3007 wk 2 lec

Key points wk 1 lab

Hand Hygiene

• Before and after many different tasks, interactions etc.

Glove use

• When there is a risk of blood contact

• Avoid routine use where possible, unless risk is present

ANTT

Aseptic Non-Touch Technique

• Avoid touching KEY PARTS

  • even if sterile gloves are used

Maintenance of Aseptic Field

• Scrub key part for at least 15secs!

General use of sterile equipment and sterile technique

How to check patency of CVC line

1) Scrub the hub - 15secs

2) Let air dry

3) Follow ANTT

4) Aspirate 2 - 5mls to check that line is patent, and to ensure no drugs are left in the line

5) Remove syringe and discard

6) Flush using NS with pulsatile “start stop” motion

When you’re done, always remember to clamp at the end!

Considerations for pushing meds through CVC

• The line has a certain amount of mL → it is generally much longer than the avg. PIVC

• Therefore, the flush that you do after pushing a drug through HAS to go at the same rate (usually a line may be around 0.5mLs - so slow pushing around 2mLs will ensure the drug in the line is pushed into vascular system safely)

What happens if a CVC bung falls of or is removed?

#1 = check pt if they are stable

• Risk of air embolism

• Risk of infection

• Risk of blood loss through open lumen

→ Therefore, ensure clamping bung when not in use to protect against potential incidents like this!

Tunnel vs Non-tunnelled CVC

Tunnelled = Goes straight into vasculature

Non-tunnelled = Goes into and UNDERNEATH subcut tissue before entering the vascular space (often,

WEEK 2 RESPIRATORY FAILURE

Diffusion

Random movement of free molecules in solution

→ Often driven by concentration gradient (high conc to low conc to balance out)

• No energy req

Anatomy reminder

Normal gas exchange

Ventilation

• Diaphragm contracts

• Increasing total space inside chest cavity

• Pressure decreases within to be less than outside pressure

• Air passively enters the lungs

• Air slowly exhales as diaphragm slowly relaxes

Diffusion

• Blood diffuses in alveoli

• CO2 enters alveoli

• O2 is released from alveoli in exchange for CO2

Perfusion

• CO2 is released from organs and passed through blood stream to alveoli

• O2 is released from alveoli into blood stream for perfusion

Tidal Volume

Volume of each breath in mLs

How do we breathe? What is our respiratory control?

Central chemoreceptors

• In brain medulla

• Responds to alterations in CO2

  • Responding to pH changes

  • Increase H = acidic → higher RR and TV

  • Decrease H = basic → lower RR and TV

Peripheral chemoreceptors

• In Carotid and aortic bodies (neck / heart)

• Responds to low O2

2 Main breathing aspects

Oxygenation

• Delivery of oxygen to lungs → circulation → tissues

  • SpO2

  • Haemoglobin

  • Does not account for CO2 levels

Ventilation

• Process of inspiration and expiration

  • Air moving in and out of lungs

  • Removal of CO2 from body

Measures as minute ventilation = RR x TV

Visual of perfusion and gas exchange

• PCO2 is much lower in the environment

  • PCO2 is higher when it is being expired as the result of energy use from within our body (since CO2 is byproduct of energy production)

• Consider diffusion in this context!!

  • The body is seeking O2 initially, the CO2 is exchanged and released

  • Hence the highest O2 uptake at the beginning, then highest CO2 output on expiration

Conditions that influence Respiratory Failure

• General lung function

• O2 delivery

• Cardiac Output

• Baseline metabolic rate (e.g. fever? Sepsis?)

Acute resp failure

Sudden onset

→ Impaired gas exchange becoming life-threatening

Type 1 Respiratory Failure

Due to OXYGENATiON

• Failure to oxygenate

PaO2 < 60 - 70mmHg (less than SIX SEVENNN ty)

OR Decreased SaO2 / SpO2

Causes of T1RF

• Pneumonia

• Left HF

• Pulmonary oedema

• Acute Respiratory Distress Syndrome (ARDS)

Treatment of T1RF

1) Increase FiO2 (dial up O2 therapy)

2) Apply pressure to airway to adjust diffusion gradient for improved diffusion

Type 2 Respiratory Failure

Failure to remove CO2 from the body

• Hypercapnic

  • Failure to ventilate = insufficient removal

PaCO2 > 50 mmHg within the body (greater than FIFTY)

The issue here is that air is not moving!!

