Respiratory System
Chest Trauma
Mechanics of Respiration
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Breathing- Neg. pressure- pressure in chest cavity lower than atmosphere
Inspiration- Contraction of diaphragm, intercostals musc., chg in thorax (enlarges) & cohesion of
pleura
Expiration- relaxation
(Intrapleural pressure is negative at all times) (756mmHg)
Hemothorax
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collection of blood in the pleural space
o laceration, puncture, surgery, knife, or gun shot wound
S&S
o Chest pain
o Cyanosis
o Dec BP, inc. pulse, inc. RR
o Dyspnea (Shortness of breath)
o Dullness on percussion
o Shock
o Acidosis/ alklosis state
size
o Small- less 400, no S&S (clears itself in 10-14 days)
o Moderate- 500-2000cc,- Pallor, restless, anxiety, ^ HR, ↓BP, chest tightening, bloody
sputum, ↓ or absent LS on side.
o Massive- SOB, ↑HR, ↓BP, hypoxia, shock (fluid in half of lung), absent LS
Pleural Effusion
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causes: CA, pneumonia, lt side CHF, blocked lymph system
Emphysema
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Pus, fluid
PNEUMOTHORAX
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closed- chest wall intact
o Spontaneous- may have Hx of COPD, TB, Cystic Fibrosis, Cancer
o S&S- sudden sharp pain, cough, sudden SOB, ↓ BP, rapid pulse, tightness in chest,
asymmetric chest movement, hypersonant,
(BP inc. or dec., resp, inc., pulse inc.)
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Tension pneumothorax
o Untreated closed
o S&S- severe SOB, deviation of larynx to unaffected side, distended neck veins, inc. pulse
and RR, dec. BP, SQ emphysema, crepatis, change in PMI, muffled heart tones.
( if open to outside do not occlude)
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Open- penetration of chest wall
o S&S- sucking chest wound, chest pain, inc. HR, inc. RR, dec. breath sounds on side of
injury, unequal expansion, shallow breathing (resp. alk)
o TX- cover on three sides with a gauze with patient breathing out
Mediastinal flutter
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Inspiratory movement- shift to unaffected side
Expiratory movement- shift to affected side
Hemo- pnuemothorax
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blood & air in the thoracic cavity
Dx/ Tx is basically the same
o May see with chest tubes
 High or anterior for air
 Low or posteriorlateral for blood
Fractured Ribs
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painful and dec. chest movement which can lead to atelectasis
shallow resp., guarding, grunting at end of inspiration, asymmetrical resp., crepitus
Danger: contusion, rib piercing lung
Tx: anesthetic block, analgesics, splint area
Flail chest
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inspriatory movement- sucking in of ribs
expiratory movement- puffing out of ribs
S&S- extreme distress
o Desperately tries to breathe in spite of pain
o Hypoxia, cyanotic, severe SOB
o Grunting resp
o Paradoxical movement
Tx: HOB elevated and patent airway
o Mild= C&DB, suction, pain control, lay on affected side or splint
o Moderate= fluid restriction, diuretics, steroids, albumin, tx resp
o Severe= intubate and vent
CHEST TUBES
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type of drain into the pleural space that also prevents leak of air back into that space
Chest tube placement
o Air- 2nd intercostals space mid cav. Area
o Liquid- 5th intercostals space mid axillary area
o Open heart- medialstinal
Pleurodesis
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sclerosing agents- doxycycline, minocycline, bleomycin
o cause inflammation reaction
o Post care: watch patient may have low grade temp and pleuritic pain
TYPES OF CHEST DRAINAGE
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one bottle
o expiration- air leaves pleural space
o inspiration- water will fluctuate upward toward the chest
(2cm of H2O in bottle- underwater seal)
(intermittent bubbling during expiration)
(movement of fluid during expiration/ inspiration is tidaling)
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two bottles
o bottle one- tubing to patient, Blood (drainage) in bottle
o bottle two- tubing connecting bottles, tubing to suction, underwater seal
three bottles
o More negative pressure (15cm of water pressure)
o Suction control bottle
o Inc. suctioning the more neg. usually -20cm
o Wall suction with thoracic unit- gentle bubbling
o Tidaling
 bottle one- tubing to patient
 bottle two- tubing connecting bottle 1&2, drainage in bottle
