respiration- rise with inspiration and fall with exhalation
❖ Normal
❖ No tidaling: re-expansion or obstruction
▪ Drainage output every hr
❖ Report >100 ml to provider
▪ Water seal: air exits, can’t enter
❖ Level should be at 2 cm ALWAYS
❖ Sterile water or saline
❖ There should never be any bubbling in the water seal chamber:
indicates air leak
o Nursing interventions:
▪ Place upright and below the chest
❖ Usually on floor by end of bed
▪ Coil tubing in bed
▪ NEVER clamp the tube
▪ NEVER milk the tube: can create high negative pressure
▪ Keep at bedside:
❖ 2 hemostats
❖ Sterile water
❖ Sterile occlusive dressings
▪ Frequent respiratory assessments
▪ Suction control chamber:
❖ Dry suction: know it’s on when orange thing at top is blown up
❖ Wet unit: add sterile water/saline
• Bubbles should occur when connected to suctioning
❖ Constant suction: usually 20 units of pressure
o Patient teaching:
▪ Instruct on coughing and deep breathing
• Flail Chest: 3 or more ribs are fractured at 2 or more sites, resulting in free-floating rib
segments
o Clinical manifestations:
▪ Hypoxia
▪ Hypercarbia
▪ Increased retention of secretions
o Nursing assessment:
o Nursing interventions:
▪ Humidified O2
▪ Pain management
▪ Deep breathing
▪ Mechanical ventilation
▪ Drug therapy
▪ Monitor for shock
o Patient teaching:
4. Swanz Ganz catheter, central lines, and arterial lines: use of and care of these lines, assessment data that might indicate a problem
• Swanz ganz:
o Use:
▪ Determine hemodynamic status in critically ill patients
▪ Provides information about right and left sided intracardiac pressures and CO
▪ Critical care area and in operating room for CV surgeries
▪ Guides therapeutic interventions including administration of fluids and diuretics and titration of vasoactive and inotropic meds
▪ Distal lumen port: monitors systolic, diastolic and mean pressures in the pulmonary artery
▪ Proximal lumen port: monitors the right atrial pressure and injects the solution used to obtain CO
▪ Balloon inflation port: obtains the pulmonary artery wedge pressure (PAWP)
▪ Insertion of PA cath indications:
❖ Hypotension unresponsive to fluid replacement
❖ CHF
❖ Cardiac tamponade
❖ Significant dysrhythmias
❖ Acute pulmonary embolism anesthesia with cardiac surgery
❖ General surgery
❖ Cardiac and pulmonary disorders
❖ Sepsis
❖ Trauma, burns
o Care:
▪ Placed by inserting a PA cath introducer into the subclavian or jugular vein, the introducer has a port for IV fluids and once a PA cath is no longer needed, you can used the introducer as an IV access
▪ NEVER put IV fluids or meds in this cath, used for monitoring only
▪ NEVER use any syringe other than the one that comes with the PA cath kit for balloon inflation, if you use another syringe you can rupture the balloon and cause an air embolus
▪ Note insertion site, length of cath by centimeters marks, and changes in waveforms to make sure that that PA cath has not migrated in or out
▪ Perform systematic cardiovascular, peripheral vascular and hemodynamic assessments before and after insertion of PA cath
o Assessment data that might indicate a problem:
o Complications:
▪ Pulmonary artery infarction
▪ Rupture
▪ Pulmonary artery cath knotting
▪ Thromboembolism
▪ Sepsis
▪ Hemorrhage
▪ Vessel wall erosion
▪ Ventricular dysrhythmias
▪ Misplacements
▪ Hematoma
▪ Venous air embolism
▪ Pneumo and hemothorax
• Central lines (central venous catheters): large, non-tunneled IV access
o Uses:
▪ Hemodynamically unstable patients
▪ Admin of multiple meds
▪ TPN
▪ Vasoactive meds
▪ Hyperosmolar solutions
▪ Concentrated electrolyte solutions
o Care:
▪ Insertion sites:
❖ Subclavian vein: most common
❖ Internal jugular vein
❖ Femoral vein: not recommended due to higher risk of infection
❖ 16-18 gauge
▪ All central lines contain a radiopaque strip to identify it on x-ray or fluoroscopy after insertion
▪ No central line should be used until placement is confirmed by x-ray or fluoroscopy
▪ Hand hygiene: most important intervention to prevent a cath related bloodstream infection
▪ Always use gloves when handling a central line
▪ Always use a 10 mL syringe with central lines