Causes of T2RF

• COPD

• Asthma

• CNS depression

• Trauma impacting ventilation

Treatment of T2RF

1) Increase minute ventilation ( = TV x RR)

2) Increase RR / Increase TV

Hypoxaemic RF

T1RF

1) Mismatch between ventilation and perfusion

• V / Q mismatch

→ Blood flow may be perfused, but is not ventilating

e.g. Sputum in alveoli preventing airflow from diffusing into bloodstream OR PE / blood clot preventing blood from perfusing well due to stagnation

2) Shunt

• Blood completely bypasses the lungs, and flows from the R) side heart → L) side heart

• No diffusion with alveoli, leaving blood poorly oxygenated

3) Diffusion limitation

• Oxygen has difficulty crossing into blood stream

  • Poor diffusion from alveoli into blood stream

4) Alveolar hypoventilation

• Inadequate ventilation

  • Alveoli not achieving enough air flow → decreased oxygen and increased CO2 levels (because poor inhalation and poor exhalation)

Hypercapnic RF

Imbalance between:

1) Ventilation supply

• Generally affected by airflow obstruction or trapping

  • e.g. Asthma, COPD (generally conditions that cause air to stop moving)

2) Ventilation demand

Amount of ventilation required to keep PaCO2 within normal limits

Assessing clinical deterioration

RR is a key indicator of a compensatory mechanism for malfunctioning physiological processes!!!

e.g.

RR > 27 is a key predictor for cardiac arrest in adults in hospital

Inspection

Auscultation

Palpation ?

Percussion (for signs of fluid overload or density)

CO2 monitoring

Measuring amount of CO2 exhaled

→ Want to ensure that CO2 levels are maintained within the body

PCO2 is what we use to measure this!!! (view image)

- Exhalation when there is a reading, inhalation when reading is minimal (because we don’t breathe in CO2 lol)

EVIDENT S&S of Hypoxaemia

1) SPo2 < 80%

2) Late cyanosis

• Dyspnoea

• Tachypnoea

• Drowsiness increasing

S&S of Hypercapnia

1) Dyspnoea

2) Tachypnoea with shallow breathing

• Decrease TV

• Decrease Minute Ventilation

Common O2 goals in critical care

PaO2 70 - 100mmHg

PaCO2 35 - 45mmHg

SPo2 92% - 96%

Range can be 88% - 92% for someone with Hx of chronic respiratory diseasse

NOTE: The more O2 we give (we can’t just automatically give 100% O2 → the higher risk of death). Therefore, we often lower the sats threshold in order to provide oxygen that is adequate enough to sustain living capacity

Main things to monitor in critically ill respiratory patients

• Mental status

• Ventilation rate

• SpO2

• ABGs (if available → this is pretty much a blood test but taken from an artery to measure O2, CO2, pH etc. from an oxygenated blood line)

  • Generally keep using this until PaO2 & PaCO2 returns to normal baseline

Non-invasive Positive Pressure ventilation

• HF nasal prongs

  • Pushing large amounts of air to keep lungs open

    • leads to lower levels of Positive End-Expiratory Pressure (PEEP)

    • → CONSIDER PEEP as pressure that exists in the air sacs after expiration! You don’t want too much because too much pressure is bad. Lower PEEP can be preferred in conditions where air trapping or over-pressure is the issue

    • Allows for improved oxygenation as more SA is present when air sacs are kept open

      • Prevents lung collapse

      • Reduces breathing effort

• Mask

  • Delivers large amounts of air when patient is breathing spontaneously (on their won)

Positive Pressure Ventilation because there is a positive pressure going into the lungs to maintain breathing

When should we not use PPV Mask?

1) NOT for patients with excessive secretions

2) Decreased LOC

3) High O2 requirements

4) Facial traumas (becuase how is the PPV going to work effectively)

What can Masks deliver?

CPAP

Constant Positive Airway Pressure

• PEEP

• Supports oxygenation

BiPAP

Bilevel Positive Airway Pressure

• Different pressure levels for inspiration and expiration (IPAP & EPAP)

• Supports oxygenation and ventilation

When to use non-invasive PPV

• Increased dyspnoea

• Severe tachypnoea (RR > 24)

• Increased WOB, use of accessory muscles

• Muscle / breathing fatigue

OR

PaCO2 > 45mmHg

PaO2 < 60 mmHg

Contraindications for Non-invasive PPV

• LOC → unable to breathe independently and on their own

  • would consider invasive in this instance

• Mask doesn’t fit appropriately (e.g. facial trauma)

• Hypotensive shock

  • Because increasing and forcing pressure into the lungs can cause great increases in thoracic pressure which can cause DECREASED BP because of the pressure

• Upper GI bleeding

  • Because it causes high risk for vomiting and increased GI distress

• Inability to protect or maintain airway

Poor toleration or ineffectivity of non-invasive PPV

What are things that can compromise airways?

FOOD!