 bottle three- tubing connection bottle 2&3, tubing to suction, underwater seal
INSERTION
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Equipment
o CT tray (suture) & CT
o Local anesthetic & betadine
o Gloves, protective gear
o Drainage system
o Dressing
o Hemostats
o Fill chamber to 2cm water level
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Check placement of CT with x-ray
Nursing Care
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Positioning patient and chest tubes (coil on bed to promote drainage)
Clamping
Assessing
o Patient- VS, LS
o Entry site- for crepetis
o Tubing- all connections taped
o Drainage unit- below chest, check amount, color of drainage
Chest x-ray
Interventions
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Sit in semi fowlers position
C&D, splint
Turn q 2hrs
Do not lie on tubing, keep coiled
Passive ROM
Keep below level of heart
Charting
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Size CT & site- date- time- who
Position
Color drainage & amount
Patient status
Meds used
Fluctuation- tidaling
Air leak- vs intermittent bubbling
Trach midline
Chest x-ray
Dressing change with doctors order
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if soiled
as ordered
Removal
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Equipment
o Suture set
o Vaseline gauze
o Tape
o Pain med
Procedure
o Hold breath while pulling out
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o Blow breath out after removed
Chest x-ray
Occlusive dressing
(pre- assess & post- assess- VS, LS, trachea, pulse ox)
Mobile Drains
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patient more mobile
gravity drainage
suction may inc time of CT- pulls tissue apart
new cells seal the hole faster
patient can be discharged with CT (teaching important)
assess LS (hollow-air, dull/flat-fluid)
Rapid breathing may indicate collection of fluid or air or they may indicate an increase in pain
CHEST SURGERY
Pre-op
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general assessment
general health
cardiopulm status
cardinal indicators of resp disorder
5 basic questions to ask
Report to surgeon
CARDINAL INDICATORS
Cough
Dyspnea
Hemoptysis
Chest pain
Sputum
Wheezing
Five Basic Questions
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Current S&S
Onset time?
How? i.e. exercise, eating, coughing, awakens you, what events
When do S&S affect you?
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What relieves S&S?
Report to Surgeon
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acute resp infection
skin lesions
oral cavity or teeth problems
need for PD or RT
change in sputum
Pre- op teaching
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anxiety/fear
o repeat instructions several times
o help to make the patient more calm
o what does the patient and family know
o management of pain
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knowledge
o incision
o surg
o post op expectations
 IV, foley, CT, ET or vent, VS, NG, A line or Swan
 Type of incision

Smoking
o Stop smoking at least 2wks prior, no more than 24hrs before
o Causes bronchopulmonary irritation
o Inc tracheobronchial secretions
o Dec blood O2 sat
o Inc blood carboxyhemoglobin
C&DB (huff)
Leg exercises
Arm and Shoulder exercises
Pain (IV, PCA, epidural meds)
Pulmonary Function tests
Pre-op
o Consent, allergies, hygiene, meds, and check list
o Do oral and nasal hygiene
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Surgery
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exploratory- thoracotomy
o locate source of injury or bleeding
o inspect and/or bx tissue
o plicate or ligate- folded over and sutured/clamped
o wedge resection
PNEUMONECTOMY
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chiefly for cancer or lung abcess
Entire lung (Rt lung more dangerous, large vascular bed)
Phrenic nerve crushed- in up position- to partially fill space (raises diaphragm, may fill with fluid,
within 6 fluid will insoluate and prevent shift
PARTIAL REMOVAL
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Lobectomy
o CT
Segmental
o CT
Wedge Resection
o Small localized area near surface
o CT
Poor outcome
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older than 70
advanced CA
Male
Borderline pulm func test
Hx of COPD
Post- Op
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CRITICAL: MUST MOVE
Gas Exchange
o Assess
 General appearance
 Breathing, LS
 Pulse ox
 Tracheal diviation
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NOTE: DO NOT PUT GOOD LUNG DOWN
Pneumonectomy- back and operative side only- unless ordered different
