NR341 Complex - Week 2 Notes version 2

29 June 2024

NR341 Complex - Week 2 Notes

NR341 Complex - Week 2 Notes

Complex Adult Health (Chamberlain University)

NR341: Complex - Week 2: Notes

Chest Tubes

Indications for chest tube:

  • Pneumothorax
  • Hemothorax
  • Pleural effusion
  • Post-op after cardiothoracic surgery

Monitoring patients with chest tubes:

  • Monitor vital signs and respiratory status
  • Auscultate lung sounds
  • Palpate tissue around the site for subcutaneous air
  • Ensure that connections are secure, tubing is free of kinks, and the collection system is below the patient’s chest level
  • Check for the presence of an intact, occlusive dressing at the insertion site

Monitoring Chest Tube Drainage Systems:

  • Monitor and record drainage color and amount as ordered
  • Notify the physician for changes in characteristics of drainage or for >150ml of drainage over a 2-hour period
  • Assess the water seal for the presence or absence of bubbling
  • Bubbling in the water seal chamber indicates an air leak, which should resolve as the pneumothorax resolves
  • Ensure secure connections between the chest tube and the drainage collection site
  • Assess the fluctuation in water levels, which should rise and fall with inspiration and expiration
  • Assess water level in the suction control chamber

Unplanned Removal:

  • Immediately cover the insertion site with a gloved hand
  • Have the patient forcefully exhale as you lift your hand off the insertion site
  • Quickly cover the site again before the patient’s next inhalation
  • Apply a petroleum gauze and cover it with a dry 4x4 and tape
  • Notify the physician
  • Obtain a chest X-ray and assess the patient

Post Chest Tube Removal:

  • Monitor the patient’s vital signs and respiratory status
  • Frequently listen to lung sounds
  • Check the dressing on the insertion site

Airway and Ventilatory Management

Ventilatory Assistance:

  • Measurements of oxygenation:
    • Partial pressure of arterial oxygen (PaO2) norm is 80-100 mmHg
    • Arterial oxygen saturation of hemoglobin (SaO2) norm is 92-100%
    • Values used to determine hypoxia

Arterial Blood Gas Interpretation:

  • Steps:
    1. Look at each number and label
    2. Evaluate oxygenation
    3. Determine acid-base status & evaluate pH
    4. Determine the primary cause of the acid-base status (respiratory or metabolic)
    5. Determine compensation (none, partial, or complete)
  • pH:
    • Concentration of hydrogen ions (H+)
    • Normal range 7.35-7.45
    • pH < 7.35 = acidosis
    • pH > 7.45 = alkalosis
  • PaCO2:
    • Partial pressure of carbon dioxide in arterial blood
    • Normal value 35-45 mmHg
    • PaCO2 > 45 = acidosis
    • PaCO2 < 35 = alkalosis
  • HCO3:
    • Concentration of sodium bicarbonate in the blood
    • Normal value is 22-26 mEq/L
    • HCO3 < 22 = acidosis
    • HCO3 > 26 = alkalosis
  • Potassium Levels in acidosis:
    • Potassium increases in acidosis

Respiratory Acidosis:

  • pH decreases (below 7.35)
  • PaCO2 increases (above 45 mmHg)

S/S:

  • Hypoventilation leads to hypoxia
  • Rapid, shallow respirations
  • Low BP
  • Skin/mucosa pale to cyanotic
  • Headache
  • Hyperkalemia
  • Dysrhythmias
  • Drowsiness, dizziness, disorientation
  • Muscle weakness, hyperreflexia

Causes:

  • Respiratory depression (anesthesia overdose & increased ICP)
  • Airway obstruction
  • Decreased alveolar capillary diffusion (pneumonia, COPD, ARDS, PE)

Respiratory Alkalosis:

  • Increased pH (above 7.45)
  • Decreased PaCO2 (below 35 mmHg)
  • Hyperventilation (increased rate & respiration)
  • Tachycardia
  • Low or normal BP
  • Hypokalemia
  • Numbness & tingling of extremities
  • Hyper reflexes & muscle cramping
  • Seizures
  • Increased anxiety & irritability

Causes:

  • Hyperventilation (anxiety, PE, fear)
  • Mechanical ventilation

Metabolic Acidosis:

  • Decreased pH (below 7.35)
  • Decreased HCO3
  • Decreased ability of kidneys to excrete acid or conserve base

S/S:

  • Headache
  • Decreased BP
  • Hyperkalemia
  • Muscle twitching
  • Flushed skin
  • Warm, flushed skin (vasodilation)
  • Nausea, vomiting, diarrhea
  • Changes in LOC (confusion, increased drowsiness)
  • Kussmaul respirations

Causes:

  • DKA
  • Severe diarrhea
  • Renal failure
  • Shock

Metabolic Alkalosis:

  • Decreased acid or increased base
  • Increased pH (above 7.45)
  • Increased HCO3

S/S:

  • Restlessness followed by lethargy
  • Dysrhythmias & tachycardia
  • Compensatory hypoventilation
  • Confusion (decreased LOC, dizzy, irritable)
  • Nausea, vomiting, diarrhea
  • Tremors, muscle cramps
  • Tingling of fingers & toes
  • Hypokalemia

Causes:

  • Severe vomiting
  • Excessive GI suctioning
  • Diuretics
  • Excessive NaHCO3

Metabolic or Respiratory Compensation:

  • Respiratory compensation is quicker than metabolic compensation
  • Partial: mechanisms occurring, pH abnormal
  • Complete: mechanisms occurring, pH normal range

Airway Management:

  • Positioning (head tilt-chin lift)
  • Oral airway - keeps tongue from obstructing airway, useful in decreased LOC situations
  • Nasopharyngeal Airways (nasal trumpet) useful in times of seizure or oral trauma
  • Endotracheal intubation: insertion of ETT tube into the trachea through either the mouth or the nose

Noninvasive Positive Pressure Ventilation (NPPV):

  • CPAP/BiPAP machine
  • Indications:
    • Acute exacerbation of COPD
    • Cardiogenic pulmonary edema
    • Early hypoxic failure in immunocompromised patients
    • Obstructive sleep apnea
    • To prevent reintubation in a client who has recently been extubated

Contraindications to NPPV:

  • Apnea
  • Cardiovascular instability (hypotension, dysrhythmias, myocardial ischemia)
  • Claustrophobia
  • Somnolence
  • High aspiration risk
  • Viscous or copious secretions
  • Facial or gastroesophageal surgery
  • Craniofacial trauma, burns

Endotracheal Intubation:

  • Insertion of an endotracheal tube (ETT) through the mouth or nose
  • Orotracheal route preferred to reduce infections
  • Used to maintain an airway, remove secretions, prevent aspirations, and provide mechanical ventilation

Procedure:

  • Choose the proper size ETT tube, an average size is 6.5-8 for women and 7.5-9 for men
  • Client is usually sedated and sometimes even paralyzed for intubation and ventilation
  • Client positioned in sniffing position, laryngoscope stylet used to place ETT tube
  • Person performing the intubation must be careful not to damage the client’s teeth
  • Landmarks of glottis, epiglottis, and vocal cords used for intubation

Nursing Interventions:

  • Auscultate the epiglottis area
  • Auscultate bilateral breath sounds
  • ETCO2 detector
  • Esophageal detector device
  • Secure the tube when placement is verified
  • Chest X-ray 3-4 cm above carina
  • Record ETT size and cm at the lip line for reference

Endotracheal Suctioning:

  • Suction as indicated by assessment (visible secretions, coughing, rhonchi, high pressure on ventilator, ventilator alarm)
  • Conventional versus closed suction
  • Procedures:
    • Preoxygenate and hyperoxygenate throughout the procedure
    • Avoid normal saline instillation