❖ any smaller sized syringe can cause a high intra-lumen pressure and potentially rupture the line causing an embolus
▪ Change dressing, tubing, and port caps per facility protocol
▪ Ports not in use should be flushed at a minimum of every shift to ensure patency
▪ Always clamp the line while flushing to create positive pressure within the lumen to decrease the risk of clotting
▪ Always document what is infusing into what port
▪ TPN should always be infused through the brown (distal) port and primary fluids should be infused through the white (proximal) port
▪ CVP monitoring must be done through the brown (distal) port
o Assessment data that might indicate a problem:
o Potential complications:
▪ Infiltration
▪ Extravasation
▪ Thrombosis
▪ Pneumothorax
▪ Infection
• Arterial lines:
o Uses:
▪ Continuously monitor blood pressure directly and accurately
▪ Titrate vasoactive agents**
▪ Obtain serial blood gases or other lab patients in critically ill patients
▪ Conditions include:
❖ Acute hypotension or HTN
❖ Hemodynamic instability
❖ Cardiac arrest
❖ Hemorrhage
❖ Shock
❖ Infusion of vasoactive meds
o Care:
▪ Placement:
❖ Radial: most common
❖ Brachial:
• Potentially immobilizes limb
• Thrombosis
❖ Femoral:
• Infection
▪ Mod Allan’s test: checks for collateral circulation of radial and ulnar artery
❖ Elevate hand and clench fist for about 30 seconds
❖ Apply pressure to radial and ulnar arteries to stop bloodflow
❖ Open hand should be blanched
❖ Release ulnar pressure while maintaining radial pressure to assess for adequate circulation back to the hand
❖ Positive sign: hand returns to normal color and becomes warm
• One artery will be enough to ensure blood flow to hand and fingers
• Radial artery can be used
▪ Waveform in red for BP
▪ Zeroing out:
❖ Done when line is placed and position changing
❖ Should be done every shift, every 4 hr, after blood is taken, and PRN
❖ Transducer needs to be at heart level
▪ Neurovascular assessment:
❖ 5 Ps:
• Pain
• Paresthesia
• Pulses
• Pallor
• Paralysis
▪ Saline bag should be changed daily and tubing system every 72 hrs
▪ Drawing blood:
❖ Waste first 10 ml
❖ Use shielded blunt cannula
❖ Turn off stopcock to saline bag so it’s open between the pt and port drawing from
❖ Draw blood without additives, then tubes with additives, anticoagulation profiles, and ABGs
▪ Removing:
❖ Check coag studies: PT and PTT
❖ Keep tip sterile in case culture is needed
❖ Apply direct pressure for at least 15 minutes, then apply pressure dressing
• Check for bleeding, hematoma, or bruising
❖ Continue to assess 5 P’s
o Assessment data that might indicate a problem:
▪ Warmth, redness, pain, or wet feeling at the insertion site
▪ Neurovascular compromise
▪ Bleeding at sight
▪ Infection and sepsis
▪ Arterial line failure: kinked cath or thrombus at tip
o Complications:
▪ Infection at insertion site
▪ Clot formation in cath leading to arterial embolization
▪ Cath can cause vessel perforation resulting in extravasation of blood and flush solution into tissues
▪ Extremity can develop circulatory or neurologic impairment
5. Preload and afterload: influence CO
• CO: amount of blood the heart pumps throughout the body per minute
o HR x SV
o SV: amount of blood pumped by a ventricle with each beat
▪ Affected by contractility, preload, and afterload
o Normal: 4-8 L/min
• Preload: amount the ventricles stretch at the end of diastole
o Diastole: relaxation, filling phase
o AKA: end diastolic volume
o Increase preload:
▪ Fluids
▪ Sympathetic nervous system: vasopressors cause vasoconstriction
o Decrease preload:
▪ Diuretics: furosemide (Lasix)
▪ Nitroglycerin: vasodilation
• Afterload: pressure the ventricles must work against to pump blood out of the heart
o Affected by systemic vascular resistance (SVR)
o Increased afterload: caused by vasoconstriction
▪ Pulmonary HTN
▪ Aortic stenosis
o Decreased afterload:
▪ Vasodilators: decrease vascular resistance
6. Central venous pressure (CVP): measure of pressure in the vena cava
• Normal level: 8-12 mmHg
• Can be used as an estimation of preload and right atrial pressure
• Used as an assessment of hemodynamic status
• Can be measured with a central line
7. Ventilator modes: understand difference between modes (assist control and SIMV), CPAP/BiPAP (invasive and noninvasive)