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Airway clearance
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o Inc. fluids
o C&DB q 1hr/24hrs
o Turn, sit up, walk
Tx: Albuterol-bronc spasms
o Tegerol PRN
o Mucoletic
o O2 humidifiers
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Fluid Volume Deficit
o Watch hemorrhage
o
o
o
o
o
o
o
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Replace fluids-(remember age of patient)
Remaining lung needs 2-4 days to adjust to inc blood flow
 Watch for pulm edema
 Crackles in lungs
 Mucus membranes
 HTN
 Bounding pulse
 Urinary output
O2 well prior to suctioning
Comfort/pain
Impaired mobility
 MUST MOVE
 MUST DO ARM EXERCISES PROGRESSIVELY
Nutrition
 TPN or inc. protein, calories, vitamins (esp Vit C)
Coping
Knowledge
 Will tire easily
 Stop smoking
 Good resp support
 Home in 3 days
 Pain for 4 wks
 Don’t lift heavy objects
ATLELECTASIS
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Collapsed alveoli
o Usually caused by bronc secretions
o Not being C&DB
o May be all or part of lung
S&S
o Restlessness
o Tachycardia
o Dec PaO2
o Dec cap refill
o Tachypnea
o Fever- infection/ATB
o Inadequate chest expansion
o Dullness of percussion
Treatment
o Inc C&DB (huff)
o All resp activity that can be done
o Adhesions may develop if lung is not reinflated
HEMORRHAGE
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Hemothorax- hypovolemia=SHOCK
S&S
o Dec BP - Inc HR
o Restless - Pallor
o Dec CVP - Dec UO
o PVC or Afib on cardiac monitor
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Give fluids and blood
May return to surgery
PULMONARY EMBOLISM
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S&S
o
o
o
o
o
Tx
o
o
o
Pain - Dyspnea
Fever - Hemopotysis
RT CHF - Hypoxia
Dist JVD - Chg in resp
Feeling of impending doom
Surg, anticoag, vasoconstictors shock
Tx resp distress
D-dimer, Spiral CT, ABG
OTHER COMPLICATIONS
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Cardiac impairment
o Arrhythmia’s
Bronchoplueral fistula
o Occurs 5-8 days post op (educate patient)
o Air leak (SQ emphysema, blood sputum)
Subcutaneous emphysema
o Air tissue under skin/ reabsorps in 10 days
PULMONARY EDEMA
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lungs doesn’t expand quick enough and circ. Overload
early S&S
o cough - dyspnea
o restless - anxiety
o low pitched wheezes
Advances S&S
o Acute SOB - blood tinge sputum
o Inc HR - Dec BP
o Anxiety - cool/clammy skin
Treatment
Morphine
Aminophylation
Digoxin
Diuretic
Oxygen
Gases
MEDIASTINAL SHIFT
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chech trachea (midline)
shift to unaffected side
S&S
o Severe dyspnea - inc RR
o Creptius - cyanosis
o Acute CP - chg PMI (where check apical pulse)
o Unequal chest expansion
o Restless - muffled heart tones
o Dec BP - dec HR
DISCHARGE TEACHING
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use heat or oral analgesia for pain
alternate walking with other activities (inc over time)
freq rest periods
BREATHING EXERCISES!! USE ICS
Avoid lifting more than 20#
Avoid irritants, inf, flu
STOP SMOKING
ACUTE RESPIRATORY FAILURE
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Abrupt inability of the lungs to exchange gases sufficiently to oxygenate the blood
Diffuse noncardiac pulmonary edema- inc. permeability of pul cap.
(CANT GET ENOUGH O2 AND CANT GET RID OF CO2)
Criteria
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ARDS
PaO2 less than 50
PaCO2 greater that 50
pH less than 7.3
Vital capacity less than 15ml/Kg
RR greater than 30 or less than 8
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group of diseases, insults or conditions resulting in acute lung disorder
resp causes
o severe infection - pulm. Edema
o pulm. Embolus - COPD
o ADRS - Cancer
o Chest trauma - Severe atelectasis
Non-Pulmonary
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CNS
Neuromuscular Disease
Post-op
Mech Vent
Obesity
Sleep apnea
Excessive blood transfusions
Predisposing factors or Injury
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Aspiration, near drowning, inhalation
SHOCK
SEPSIS
Microemboli
Inhalation
Drug Overdose
Pancreatitis
Oxygen Toxicity
SIX STAGES OF ARDS (48HRS)
1.
Inflammation and damage to Alveolar/Capillary membranes
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Release these substances cause inflammation/damage
o Histamine, serotonin, bradykinin
2.
Increase Capillary permeability(histamine) fluid shifts to the interstitial space (alveoli is still
open)
Increased permeability (protein) increase osmotic pressure=pulm. Edema
3.
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4.