Rapid Sequence Intubation (RSI):

  • RSI is the term used to describe the sequencing of medications administered to clients prior to tracheal intubation. The nurse is responsible for administering these medications correctly through the venous access device (VAD), within the proper sequence as outlined by their facility policy
  • RSI drugs:
    • Sedative-hypnotic amnesic: Propofol, etomidate - Induce unconsciousness
    • Rapid onset opioid: Fentanyl - Induce unconsciousness
    • Neuromuscular blocking agent: Rocuronium - Skeletal muscle paralysis

Tracheostomy:

  • Indications:
    • Long-term mechanical ventilation
    • Frequent suctioning
    • Protecting the airway
    • Bypass an airway obstruction
    • Reduce WOB
  • Performed in the operating room or bedside (percutaneous)

Indications for Mechanical Ventilation:

  • Hypoxemia: PaO2 < 60 on FiO2 > .50
  • Hypercapnia: PaCO2 > 50 with pH < 7.25
  • Progressive deterioration: increasing RR, decreasing V1, increased WOB

Complications of Mechanical Ventilation:

  • ETT out of position (right main stem bronchus, dislodged)
  • Unplanned extubation (securing of tube important)
  • Laryngeal/tracheal injury (prevent excessive head movement, routine monitoring of ETT cuff pressure)
  • Damage to oral and nasal mucosa
  • Barotrauma (pneumothorax, tension pneumothorax)

Detecting Barotrauma:

  • High peak airway pressure on vent
  • Decreased breath sounds
  • Tracheal shift
  • Subcutaneous crepitus
  • Hypoxemia

Treating Tension Pneumothorax:

  • Manually ventilate
  • Needle thoracostomy

Infection:

  • Normal protective mechanism bypassed by ETT tube
  • Ventilator-associated pneumonia (VAP)
  • Ventilator bundle: HOB 30-45 degrees, awaken daily and assess readiness to wean, stress ulcer prophylaxis, DVT prophylaxis, oral care Q2hr (chlorhexidine in some bundles)

Weaning from Mechanical Ventilation:

  • Individualized decision
  • Collaborative team effort
  • Readiness to wean: underlying cause of mechanical ventilation resolved, hemodynamic stability, adequate cardiac output, adequate respiratory muscle strength, adequate oxygenation without a high FiO2 and/or high PEEP, absence of factors that impair weaning, mental readiness, minimal need for medicines that cause respiratory depression

Stopping the Weaning Process:

  • RR > 35 or < 8 bpm
  • Low spontaneous V1 < 5
  • Labored respirations
  • Use of accessory muscles
  • Low oxygen saturation < 90%
  • HR or BP changes > 20% from baseline
  • Dysrhythmias
  • ST segment elevation
  • Decreased level of consciousness
  • Anxiety

Ventilator Settings:

  • Ventilators use positive pressure ventilation
  • Fraction of inspired oxygen (FiO2): percentage of inspired O2 the ventilator is giving to the client (ranges .21 to 1.0 or 21% to 100% O2)
  • Respiratory rate (RR): number of breaths to be delivered to the client per minute
  • Positive end-expiratory pressure (PEEP): amount of positive pressure applied to the airways during expiration

Alarms and Troubleshooting:

  • NEVER SHUT ALARMS OFF! Silence only
  • Manually ventilate if unsure of the problem until a new ventilator is available
  • Most ICUs have a dedicated RT who will manage the mechanical ventilation among the nurse and the physician

Types of Alarms:

  • High pressure alarms: increased secretions, wheezing, bronchospasm, displaced ETT, blocked ventilator tubing, client cough/gag/bite, client is anxious and fights off the ventilator
  • Low pressure alarms: disconnection or leak in ventilator or client’s airway cuff, client stops breathing

Extubation:

  • Determine the need for secretion management
  • Assess: stridor, hoarseness, change in vital signs, low oxygen saturation
  • NPPV may prevent the need for reintubation

Care for Extubation:

  • Assess respiratory alterations
  • Initial responses to hypoxia: tachypnea and increased VT, shallow respirations, decreased RR is ominous
  • Inspect, palpate, auscultate
  • Testing: serial chest x-rays, labs, pulse oximetry and end-tidal CO2, pulmonary function testing
  • Interventions: maintain a patent airway, optimize O2 delivery, minimize O2 demand, treat the cause of ARDS, prevent complications
  • Positioning, blood transfusion, decreased metabolic demand

Medical Management of Respiratory Failure

Oxygen:

  • Bronchodilators
  • Corticosteroids
  • Transfusions
  • Nutritional support
  • Hemodynamic monitoring
  • Sedation
  • Therapeutic paralysis

COPD

Acute Respiratory Failure in COPD:

  • Worsening V/Q mismatch
  • Secretions and bronchoconstriction can lead to acute respiratory failure
  • Causes: acute exacerbations, CHF/pulmonary edema, dysrhythmias, pneumonia, dehydration, and electrolyte imbalances
  • Risk factors: smoking, air pollution, exposure to dust and chemicals, genetics
  • Interventions: correct hypoxia, cautious administration of O2, noninvasive positive pressure ventilation, ventilatory assistance

O2 Therapy:

  • Goal of keeping PaO2 > 60 and SaO2 > 90%
  • Medications:
    • Beta2Agonist: albuterol (causes smooth muscle relaxation but can cause tachycardia)
    • Anticholinergic
    • Corticosteroid: solu medrol (used to treat inflammation)
    • Antibiotics may be given to vented clients

Asthma

Acute Respiratory Failure in Asthma:

  • Chronic inflammatory disorder causes airways to become hyperresponsive
  • Causes: exposure to allergens, viruses, or other irritants
  • Treatment: beta2agonist, inhaled bronchodilators, systemic steroids, intubation may be necessary in some cases

Asthma Exacerbation:

  • Wheezes, dyspnea, chest tightness, tachypnea, tachycardia, agitation
  • Use of accessory muscles and retraction noted on assessment
  • Causes: bronchodilators no longer working, noncompliance with medications
  • Effects: hyperventilation with air trapped results in respiratory acidosis, severe hypoxia

Pneumonia

Acute Respiratory Failure in Pneumonia:

  • Types: community-acquired, healthcare-acquired, ventilator-associated pneumonia (VAP)
  • VAP: aspiration of bacteria from the oropharynx or GI tract, treatment is bacteria-specific antibiotic therapy
  • Prevention is key: VAP bundle, elevate HOB 30-45 degrees, awaken daily and assess readiness to wean and extubate, stress ulcer disease prophylaxis, venous thromboembolism (VTE) prophylaxis, oral care, handwashing, and standard precautions, surveillance, avoid normal saline during suctioning, avoid reintubation, oral intubation, ETT with continuous aspiration of subglottic secretions, sedation and weaning protocols, aseptic suctioning of ET tube, nutrition, mobilization

Increased Risk:

  • Elderly, smokers, head injury, alcoholic, chronic diseases, immunosuppression

Pulmonary Embolism

Acute Respiratory Failure with Pulmonary Embolism:

  • Virchow’s triad: venous stasis, altered coagulability, damage to vessel wall
  • Embolus results in a lack of perfusion to ventilated alveoli (V/Q mismatch)

Prevention:

  • Medications, mechanical, position changes, treatment of atrial dysrhythmias, prophylactic anticoagulant therapy

Treatment:

  • ABCs, oxygen, patient position (semi Fowler’s), anticoagulants, surgical procedures (embolectomy, vena cava umbrella), thrombolytics

S/S:

  • Tachypnea, decreased PCO2, hypoxia (decreased PO2), dyspnea, tachycardia, hemoptysis, sudden sharp chest pain