• Assist control (AC):
o Ventilator is doing all the work breathing
o Preset tidal volume and rate, and FiO2
o Patient can initiate a breath after the preset rate is done but they will still receive the preset tidal volume
o Not great for COPD patients
• Synchronized intermittent mandatory ventilation (SIMV):
o Patient is assisting in ventilation
o Preset tidal volume and rate
o Patient can initiate a breathe after the preset rate is done but they will now pull in what tidal volume they’re able to on their own
• Continuous positive airway pressure (CPAP): provides positive pressure to the airways
through the respiratory cycle
o 1 continuous level of pressure
o Invasive: adjunct to mechanical ventilation with a cuffed ET or trach tube to open the alveoli
o Noninvasive: leak proof mask to keep alveoli open
• BiPAP: offers independent control of inspiratory and expiratory pressures
o 2 levels of pressure: 1 on inhalation, 1 on exhalation
o Noninvasive: machine with mask, nasal pillow
▪ Allow time for patient to improve
o Invasive: patient is intubated
▪ Weaning off
8. Review ventilator add-ons: PEEP and pressure support
• Positive end expiratory pressure (PEEP):
o Delivers a small burst of air at the end of expiration to keep the alveoli open for
better gas exchange on exhalation
o Keeps them from closing to ensure the patient can get the proper oxygen into the lungs and release CO2 from the lungs
o Normal level: +5
▪ Considered therapeutic
o High peep:
▪ Increased risk for BP issues
▪ Decreased BP means there’s too much intrathoracic pressure
• Pressure support:
o Assists the patient during inhalation to make breath bigger
o Patient has to be able to breathe on their own
9. Blood gases: be able to interpret an ABG if given values, causes, and treatment
• ABGs: measurement of gases carried by the blood to help us determine if a patient is maintaining a normal acid/base balance
o Used to measure how much O2 is available to tissues
• Normal levels:
o pH (potential of hydrogen ions): indicates blood acidity or alkalinity
▪ 7.35-7.45
o PaCO2: reflects the adequacy of ventilation to lungs
▪ Respiratory: 35-45 mmHg
▪ Lungs will increase or decrease rate to remove appropriate amount of CO2
▪ Lung compensation begins quickly
▪ Volatile acid
▪ Increase RR: blow off CO2 and decrease CO2 acid level giving you alkalosis
▪ Decrease RR (hypoventilation): retain CO2 and increase CO2 acid level giving you acidosis
o HCO3 (bicarbonate): reflects activity of kidneys in retaining or excreting bicarbonate
▪ Metabolic: 22-26/28 mmHg
▪ Slowest response: hours to days
▪ Excess acid (acidosis) disrupts homeostasis
o paO2: reflects body’s ability to pick up O2 from lungs (dissolved O2 in blood)
▪ 80-100 mmHg
▪ Measures oxygen in blood
▪ Aka PO2 or oxygen tension
▪ Amount of dissolved oxygen molecules freely floating in blood
❖ Higher PO2: higher concentration of dissolved O2 in blood
o Pulse ox: 95%-100%
▪ Not accurate
▪ Potential vasoconstriction
• interpret:
▪ Nail polish
▪ Cold fingers
o pH: 7.35-7.45
▪ ≤7.40: acidotic
▪ ≥7.40: alkalotic
▪ compensated: pH is within normal limits
▪ uncompensated: pH is out of normal range
o PCO2: 35-45
▪ ≤40: alkalotic
▪ ≥40: acidotic
▪ Respiratory
o HCO3: 22-28
▪ ≤25: acidotic
▪ ≥25: alkalotic
▪ Metabolic
o ROME:
▪ Respiratory
▪ Opposite
❖ pH ↑ PCO2 ↓: alkalosis
❖ pH ↓ PCO2 ↑: acidosis
▪ Metabolic
▪ Equal
❖ pH ↑ HCO3 ↑: alkalosis
❖ pH ↓ HCO3 ↓: acidosis
• Causes:
o Respiratory acidosis: increase in PCO2 in the lungs
▪ Under elimination of hydrogen ions
▪ Respiratory depression
▪ Anesthetics
▪ Drugs: especially opioids
▪ Electrolyte imbalance
▪ Head or neck trauma
▪ Inadequate chest expansion
▪ Skeletal deformities
▪ Muscle weakness
▪ Airway obstruction
▪ Alveolar-capillary block
o Respiratory alkalosis:
o Metabolic acidosis:
o Metabolic alkalosis:
• Treatment:
o Compensation: the body tries to fix itself
▪ Performed by the opposite system
▪ Ex: metabolic imbalance is resolved by the respiratory system
▪ Respiratory:
❖ Increased hydrogen ions or increased CO2
• Stimulate central respiratory neurons, leading to increased rate and depth of breathing, causing more CO2 to be lost and decreasing the hydrogen ion concentration
