Respiratory

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Respiratory
Competencies
By Paula Willmore
Origins of Competences
Led initially by the DoH
NICE
“All staff should have competence in monitoring,
measuring and interpreting vital signs”
“Education and training should be provided to
help staff competences and competence should
be developed”
The Aim of the Competencies
Should be used in conjunction with formal and
informal teaching
Develop and build on existing knowledge
Increase confidence
Develop clinical practice
Create a platform to encourage ward based
learning
Improve patient care
Improve patient care
Anatomy and Physiology
Gross anatomy and
physiology of the
respiratory system
Anatomy and Physiology
Mechanism of breathing
Anatomy and Physiology
Transport of oxygen
Anatomy and Physiology
Regulation of Ventilation
Complex and not completely understood
Regulated by;
Controller
Effectors
Sensors
Controller
Housed by the CNS
Not located in one specific area
Several areas work together to provide
coordinate ventilation
Brainstem regulates automatic ventilation
Cerebral cortex allows voluntary ventilation
Neurons housed in the spinal cord process
information
This information is then sent to the muscles of
ventilation
Effectors
The muscles of ventilation
They function in a co-ordinated
fashion
Regulated by the CNS
Sensors
Central and peripheral chemoreceptors
Chemoreceptors respond to changes in
chemical composition of blood or other fluid
around them
Other sensors have a smaller role
Found in the lungs
Irritant receptors, stretch receptors and the
juxtacapillary (J) receptors
Respiratory Assessment
4 techniques are used in
respiratory assessment;
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
Inspection
3 areas focused on
1. Observation of the tongue
and sublingual area
2. Assessment of the chest wall
configuration
3. Evaluation of respiratory
effort
Palpation
Three areas of focus;
1. Confirmation of the position of
the trachea
2. Assessment of thoracic
expansion
3. Evaluation of fremitus
Percussion
2 areas of focus;
1. Underlying lung structure
2. Diaphragmatic excursion
Auscultation
Focus on 3 different areas;
1. Evaluation of normal breath
sounds
2. Identification of abnormal
breath sounds
3. Assessment of voice sounds
Airway obstruction
Partial or complete
Partial obstruction often
precedes complete
Can occur at any level from the
nose and mouth down to the
bronchi
Causes of Partial Airway
Obstruction
Cerebral or pulmonary oedema
Exhaustion
Secondary apnoea
Hypoxic brain injury
Eventually cardiac arrest
Causes of Airway
Obstruction
CNS depression
Blood
Vomit
Foreign body
Direct trauma to face or throat
Epiglottitis
Pharyngeal swelling
Laryngospasm
Bronchospasm
Bronchial secretions
Recognition of Airway
Obstruction.
Look, Listen and Feel
LOOK for chest and
abdominal movement
LISTEN and FEEL for
airflow at the nose and mouth
Partial Airway Obstruction
Creates Sounds
Inspiratory stridor
Expiratory wheeze
Gurgling
Snoring
Crowing or stridor
Airway Management
Unless an airway obstruction
can be relieved within a few
minutes to enable the patient to
breath, injury to the brain and
other vital organs and cardiac
arrest will occur
Treatment for Airway
Obstruction
Basic Techniques for
Opening an Airway
Head tilt
Chin lift
Jaw thrust
Adjuncts to Airway
Techniques
Oralpharyngeal airway
Attempt insertion only in
unconscious patients
Need to maintain head
tilt/chin lift or jaw thrust.
Continue to check
patency of airway
Adjuncts to Airway
Techniques
Nasopharangeal airway
Used in patients that are
not deeply unconscious
Once in place use the
look, listen and feel
techniques to assess
patency of airway
Head tilt/chin lift may be
required
Suction
Oropharangeal suction
Wide bore rigid suction (yankauer)
To remove;
Blood, saliva, gastric contents
Caution...
If the patient has a gag reflex it can provoke
vomiting
Suction
Suction via a nasopharangeal
airway.
The need for suctioning should
be assessed
Complications include
hypoxemia, broncospasm,
cardiac dysrhythmias and
airway trauma
Recovery Position
Refers to a side lying position
The position allows the drainage of fluid from the
patient nose and mouth
Can be useful in a patient at risk of a partial
airway obstruction
The airway should be continually monitored for
patency
Importance of Accurate
Respiratory Observations
Often first observation to change
Look at the trend
A high respiratory rate is a marker of illness and
a warning that the patient may deteriorate
suddenly
Oxygen Therapy
Oxygen is a drug and as such most trusts now
require it to be prescribed with a goal Spo2
Once oxygen therapy has begun the patients
oxygenation status should be evaluated and
reevaluated so that the lowest possible level of
oxygen is administered
Methods of Delivery
Low flow system
Allows flows of less than
or equal to 4L/min
Inspired oxygen content
varies
Can deliver up to 36%
Methods of Delivery
Variable flow meters
Allows for a oxygen
percentage to be
delivered rather than
L/min
Can deliver up to 60%
Methods of Delivery
Reservoir systems
Stores oxygen in the
reservoir
Less mixing of room air
Can deliver up to 70%
Humidification
Oxygen use causes the mucosal layer of the
upper respiratory tract to become dry
External humidification prevent drying and
irritation of the respiratory tract
Prevent loss of body water
Facilitate secretion removal
Complications of Oxygen
Therapy
Hyperoxia produces an
overabundance of oxygen free
radicals
Free radicals damage alveolarcapillary membrane
This lung damage can lead to
acute lung injury
Carbon dioxide retention
Absorption atelectasis
Oxygen Saturation
A measure of the amount of oxygen bound to
haemoglobin
Cool peripheries prevent make pulse oximetry
difficult and often produce inaccurate results
Wave form measurements enable a more
accurate assessment
Does not measure Co2
Respiratory Distress
Identified by;
Increased respiratory rate
Increased work of breathing
Use of accessory muscles
Difficulty speaking in full sentences
Spo2 may be lowered
Causes of Respiratory
Distress
Shock- Especially septic shock
Trauma- Lung contusion
Infection- Pneumonia
Inhalation injury- Smoke
Haematological- Massive blood
transfusion
Obstetric-Amniotic fluid
embolism
Drug overdose- Heroin
Miscellaneous- Pancreatitis
Treatment
Positioning
Oxygen therapy
Nebuliser therapy
Secretion removal
Physiotherapy
Know when to ask for help
Respiratory Failure
Divided into 2 categories
Type I
Type II
Type I
Acute hypoxemia
Common causes include;
Pulmonary oedema
Pneumonia
Fibrosing alveolitis
Type II
Ventilatory failure
Common causes include;
COPD
Respiratory muscle weakness
Depression of the respiratory centre
Untreated type I respiratory failure
Monitoring in Respiratory
Failure
Respiratory assessment
Pulse oximetry
ABG
Management of
Respiratory Failure
Oxygen therapy
Positioning
Secretion removal
Nebuliser therapy
Physiotherapy
Treatment of underlying cause
Positive pressure may be required in type II
Nebuliser Therapy
Considerations
O2 vs Air
Patient position
Drugs effect
Embedding
Competencies into
Practice
Measurable impact on staff performance
Staff understand their contribution
Measurable impact on patient outcome
Consistency
Evidence based care
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