Pneumothorax

Air in the Pleural Cavity, Resulting in Lung Collapse:

  • S/S: dyspnea, tachycardia, pleural pain, asymmetrical chest wall expansion, decreased breath sounds
  • Causes: ruptured BLEB (COPD), thoracentesis, trauma, secondary infection
  • Diagnosed by: chest x-ray, ABGs
  • Treatment: chest tube, oxygen

Acute Respiratory Distress Syndrome (ARDS)

Noncardiogenic Pulmonary Edema:

  • Diagnostic criteria: hypoxia, bilateral infiltrates
  • Acute lung injury scoring
  • Complication of other disease processes
  • Direct or indirect pulmonary injury
  • Causes: chest trauma, aspiration, inhalation injury, near drowning, fat emboli, sepsis (50%), any type of shock, drug overdose, renal failure, COPD, Guillain-Barré syndrome, myasthenia gravis, pancreatitis, massive blood transfusion
  • Cause isn’t always obvious

Developing ARDS:

  • ARDS usually develops within 12-18 hours of the inciting event, sometimes it may take days
  • ARDS clients who survive will have some lasting lung compliance issues for up to one year, and its lasting effects may affect the client’s quality of life for 2 years

S/S:

  • Tachypnea, dyspnea, retractions, hypoxia, tachycardia, decreased pulmonary compliance
  • ABGs: decreased PO2, increased dyspnea

Interventions:

  • Mechanical ventilation (oxygenate)
  • High PEEP levels
  • Sedation and paralytics
  • Prone positions (ARDS protocol: standardization in how to manage ARDS, calls for conservative fluid administration except in cases of shock)
  • Nutritional supplement (enteric feedings)
  • Long recovery, client/family will need psychosocial support

Nursing Interventions:

  • Ventilator settings as appropriate
  • Suctioning, oral care
  • Monitor ABGs/pulse oximetry
  • Monitor ECG, vital signs
  • Position every 2 hours
  • Coughing and deep breathing
  • Prone positioning for clients with refractory hypoxia that do not respond to other strategies to increase PaO2 (optimal treatment time is 24 hours, done in severe cases)

Medical Management:

  • Treatment is supportive and aims to treat the underlying cause
  • Oxygen, corticosteroids, diuretics, morphine, digoxin, antibiotics

Prevention:

  • Ventilator bundles, oral care
  • PEEP (early)
  • Pump (cardiovascular treatments)
  • Pipes (fluid management)
  • Paralysis (decreased oxygen demand, must be combined with sedation)
  • Positioning (labor intensive, improved oxygenation by perfusion of alveoli in dependent positions)
  • Prone position (not used much due to danger)
  • Improvement in prognosis

Complications:

  • Renal failure, multiple organ dysfunction syndrome, disseminated intravascular coagulation, long-term pulmonary effects associated with high oxygen and other therapies

Summary

  • Acute respiratory failure may occur with many disease processes
  • Goals must be to maintain airway, provide oxygenation/ventilation support, and keep the client free from infection
  • ABG interpretation takes practice; don’t be intimidated

Quiz 1 Review

Top Stressors:

  • Pain
  • Inability to sleep
  • Financial

Why is the family considered part of the healthcare team?

  • They play a role in the patient’s recovery

What should you do if a patient in ICU for days has a disrupted sleep pattern and starts having issues from sleep deprivation?

  • Cluster nursing activities so the patient has uninterrupted sleep times

Know parts of the SBAR:

  • Situation
  • Background
  • Assessment
  • Recommendation

You are giving a report to the oncoming shift and say “He is 4 days post-op and his incision is open to air.” What part of the SBAR did you give?

  • Background

What should you do if a client receives a double dose of medication?

  • Assess the patient and then report it as a medication error

How can you get family members involved in the plan of care?

  • Meet with them and invite them to be a part of the multidisciplinary rounds
  • Ask them to bring in personal items