Transcript RESPIRATORY PROBLEMS Adult Health II, 2008

Adult Health Nursing II
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…a concept map…
Nursing care
planning
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Module 4.1
Chest Tubes
Placed to drain air & blood from pleural space, restore
negative intrapleural pressure & re-expansion of lung
Nursing responsibilities (Chart 32-13, p. 648)
– Monitor output hourly  call MD if >70ml/hr
– Tape tubing junctions
– Keep occlusive dressing, sterile 4x4s, and tape at bedside.
Use to cover chest puncture site if chest tube falls out.
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Nursing Responsibilities (cont’d)
– Assess for tidaling in water seal chamber  should be
gentle rise & fall of water when pt breaths in & out
– Monitor for continuous bubbling in water seal chamber 
indicates an air leak in the tubing.
– Keep 2 padded Kelly forceps at bedside to locate air leak in
tubing.
– Avoid kinks in the chest tube & drain tubes
– Use only sterile water – not normal saline
See Craven’s pp. 839-841
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Chest Tube Indications
Pneumothorax: Air in the pleural space caused by trauma, lung disease, invasive
pulmonary procedure, forceful coughing, surgical complication, or may occur
spontaneously
–To drain air, the chest tube is placed in anterior chest at the second or third
intercostal space
Hemothorax: Blood in the pleural space caused by blunt/penetrating trauma or a
complication of chest surgery
–To drain fluid, the chest tube is placed at lung base
Pleural effusion: Excessive fluid in the pleural space caused by pneumonia, left
ventricular heart failure, pulmonary embolism, cancer, or complication of surgery
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Chest Tube Indications
Chylothorax: Accumulation of lymphatic fluid in
the pleural space caused by chest trauma, tumor,
surgery
Empyema: Pus from an infection, such as
pneumonia; must always be drained no matter how
small amount
Other considerations: Preventively after
cardiac/pulmonary surgery to drain blood
postoperatively and prevent cardiac tamponade;
also used to instill fluids (chemotherapy, sclerosing
agent)
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Types of Chest Drainage Units (CDU)
Chest drainage unit (CDU): Traditional
chest drainage unit consists of a collection
chamber, water seal chamber, suction
control chamber; can drain large amounts of
fluid or air
Smaller/lighter portable CDU: Mechanical
one-way valve instead of water seal
chamber; good for patient who needs
drainage only (not suction to reexpand
lung), such as noncomplicated
pneumothorax
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Heimlich valve:
Contains a one-way
flutter valve; air
drains out when
patient exhales; keep
collection device
upright and vented to
prevent air buildup
Examples of underwater
conventional CDUs
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Chest Tube Insertion
Done in patient’s room, interventional
radiology, or the operating room
Local anesthetic; patient may feel
pressure as tube is inserted
Aseptic (sterile) procedure
Patient’s breathing will be easier once
lung is re-expanded
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Chest tube insertion
Position patient for comfort depending on site to
be inserted
Tube will be anchored with a suture
Insertion site will have an occlusive dressing
applied
Connections securely taped
Chest X-ray to confirm position and lung reexpansion
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Risks and complications
Bleeding: Usually minor, but may require surgery if
extensive
Infection: Likelihood increases the longer the chest tube is
in place
Subcutaneous emphysema (crepitus): Characterized by
swelling in face, neck, and chest; crackles on palpation
Lung trauma/bronchopleural fistula: Rare, but patient will
have signs and symptoms of respiratory distress, bloody
chest tube drainage; tube will be left in place until healed
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Nursing Considerations
Monitor vital signs
Assess breath sounds
bilaterally
Assess the insertion site
Encourage the patient to
cough
Make sure connections
are taped securely
Keep CDU below the level
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of the patient’s chest
Check water seal and
suction control chambers
frequently
Assess drainage for color
Measure drainage at least
every 8 hours
Document assessment
Report immediately bright
red blood or red freeflowing drainage
>70ml/hour
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Care of Chest tube and CDU
Tubing: Avoid loops, aggressive manipulation
such as “stripping” or “milking”
Patency: To maintain patency, try “gentle” handover-hand squeezing of tubing and release
Clamping: Avoid except when replacing CDU,
locating air leak, or assessing when tube will be
removed
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Removing the Chest Tube
Chest tube can be removed when:
•There’s little to no drainage
•Air leak is gone
•Patient is breathing normally without respiratory
distress
•Fluctuations in water seal chamber stopped
•Chest X-ray shows lung reexpansion with no
residual air or fluid
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Procedure for Chest Tube Removal
Gather supplies and explain procedure to patient
The clinician will remove the dressing and sutures
During peak exhalation, the clinician will remove the
chest tube in one quick movement
Immediately apply a sterile gauze dressing containing
petroleum to prevent air from entering pleural space
Monitor patient’s respiratory status
Arrange for chest X-ray to confirm lung reexpansion
Monitor patient’s respiratory status and SpO2 for 1-2
hours after removal
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Medical Management with Chest Tube
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Acute Respiratory Failure
Not a disease, but a consequence of severe
respiratory dysfunction
Lungs are unable to oxygenate blood &
remove CO2 adequately, even at rest
Patient is always hypoxic
COPD most common cause. Also: other
lung diseases, chest injury, inhalation
trauma, neuromuscular disorders, & cardiac
conditions
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Acute Respiratory Failure
Critical values of blood gases:
–
–
–
–
SaO2 <90%
PaO2 <50mm/Hg (hypoxemia)
PaCO2 >50mm/Hg (hypercapnia)
pH <7.35 (acidemia)
Respiratory mechanisms leading to ARF:
–
–
–
–
Ventilatory failure
Oxygenation failure
Ventilation-perfusion mismatching
Shunting
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Ventilatory and Oxygenation Failure
Ventilatory failure: Gas exchange (ventilation) at
the alveolar-capillary membrane is inadequate –
too little oxygen reaches the blood and carbon
dioxide is retained.