S&S
o
Inc. RR, cyanosis, hypoxemia
Damage to surfactant = collapse of alveoli = atelectasis
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S&S:
o
o
Thick, frothy, sticky sputum,
Marked hypoxemia with inc RR
5.
Inc RR, O2 can’t leave, inc loss of CO2 (alkalosis)
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S&S:
o
Inc RR, hypoxemia, hypocapnea
6.
Inc pulm edema, hypoxemia leads to resp and met acidosis
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S&S:
o
Dec pH, inc. PACO2, dec O2 level, confusion, dec. HCO3 level
Direct Effects
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Refractory hypoxemia – low O2 sats regardless of how much O2 you give
Decreased CO (with VENT esp PEEP)
Dec venous return
Edema from vol overload
Dec BP from shock
Inc secretions
Inadequate ciliary motion
Fear, exhaustion
Signs and Symptoms
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Freq. monitor resp distress
Tachypnea (1st sign) >40 short, shallow
Dyspnea- labored, grunting
Hypoxemia – Cardinal Sign, Cyanosis- late sign
Diminished LS, fine crackles bases
Secretions are thicker (protein leak) (pulm. Edema- thin, frothy sputum)
Restless, anxious, irritable
Chg pulse ox or ABG’s
Inc PA pressures, PAWP <18mmHg (left side) (Pulm. Artery)
Inc Rt. Vent workload
Chest x-ray
Diagnostic
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ABG’s
Electrolytes- K, alk inc, acid dec
Sputum culture
Blood culture
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Urine culture
Chest x-ray
On a Vent
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dec vital capacity
dec lung compliance
inc airway pressure
dec func residual capacity
Treatment
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Treat the CAUSE!!
Airway
o Vent:
 TV 5ml/kg
 Peak flow <25cm H2O
 Use peep- positive end expiratory pressure
 Anytime you use PEEP you change the pressures in the thoracic cavity
and this can cause dec cardiac output- dec blood return
 Pressure control instead of volume
 Longer inspiratory time (dec peek airway pressure- more even gas distribution
 I/E ration 1:1 or 2:1
correct acid base balance
Fluid and lyte balance
o Watch am’t of fluids
Nutrition
o Enternal
o TPN (for the patient with GI problems or pancreatitis)
CHECK BLOOD SUGARS ON EVERYONE!!
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D/T change in Body during stress
Insulin becomes resistant
Also… watch for organ failure of other systems
MEDICATIONS
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Sedation- Diprivan good, Versed, Ativan
ATB: plus tx fever
Bronchodilator (can be via vent)
Primacor support rt vent function
Diuretics- Lasix, Bumenex
Corticosteroids (may cause fluid retention)
o Pos- Dec cap permeability, inhibits white blood cells from aggregating, inc. surfactant
o Neg- inc blood sugar, inc fluid retention, inc chance of infection
Low dose heparin
Vasodilators- Nitro, nipride
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Mucolytics
Colloids- albumin (after membranes have healed) (no more protein leak) (pulls fluid from 3 rd
space)
Ketoconazole, antifungal
Nitric oxide- relaxes vascular smooth musc.
Surfactant replacement (children)
ECMO (Extracorporeal membrane Oxygenation) – pull blood off body, oxygenate and put it back
Aerosolized prostacyclin- less toxic than nitric oxide, heavy so it gets in alveoli
Partial liquid ventilation- perfluorocarbon
o Helps gases freely disfuse like being on PEEP must sedate patient
THE PRIORITY NSG DX- IMPAIRED GAS EXCHANGE
Nursing Interventions
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VS, LS, LOC
O2 or vent (humidification & PEEP)
Suction – hyperventilate with O2 for 5 min
I&O & daily wt
Nutritional support or TPN
Fluid restrictions
ROM, freq rest periods, turn freq
Prone position
Good handwashing
MECHANICAL VENTILATION
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Mechanical Ventilation supports and maintains the respiratory system
Improves ventilation and decreases work load
Improves oxygenation
Indications for ventialation
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CNS disorders
Neuromuscular
Muscularskeletal
Disorders of Conducting Airway
Alveolar- Capillary membrane disorders
Criteria for Intubation
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Can the patient move air?
o Working too hard to breathe
o Can’t breath
Can the patient move secretions?
o Will fill up with secretions if they can’t move
Can the patient move blood?
o Poor cardiac output, poor breathing
ABG’s
RR> 35 or more, or less than 8
PO2 < 50 with FIO2 >60
PCO2 > 50 (unless COPD)
pH < 7.25
Neg Inspiratory force (<20 cm H2O)
Nursing Responsibilities During Intubation
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Activities
o Assemble equipment
o Ambu bag, O2 set up, suction equip., sterile gloves, laryngoscope, blades, xylocaine, ET
tube
 If awake give paralitic agent short acting
Observations
o Warm air, = breath sounds,= chest expansion—no gurgling in abd.