❖ Decreased hydrogen ions or decreased CO2
• Inhibit central respiratory neurons, leading to decreased rate and depth of breathing, causing normally produced CO2 to be retained and increasing the hydrogen ion concentration
❖ Primarily assist in buffering systems when the fluctuation of
hydrogen ion concentration is acute
▪ Renal:
❖ Mechanisms to decrease pH:
• Increase renal excretion of bicarbonate
• Increase renal reabsorption of hydrogen ions
❖ Mechanisms to increase pH:
• Decrease renal excretion of bicarbonate
• Decrease renal absorption of hydrogen ions
❖ The most powerful regulator of acid-base balance
❖ Respond to large or chronic fluctuations in hydrogen ion production or elimination
❖ Slowest response: hours-days
❖ Longest duration
o Correction: we fix it
▪ Ex: IV sodium bicarbonate increases ventilator rate
o Respiratory acidosis:
▪ Maintain a patent airway and enhance gas exchange
▪ Drug therapy
▪ Oxygen therapy
▪ Pulmonary hygiene
▪ Ventilatory support
▪ Prevention of complications
10. Review proper suctioning technique for patients with ET tubes and trachs
• Closed suction: STERILES PROCEDURE
o Hyper-oxygenate patient, and grasp where the ventilatory circuit and ET/trach connect with your non-dominant hand
o Quickly and gently insert the cath until slight resistance is met or the cough reflex is stimulated
o Apply suction and pull the cath out
▪ Don’t apply suction for longer than 5 seconds
o Note the color, amount, and consistency of secretions
o Process should take no longer than 10 seconds
o Perform oral care with every suctioning or at least every 4 hr
• Open suction:
o STERILE PROCEDURE WITH STERILE GLOVES
o Sputum trap: catches any sputum the patient may have
▪ Do before the patient receives first dose of antibiotic
▪ Attach suction to trap
o Attach suctioning cath to the trap and prime with normal saline
o Push down past oropharynx until cough or resistance
o Need a min of 5 mL
o Remove cath and label trap with date, time, patient, DOD
11. Care of patient receiving mechanical ventilation via ET tube and/or trachs
• Correct tube placement
• Proper cuff inflation
• Tube patency:
o Frequent suctioning is required due to secretions
▪ Performed by nursing and respiratory therapy
o Every 4 hours
• Oral care
• Safety
• Comfort
• Communication
12. Patient teaching for patients with trachs:
• Admin adequate warmed humidity and minimize dust
o Remove drapes and upholstered furniture
o Use air filters
o Wash floors, dusts, and vacuum frequently
• Suction as prescribed
• Change tape and dressing as needed or prescribed
• Monitor for s/sp of infection: temp
• Maintain adequate hydration
• Use sterile technique when suctioning and performing trach care
13. Chest drainage systems:
• What do you do if the chest tube becomes disconnected?
o Place the end of the tube in saline or water ASAP
• What do you do if the patient pulls out the chest tube?
o Cover the chest wound with saline impregnated gauze and tape on 3 sides
• Nursing care of a patient with chest tubes/chest drainage system
o Perform frequent respiratory assessments
o Drainage system should always be below the patient
▪ Usually set on floor at end of bed or hangs on bed side
o NEVER CLAMP THE CHEST TUBE
o Check the patency and intactness, tape the tube securely
o Instruct on coughing and deep breathing
o Monitor amount and consistency of drainage
o Keep gauze at the bedside incase the chest tube comes out
14. Airway management/rapid sequence induction (RSI)
• Provides management of the patient in a situation similar to that in the OR
• Meds used:
o Sedative
o Analgesic
o Neuromuscular blockade agent
15. Ventilator acquired pneumonia
• A subset of HAP that is classified by ET intubation and receiving mechanical ventilation for at least 48 hours
• Increase of VAP increases with duration of ventilation
• VAP occurring within 96 hours of the onset of mechanical ventilation is usually due to antibiotic-sensitive bacteria that colonize in the patient prior to hospital admission, whereas VAP developing after 96 hours of ventilatory support is more often associated with MDR bacteria
• Prevention measures:
o VAP bundle:
▪ Elevate HOV 30-45
▪ Daily sedation vacations and assessment of readiness to extubate
▪ Peptic ulcer disease prophylaxis
▪ DVT prophylaxis
▪ Daily oral care with chlorhexidine
16. What are indications for mechanical ventilation?
• Indications:
o Patients who cannot maintain their respiratory status or normal levels of CO2
and O2 in the blood
o Emergency situation with severe respiratory problems:
▪ Drowning, obstructive airway, asthma, chronic bronchitis, emphysema, pneumonia, ARDS, muscle weakness, damage to muscles or bones of
chest
o General anesthesia for surgery:
▪ Delivers anesthetic drugs
▪ Prevents aspiration of stomach content into lungs
▪ Controls levels of O2 and CO2 in blood
• What are some complications of mechanical ventilation?
o Tension pneumothorax
o Infection
o Volutrauma and barotrauma
o Organ impairment (renal, GI, CNS)
o O2 toxicity
o Stress ulcer
o pH imbalances
o Tracheoesophageal fistula
o Machine malfunction: disconnect ventilator from patient and manually ventilate with an ambu bag at 100% oxygen
• What would a high pressure alarm or low pressure alarm on the ventilator indicate?
o Low pressure:
▪ Tube disconnection
▪ Tidal volume leak
▪ Ventilatory circuit leak
o High pressure:
▪ Decreased lung compliance
▪ Biting on ET tube
▪ Secretion in airway
▪ Patient coughing, gaging, or trying to talk
• How do you ensure proper placement of an ET tube?
o Symmetrical chest rise and fall
o Clear and equal breath sounds: clearer on right side
o No bowel sounds
o X-ray confirms
▪ Sits at top of mainstem in middle at bifurcation
• What would you expect to hear if the ET tube is too deep?
o Both lungs will not receive the same amount of air
o p
• What are some psychosocial problems an intubated patient may encounter?
o Fear of dying
o Depression from chronic illness
• What does PEEP do and what is its significance in the patient with ARDS?
o PEEP: increases pressure in alveoli to keep them open on exhalation and
improve gas exchange and improve PO2
o PEEP is required more and more to improve PO2 without worrying about FiO2
o PEEP must be titrated carefully with ARDS
o It prevents the alveoli from closing or being filled with fluid which prevents fibrous tissue from forming to prevent scarring of the lung tissue and lung compromise
• Weaning: the patient is gradually removed from the ventilator, then for either the ET or
trach tube, and finally from oxygen
o Performed at earliest possible time
o Started when patient is physiologically and hemodynamically stable, demonstrates spontaneous breathing capability, recovering from acute stage of medical and surgical problems, and when the cause of resp failure is sufficiently reversed
o Methods of weaning:
▪ CPAP
▪ SIMV
▪ T-piece
o Weaning from oxygen:
▪ FiO2 is gradually reduced until the PaO2 is in the range of 70-100 mmHg while the patient is breathing room air
▪ If the PaO2 is <70 mmHg on room air, supplemental oxygen is recommended
17. What are S/SP of hypoxemia?
• Altered mental status
o Impaired judgement
o Agitation
o Disorientation
o Confusion
o Lethargy
o Coma
• Dyspnea
• Increased BP
• Tachycardia
• Tachypnea
• Central cyanosis
• Diaphoresis
18. Acid-base imbalances:
• Respiratory acidosis: retention of CO2 by lungs
o Causes:
▪ Under elimination of hydrogen ions
▪ Hypoventilation
▪ Respiratory depression
❖ Anesthetics
❖ Opioids
▪ Airway obstruction
▪ Electrolyte imbalance
▪ Head or neck trauma
▪ Inadequate chest expansion
▪ Skeletal deformities
▪ Muscle weakness
▪ Alveolar-capillary block
▪ COPD, pneumonia, atelectasis
o Signs and symptoms:
▪ pH: ↓7.35, PCO2: ↑45
▪ Hypoventilation → hypoxia
▪ Rapid, shallow respirations
▪ ↓ BP with vasodilation
▪ Dyspnea
▪ Headache
▪ Hyperkalemia
▪ Dysrhythmias: increased potassium