Oxygenation failure: Gas exchange is normal but
blood flow (perfusion) to lungs is inadequate.
V/Q (ventilation/perfusion) mismatch occurs.
Ventilation &/or perfusion are inadequate.
Results in poor respiratory movements &
hypoventilation. Block 7.0 Module 4.1
V/Q Scan Mismatch
V/Q scan (ventilation/perfusion scan –
obstructed pulmonary blood flow
causes V/Q mismatch: an area of lung
is ventilated, but not perfused).
Pulmonary embolus most common
cause
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S/Sx of Acute Respiratory Failure
Early:
– Dyspnea
– Restlessness
– Fatigue
– Headache
– Air hunger
– Tachycardia
– Increased blood
pressure
– Decreased breath
sounds
– Use of accessory
muscles
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Later:
– Confusion
– Lethargy
– Tachypnea
– Central cyanosis
– Diaphoresis
– Respiratory arrest
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Interventions for ARF
O2 w/pt in high-Fowler’s position
Meds:
– Bronchodilators (short-acting) (albuterol)
– Corticosteroids (methylprednisolone)
– Na bicarb (if metabolic acidosis present)
– Anti-anxiety meds (Valium, Ativan)
– Diuretics
– Antibiotics (if underlying infection present)
May need intubation w/mechanical vent
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Nursing Interventions
Assess/monitor: ABG, SaO2 , VS,
respiratory status, neuro status
Establish & maintain airway
Suction if needed
Avoid meds that depress respirations
Turn, cough, deep breath
Prepare for mechanical vent if worsens
Provide emotional support to pt/family
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Acute Respiratory Distress
Syndrome (ARDS) (Shock Lung)
Sudden & progressive form of acute respiratory
failure w/pulmonary edema, refractory
hypoxemia & reduced lung compliance
Inflammation makes damaged alveolar capillary
membrane more permeable  fluids, protein &
blood cells leak into lungs
Loss of surfactant w/decreased elasticity &
pulmonary compliance (stiff lung). Alveoli
collapse & can be destroyed.