Inflammation (e.g. tonsilitis)

Secretions

• Mucus

Consider tongoue positioning with LOC (because decreased LOC can cause the tongue to drop back and block the airway)

Nursing interventions for Airway compromise?

• Effective / assisted coughing

• Adequate hydration

• Airway suctioning

• Pt positioning (sitting them up)

Use of airway adjuncts in maintaining airway

1) Oropharyngeal Airway (OPA)

CONTRAINDICATIONS:

• Consciousness

  • Can cause gag reflex

• Oral trauma

• Intact gag reflex (can consider NPA if this is the case)

2) Nasopharyngeal Airway (NPA)

CONTRAINDICATIONS:

• Nasal trauma

• Basal skull #

3) Supraglottic airway

CONTRAINDICATIONS:

• Limited mouth opening

→ Often used for promptly secure airway TEMPORARILY

4) Endotracheal tube

CONTRAINDICATIONS:

• Facial trauma / bleeding

• Total airway obstruction (Consider Trachy in this instance)

5) Tracheostomy

Bag Valve Mask

Used a rapid intervention for increased conc of oxygen or to provide breathing (when a patient is failing to breathe on their own)

• It is often a short-term intervention used before intubation to

Airway adjuncts may be used to keep airway patent and allow O2 to flow in effectively

Provided at 12 - 15L/min

- Should see visible rise and fall of chest (5 - 7mL / kg in adults)

What to be aware of in BVM!

Hyperventilation!

Because BVM when used aggressively causes too high PEEP → leading to circulatory complications because the lungs are used to using negative pressure to breathe

• Forced Positive Pressure Ventilation can cause disruptions to the body’s normal mechanisms of breathing

Therefore, don’t just bag them TF up → bag them according to regular breathing as opposed to just constantly squeezing and releasing

Indications for INVASIVE Airway Support

Pretty much when non-invasive is contraindicated

e.g.

• No LOC

• Cardiac arrest

• Evident medical instability

Endotracheal Intubation

Rapid Sequence Intubation (RSI)

• Plan

• Prepare (drugs equipment, monitoring nec.)

• Protect cervical spine

• Positioning appropriate for intubation

• Pre-oxygenation

• Pre-treatment (e.g. sedation medications)

• Paralysis to ensure effective intubation placement

• Placement with proof!

• Post-intubation management (often to ICU)

Plan for Intubation

Observing the airway to measure the degree of difficulty to get tube through

• Class 1 - 4

• Grade 1 - 4

Higher grade = more difficult to intubate, smaller passageway

Endotracheal Tube Securement

• Take note of the number it is at when inserted (how deep it is in to track whether the tube is staying in place)

• Record the number of teeth a patient has

Confirmation of ETT placement

Confirmed with x ray

• Position should be 3 - 5cm above Carina (the upside down Y region just before it splits into the lungs)

  • Too high = risk of damaging vocal cords

  • Too low = risk of ONLY RIGHT LUNG intubation (leaving the left without oxygen)

Note that ETT can still slightly move internally

Risks of ETT

• Thirsty

• Risk of dental injury

• Difficulty with neck / head movement

• Impaired swallowing

Nursing management of ETT

• Ensure correct tube placement

  • Secure ETT

  • Maintain its placement and position

• Ensure cuff inflation (near the end of the tube to prevent air leaks and ensure that oxygen pushed through is going into the lungs, rather than shifting the ETT from its place)

  • Imagine pushing air through it → it can risk causing the ETT to go upwards because of air pressure

• Ongoing and cautious monitoring of oxygenation and ventilation

  • Understanding weaning plan and goals for care

• Comfort and active communication with patient - understanding this difficult and often frustrating experience

  • Pain management

  • 1:1 nursing care

• Regular oral hygiene care

Things to note in ETT care

GCS for verbal would be 1T = Tube

Is a pt is paralysed as a means for intubation, motor is measured as NT (not testable)

When will we use a tracheostomy?

1) Example: Imagine major trauma to face and jaw → meaning intubating would be inappropriate

• A hole would then need to be cut to bypass this issue (it also goes by the vocal cords)

2) For improved secretion removal in the mouth

3) If prolonged ventilation is required

• You simply wouldn’t have an ETT in place for extended durations because it risks damaging the vocal cords

Benefits of Trachy

• Decreased WOB and airway resistance

• Easier, safer access to mouth

• Improved oral hygiene

• More comfortable for patient

Nursing tracheostomy care

• Be very careful with new trachys (< 7 days)

• Check security ties, placement, positioning

  • 2 person procedure

• Maintain cuff pressure

• Maintain patency

• Clean stoma (the hole in their windpipe)

• Emotional support and comfort