Charting
o Size ET, am’t air in cuff, LS, vent settings, secretions, patient reactions
Use of Anectine, pavulon
Ventilators
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Neg pressure on external chest
Dec. the intrathoracic pressure during inspiration- allows air to flow into lungs
Use chronic RF associatied with neuromuscular dis.
Positive Pressure
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Timed cycled (rare)
o Stimulated by preset line
o Forces air in
o Dec venous return
Pressure cycled
o Delivers a preset pressure
Volume cycled (most common)
o Preset volume
o If resistance is met it causes a high pressure alarm
Modes of ventilation
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Normal
Controlled
o Patient that is not trying to breath
o Ex: tidal vol 500, 16RR
Assisted
o Patient A&O, have hard time
o They take a breath and the vent takes over and delivers the amount
Assisted/Controlled
o Machine preset,
o Patient can cause it to kick in when he breaths
Intermittent mandatory
o Reservoir of O2 in vent
o Breathing not helped by the vent
o Preset positive pressure amount
o Patient breathes on own most of the time
o The vent it preset to give so many a minute
Ventilator Settings
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FIO2- fraction of inspired O2- keep patient O2 level above 90%
RR- what is vent set at, what is patient doing
TV (10-15 ml/kg)
Pressure Alarms (Hi & Low)
o Coughing, secretions, gagging, fighting , any resistance to breathing
o Comes off, air leak, valve left open
Sensitiviy- Hi/Low
Sigh
IE ratio
Pressure support- helps inspiratory effort of patient
PEEP- high levels dec cardiac output
CPAP- keeps airway open
Flowby- allows the vent to deliver a preset amount of gases through area
Problems R/T positive pressure
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Pneumothorax
o Pain, SOB, unequal expansion, no LS, SQ emphysema
Decreased Cardiac Output
o Dec LOC, dec UO, dec PP
Positive Water balance
o Inc BP & HR
o Retaining H2O
Problems R/T Artificial ventilation
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Inadequate ventilation
o Tubing- patient disconnects/ bites on
o Bucking- not in sync with machine
Atelectasis
o PEEP, Sighs, postural drainage
Alkalemia
o Inc. RR
Tissue trauma
Infection
o Suctioning is very important , good oral hygiene
o Watch of S&S of infection (sputum culture, ATB)
Immobility
o Position tubing so patient has room to move, stasis ulcers, GI bleed
Psychological
o Dependence on the vent
o Sleep deprivation
o talk to patient about what you are doing and what is going on around them
Conditions to report
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ETT displacement
Resp distress
Abn ABGs
Chg sputum color or consistency
Patient/vent dysynchrony
Consistent high pressure alarms
Cuff leak
Hypoxemia with suctioning
Weaning
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best time
o off pavulon
o AM, stable
o ABG’s stable, off PEEP
o Good inspiratory force
Tips
o Don’t sedate, well rested
o Communicate & teach
o
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Chech nutritional status
Values to watch for:
H&H >8
Remember PCO2 50 may be good for some
Vital capacity – N 10-15ml/kg
Negative Inspiratory effort- N- 20-30
TV 7-9 ml/kg
Minute ventilation 6L/min
When to stop weaning
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Pulmonary
o Retractions, use accessory musc
o RR>35, shallow breathing
o Inc SOB, cyanosis
CV
o P & BP +/- 20, arrhythmias
o Angina
o Diaphoresis
CNS
o Dec LOC, inc anxiety, agitation, exhaustion
CANCER OF LARYNX OR NECK AREA
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Head and neck cancer interferes with breathing, eating, facial appearance, self image, speech and
communication
Curable when treated early
80-90% are squamous cell
S&S and Tx
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painless sore or mass
tender
difficulty chewing, swallowing, or speaking
TX:
o Radiation, surg, or chemo
Pathophysiology
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Initially, the mucosa is subjected to irritating substances becomes tougher
Develops mucosal thickening- keratosis
Develops white, patch lesions (leukoplakia) or red, velvety patches ( erythroplasia)
Mets usually to lungs or liver
Types:
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Intrinsic = on vocal cords glottic area
Extrinsic= elsewhere on larynx or sub or supraglottic area
Etiology
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tobacco and alcohol
voice abuse
environmental exposure and poor oral hygiene
poor nutrition, GERD’s, human papillomavirus
Clinical manifestations
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Intrinsic- hoarseness or difficulty speaking, pain
Extrinsic- pain or burning when drinking hot or citrus fluids
Other- lump, color chg in mouth, lesions or sores, numb, chg in fit of dentures, sore throat, foul
breath, anorexia, and wt loss
Diagnostic tests
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Usual labs- CBC, PT, PTT, ect.