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Acute Respiratory Distress
Syndrome (ARDS)
Hypoxia persists even when oxygen at 100%
 refractory hypoxia
Decreased pulmonary compliance (stiff lung)
50% mortality rate; incidence >150,000/yr
Most deaths d/t nonpulmonary multiplesystem organ failure, often with sepsis
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Risk Factors for ARDS
2 most common causes are:
Gram-negative septic shock
Aspiration of gastric contents (pH 2-4)
Other causes:
Pneumonia
Trauma
Near drowning
Fat embolus
Drug overdose
Cardiopulmonary bypass
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“Ground glass” CXR of ARDS
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S/sx of ARDS
Early: (12-48h)
Cough
Restlessness
Progressive
dyspnea
Tachypnea
Fine scattered
crackles
Bilat infiltrates on
CXR
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Progression to late s/sx:
Labored dyspnea
Confusion
Diffuse crackles
Tachycardia
Hypotension
Cyanosis, pallor
Profound respiratory
distress w/ET intubation
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Diagnostics
ABGs w/lower PaO2
Refractory hypoxemia w/O2 at 100%
Chest x-ray w/ground-glass appearance
No cardiac involvement on EKG – no
left-sided heart failure
Insertion of pulmonary artery cath
(Swan-Ganz) to monitor pulmonary
artery wedge pressure & cardiac output
Electrolytes, hemoglobin, hematocrit
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Drug Therapy for ARDS
#1 intervention: Oxygen
IV antibiotics if organism identified
Corticosteroids to decrease
inflammation, edema
Sedatives, antibiotics, diuretics,
inotropics, H2 blockers/PPIs
Many investigational drugs – none has
been effective in reducing mortality
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Other Interventions for ARDS
Identify & treat underlying condition
Intubation & mechanical vent w/PEEP
(goal: PaO2 >60mmHg, SaO2 >90)
IV fluids for hydration & hypovolemia
Nutritional support via G tube or TPN
(35-45 kcal/kg per day)
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Nursing Responsibilities
Assess GI status (prone to GI bleed and
stress ulcers w/ARDS & mechanical
vent)
Monitor nutrition status
– Labs, tube feeding and/or TPN protocols
– Daily weights
– Hydration status (check BUN)
– H2 blockers (Zantac) or PPI (Prilosec)
Infection monitoring: vital signs
– Culture resultsBlock 7.0
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Nursing Responsibilities
Fluid volume status
– Intake & output
– Monitor for dehydration d/t insensible
losses
– Daily weights
– Electrolyte panels
– Monitor skin integrity (edema)
– Monitor for bleeding
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Mechanical Ventilation
http://www.youtube.com/watch?v=Lb
MxTk45PTs
Mechanical ventilation is delivered by
positive pressure, forcing air into the lungs
in one of two ways:
1. Invasively via endotracheal (ET) tube or
tracheostomy
2. Noninvasively via mask w/CPAP/BiPAP
& iron lung
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Types of Ventilators
Types of ventilators:
– Negative-pressure ventilators
– Positive-pressure ventilators: used
in acute care settings
Pressure-cycled ventilators
Time-cycled ventilators
Volume-cycled ventilators
Microprocessor ventilators
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Negative Pressure Ventilator
Iron Lung -- Then
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Iron Lung -- Now
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Managing Mechanical Ventilation
Normal breathing is controlled by neg pressure
system – air is drawn into the lungs
Mechanical ventilation is delivered by positive
pressure, forcing air into lungs in one of 2 ways:
– Invasively via ET tube or tracheostomy
– Noninvasively via mask (CPAP, BiPAP or APAP)
Mechanical ventilation may be lifelong in persons
with chronic, progressive neuromuscular diseases
that reduce effective ventilation (muscular
dystrophy, multiple sclerosis, etc.)
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Modes of Ventilation
The ways in which the client receives
breath from the ventilator include:
– Assist-control ventilation (AC)
– Synchronized intermittent mandatory
ventilation (SIMV)
– Bi-level positive airway pressure (BiPAP)
and others
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ET Tube Placement
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Endotracheal Intubation
ET tube passed through mouth or nose into
trachea
Usually temporary for life support (<3 wks)
Provides airway for pts who cannot maintain
one on their own, for mechanical vent, & for
suctioning lungs
Most often used for hypoxemia & progressive
alveolar hypoventilation
Mechanical ventilation may be lifelong in
persons with chronic, progressive
neuromuscular diseases that reduce effective
ventilation (muscular dystrophy, multiple
sclerosis, etc.)
Parts of ET tube
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Nursing Responsibilities for
Endotrachial Intubation
Verify tube placement: X-ray, assess
bilat BS, stomach distention, end-tidal
CO2
Stabilize the tube  do not secure to
lower jaw d/t to possible movement of
jaw & dislodgement of ET tube
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Why Patient May Need Mechanical Vent
ARDS
COPD
Thoracic/abdominal
surgery
Neuromuscular
disorders
Inhalation injury
Status asthmaticus
Drug overdose
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Acute resp failure
Pulmonary edema
Pulmonary embolus
Pneumonia
Multiple trauma
Shock
Multisystem failure
Coma
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Ventilator Modes & Settings
Respiratory rate: Number of breaths ventilator delivers/minute (4 to 20
breaths/minute).
Tidal volume (VT): Volume of gas exchanged with each breath; normal
breathing = 7 to 10 ml/kg; ventilator set lower to prevent
barotrauma/volutrauma.
Oxygen concentration: Also called fraction of inspired oxygen
delivered (FIO2)  22-100% O2. Use lowest FIO2 to maintain SaO2 >90%
& PaO2 >60 mm/Hg
Inspiratory/expiratory ratio: The duration of each: ratio usually set for
1:2 to 1:1.5.
Flow rate: speed of tidal volume  usually 40L/min
Pressure limit: The maximum pressure a ventilator delivers to achieve
tidal volume.