▪ Drowsiness, dizziness, disorientation
▪ Muscle weakness, hyperreflexia
o Treatment:
▪ Compensation: kidneys reabsorb HCO3 (base)
▪ Interventions aim to maintain a patent airway and gas exchange
▪ Increase RR
▪ Pulmonary hygiene:
❖ Positioning and breathing techniques
▪ Drug therapy
▪ Oxygen therapy
▪ Ventilatory support:
❖ Increase rate and TV
▪ Prevention of complications
• Respiratory alkalosis:
o Causes:
▪ Excessive loss of CO2
▪ Hyperventilation
▪ Fear, anxiety
▪ Mechanical ventilation
▪ Salicylate toxicity
▪ Hypoxemia-stimulated hyperventilation
▪ High altitudes
▪ Shock
▪ Early-stage acute pulmonary problems
❖ Pulmonary embolism
o Signs and symptoms:
▪ Seizures
▪ Deep, rapid breathing
▪ Hyperventilation
▪ Tachycardia
▪ Decreased or normal BP
▪ Hypokalemia
▪ Lethargy and confusion
▪ Light headedness
▪ N/V
▪ Numbness and tingling of extremities
o Treatment:
▪ Decrease RR
▪ Admin sedatives
▪ Rebreather mask
▪ Mechanical vent:
❖ Decrease RR
❖ Increase tv
❖ Sedation
• Metabolic Acidosis: decreased ability of kidney to excrete acid or conserve base
o Causes:
▪ Overproduction of hydrogen ions
▪ Excessive oxidation of fatty acids
▪ Diabetic ketoacidosis
▪ Starvation
▪ Hypermetabolism
▪ Heavy exercise
▪ Seizure activity
▪ Fever
▪ Hypoxia, ischemia
▪ Excessive ingestion of acids
▪ Ethanol intoxication
▪ Under elimination of hydrogen ions
▪ Renal failure
▪ Underproduction of bicarbonate
▪ Pancreatitis
▪ Liver failure
▪ Dehydration
▪ Over elimination of bicarbonate
▪ Diarrhea (severe)
▪ Buffering of organic acids
o Signs and symptoms:
▪ Headache
▪ Decreased BP
▪ Hyperkalemia
▪ Muscle twitching
▪ Warm, flushed skin: vasodilation
▪ N/V/diarrhea
▪ Changes in LOC: confusion, increased drowsiness
▪ pH: < 7.35, HCO3: < 22 mmHg
o Treatment:
▪ Monitor ABG levels for decreasing pH levels
▪ Maintain patent IV access
▪ Monitor I/O
▪ Monitor determinants of tissue oxygen delivery, if available
❖ PaO2, SaO2, hemoglobin levels and cardiac output
▪ Monitor loss of bicarbonate through the GI tract, as appropriate
❖ Diarrhea, pancreatic fistula, small bowel fistula, and ileal conduit
▪ Administer fluids as prescribed
▪ Administer insulin and fluid hydration for DKA causing metabolic acidosis, as appropriate
▪ Prepare patient for dialysis, as appropriate
❖ Assist with catheter placement for dialysis
▪ Institute seizure precautions
▪ Treat underlying cause: DKA, diarrhea, renal failure
• Metabolic alkalosis: decreased ability to retain acid and excrete base
o Causes:
▪ Increase of base components, decrease of acid components
▪ Oral ingestion of bases
▪ Antacids
▪ Milk-alkali syndrome
▪ Parenteral base administration
▪ Blood transfusion
▪ Sodium bicarbonate
▪ TPN
▪ Prolonged vomiting
▪ NG suctioning (excessive)
▪ Hypercortisolism
▪ Hyper aldosteronism
▪ Thiazide diuretics
o Signs and symptoms:
▪ Restlessness followed by lethargy
▪ Dysrhythmias: tachycardia
▪ Compensatory hypoventilation
▪ Confusion: decreased LOC, dizziness, irritable
▪ N/V/diarrhea
▪ Tremors, muscle cramps, tingling of finger and toes
▪ Hypokalemia
▪ pH: > 7.45, HCO3: >28 mmHg
o Treatment:
▪ Prevent further losses of hydrogen, potassium, calcium, and chloride ions
▪ Restore fluid balance: IV or parenteral
▪ Drug therapy
❖ Resolves the causes of alkalosis and restore normal fluid, electrolyte, and acid-base balance
❖ Antiemetics: for vomiting
▪ Monitor serum electrolyte values daily until normal/ near normal
19. Don’t forget about studying your drug list! This is also a crucial step!
• Bronchodilators
• Corticosteroids
• Mucolytic agents
• Neuromuscular blocking agents
• Sedative agents
• Versed
• Ativan
• Diprivan
• Theophylline
• Heparin
• Lovenox
• Opioids
• Sildenafil (viagara)
• Diuretics
• Nitroglycerin
• Proton Pump Inhibitors [Show Less]