X-rays
MRI’s
Direct or indirect laryngoscopy or panendoscopy(all areas)
Treatment
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radiation- small local area 80% cure
o 5000-7500 rads, over 6 wks
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o
o
o
chemo
o
o
Surgery
o
o
o
o
may be used in combo with surg.
Voice may get worse but will improve, rest voice
Sore throat- gargle with saline or ice chips
not usually used alone
Mexate, Oncovin, Blemoxane, & Platinol
Partial Laryngectomy
 Limited to vocal cords
 Retains normal airway and phonation
 No difficulty swallowing
Supraglottic Larynegectomy Horizontial or vertical
 Extrinsic- preserves glottic valve inc pressure for coughing, lifting, and valsalve
 Normal voice and airway, may have temp trach
Hemilaryngectomy
 Tumor extends beyond vocal cords, <1cm
 Trach 10-14 d, voice rough, rasp. Cough
Total Laryngectomy
 Upper airway separated from pharynx and esophagus and permanent trach made
 May need some radical neck
 Done in stages for a laryngoplasty so patient can speak
Radical neck dissection
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radical: removal of all tissue under skin from ramus of jaw to clavicle, cervical lymph,
(sternocleidomastoid musc, int jug vein, and spinal access musc.)
Modified: preserves one or more of the nonlymph structures
May have reconstructive grafts with skin, muscle or bone
Larynx may be preserved
Nursing Interventions
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Pre-op
o
o
o
o
o
o
Post op
o
o
o
o
o
o
o
Eval breathing, swallowing, and nutritional status
Good oral hygiene
Emotional state and ways to communicate
NPO, check allergies
Elevate HOB, ck ability to swallow
Surg may last up to 8 hrs
VS q 2hrs unless unstable
Patent airway, swallowing, suction (yankauer)
May need vent support D/T smoking
Ck wound, hemorrhage, neck edema, lymph leakage, drains (80-120cc)
Watch for necrosis of skin flap
Laryngectomhy trach tube is shorter and larger in diameter
Avoid valsalva
Radical neck
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Post op
o
o
o
o
o
o
o
o
o
o
LISTEN FOR STRIDOR over trachea with stethoscope
SUPPORT HEAD, ELEVATE HOB, C& DB
If not trached have trach set in room, usually ET for 24hrs, humidified O2, use suction
Watch for FREQ. SWALLOWING- hemorrhage
Watch for NECROSIS OF SKIN FLAP
Drains: JP, 80-120cc 1st 24hrs
Good Nutrition: FT or TPN or soft or blenderized
Mouth care: no peroxide, use 8ox H2O with 1tsp baking soda (no oral temps)
Eating: laryngectomy- 7-10days at least, then remind to belch: neck- nerve damage-soft
food easier than liquids
Laryngectomy- tube removed in 8-10 wks
Patent Airway
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Semi fowlers
Watch for restlessness
Watch for opioids depress resp
Suction
Gauze dsg over stoma
Humidification
Complications
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resp distress
hemorrhage
pulm infection
salivary fistula
lymph of chylous fistula
facial edema and wound breakdown
Discharge teaching
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how to clear airway and clean stoma
care of laryngeal tube
good oral care to prevent halitosis and infection
use of humidification
use of cloth over stoma
cover stoma with shower and shaving
good nutrition, thicken liquids first
dec taste and smell, improves later
discuss ways to communicate and fear suffocation
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have recorded messages (police and Fire dept)
keep shoulders in norm position
do shoulder exercises, heat to shoulder
with radiation dec saliva
lie on unaffected side
do not lift more than 2#
medic alert tag
CPR mouth to stoma
Support groups and regular check ups