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Nursing Responsibilities
Ventilator management:
– Monitor FIO2. ABG’s, CXR, lung sounds
– Monitor secretions type and amount
– Monitor for pneumothorax
– Sedate for ventilator compliance
– Monitor ET tube placement
– Monitor ventilator settings
– Monitor alarm settings
Keep emergency equipment at the bedside.
Assess patient for level of consciousness (LOC),
vital signs, lung sounds regularly.
Perform suctioning as needed.
Assess patient’s ability to synchronize breathing
with the ventilator. Block 7.0 Module 4.1
Nursing Responsibilities
Maintain cuff pressure 20-25mmHg
Monitor for tracheal bleeding, ischemia,
necrosis d/t continuous cuff pressure
Monitor nutrition status
– Labs, tube feeding and/or TPN protocols
– Daily weights
– Hydration status
– H2 blockers
Infection monitoring: vital signs
– Culture results
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Nursing Management
First concern is for the client; second for
the ventilator.
3 nursing goals:
– Monitor & evaluate response to
ventilator
– Manage the ventilator system safely
– Prevent complications: most d/t
positive pressure from ventilator.
Nearly every body system is affected.
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“Once a shift”(at least) checklist
 Check all ventilator settings/alarms.
 Check tubing for kinks.
 Check temperature/humidification.
 Check ventilator circuit/change per facility policy.
 Check your patient for increased heart rate, mental status
change, respiratory rate, diaphoresis, or other signs and
symptoms of increased work of breathing.
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Possible Complications
Ventilator-associated pneumonia (VAP)
– Use orogastric tube if indicated to cut
down on gastrointestinal (GI) distention,
aspiration, regurgitation.
– Elevate head of bed at least 30 degrees.
– Routinely verify tube placement.
– Follow mouth care protocol.
Volutrauma
– Monitor ventilator settings for tidal
volume/positive end-expiratory pressure
(PEEP).
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Possible Complications
(con’t.)
Cardiovascular compromise
--Monitor hemodynamic status closely,
especially signs and symptoms during
“early” preload.
GI complications
--Assess for gastric distension and
aspiration risk.
Patient-ventilator dyssynchrony
--Check settings. Encourage patient to
breathe with ventilator; may need mild
sedation.
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Weaning Patient from the Ventilator
Patient should be hemodynamically stable.
Vital capacity (amount of air exhaled) should
be 15 ml/kg.
Inspiratory pressure should be –30 cm H2O.
Readiness also based on patient’s nutritional
status, respiratory/cardiac/psychological
states.
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Weaning & Extubation
Readiness based on pt’s respiratory & cardiac
status
Weaning: going from ventilatory dependence
to spontaneous breathing
Extubation: removal of ET tube.
Stridor: high-pitched, crowing noise during
inspiration d/t laryngospasm or edema at the
glottis. Late manifestion of narrowed airway.
Always an emergency!
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Prior to Weaning
Assess patient’s mental status, SaO2, SpO2,
PaO2, pH, PaCO2, heart rate, blood pressure
(BP), respirations.
Elevate head of bed 45 degrees.
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Four Methods of Weaning
1. T-piece
2. Synchronized intermittent mandatory
ventilation (SIMV)
3. Pressure support ventilation (PSV)
4. Continuous positive airway pressure
(CPAP)
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Methods of Weaning (con’t.)
T-piece
Often used in patients with COPD,
respiratory muscle weakness.
Patient is placed on T-tube attached to ET
tube; alternate spontaneous breathing with
machine-assist ventilation, increasing
progressively as tolerated.
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Methods of Weaning (con’t.)
Synchronized intermittent mandatory
ventilation (SIMV)
Delivers preset tidal volume or pressure
in response to patient’s inspiratory
efforts. Will initiate breath if patient fails
to do so.
Gradual transition from positive pressure
ventilation to negative pressure
spontaneous breathing
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Methods of Weaning (con’t.)
Pressure support ventilation (PSV) and
continuous positive airway pressure
(CPAP)  provide positive pressure
support to the patient’s spontaneous
breathing and are useful in patients with
respiratory muscle fatigue.
Keeps alveoli open, maintains positive
pressure support, patent airway,
oxygen, eases “work of breathing,”
while patient adjusts to breathing on his
own.
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Signs of Weaning Intolerance
Decreased LOC
Systolic BP >180
mm Hg (or increase
of 20% or more) or
diastolic BP >100
mm Hg
Heart rate
>120 beats/minute
(or increase of 20%
or more)
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Respiratory rate
>30 breaths/minute
(or changing 50% or
more)
SpO2 <90%
Signs of increased
work of breathing-dyspnea, accessory
muscles use
Diaphoresis
Fatigue or pain
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finis
This concludes the
Respiratory Nursing
Presentations
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