Adult Health Nursing II Block 7.0

Adult Health Nursing IIBlock 7.0

…a concept map…

Block 7.0 Module 4.1

Nursing careplanning

Chest TubesPlaced to drain air & blood from pleural space, restore negative intrapleural pressure & re-expansion of lungNursing 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.


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 Block 7.0 Module 4.1


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


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)


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

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



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


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 re-expansion


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

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 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 free-flowing drainage >70ml/hour



Care of Chest tube and CDU Tubing: Avoid loops, aggressive manipulation

such as “stripping” or “milking”

Patency: To maintain patency, try “gentle” hand-over-hand squeezing of tubing and release

Clamping: Avoid except when replacing CDU, locating air leak, or assessing when tube will be removed


Removing the Chest TubeChest 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


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

Medical Management with Chest Tube


Acute Respiratory FailureNot 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


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


Ventilatory and Oxygenation FailureVentilatory 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.


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


S/Sx of Acute Respiratory FailureEarly:– Dyspnea– Restlessness– Fatigue– Headache– Air hunger– Tachycardia– Increased blood

pressure– Decreased breath

sounds– Use of accessory

muscles

Later:– Confusion– Lethargy– Tachypnea– Central cyanosis– Diaphoresis– Respiratory arrest


Interventions for ARF

O2 w/pt in high-Fowler’s positionMeds:– 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


Nursing InterventionsAssess/monitor: ABG, SaO2 , VS, respiratory status, neuro statusEstablish & maintain airwaySuction if neededAvoid meds that depress respirationsTurn, cough, deep breath Prepare for mechanical vent if worsensProvide emotional support to pt/family


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.


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 multiple-system organ failure, often with sepsis


Risk Factors for ARDS2 most common causes are:

Gram-negative septic shockAspiration of gastric contents (pH 2-4)

Other causes:Pneumonia Fat embolusTrauma Drug overdoseNear drowning Cardiopulmonary bypass


“Ground glass” CXR of ARDS


S/sx of ARDS

Early: (12-48h)CoughRestlessnessProgressive dyspneaTachypneaFine scattered cracklesBilat infiltrates on CXR

Progression to late s/sx:Labored dyspneaConfusionDiffuse cracklesTachycardiaHypotensionCyanosis, pallorProfound respiratory

distress w/ET intubation


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 failureInsertion of pulmonary artery cath (Swan-Ganz) to monitor pulmonary artery wedge pressure & cardiac outputElectrolytes, hemoglobin, hematocrit


Drug Therapy for ARDS

#1 intervention: OxygenIV antibiotics if organism identifiedCorticosteroids to decrease inflammation, edemaSedatives, antibiotics, diuretics, inotropics, H2 blockers/PPIsMany investigational drugs – none has been effective in reducing mortality


Other Interventions for ARDS

Identify & treat underlying conditionIntubation & mechanical vent w/PEEP (goal: PaO2 >60mmHg, SaO2 >90)IV fluids for hydration & hypovolemiaNutritional support via G tube or TPN (35-45 kcal/kg per day)


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 results


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


Mechanical Ventilationhttp://www.youtube.com/watch?v=LbMxTk45PTs

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


http://www.youtube.com/watch?v=LbMxTk45PTs

http://www.youtube.com/watch?v=LbMxTk45PTs

Types of Ventilators

Types of ventilators:–Negative-pressure ventilators–Positive-pressure ventilators: used

in acute care settingsPressure-cycled ventilatorsTime-cycled ventilatorsVolume-cycled ventilatorsMicroprocessor ventilators


Negative Pressure Ventilator

Iron Lung -- Then Iron Lung -- NowBlock 7.0 Module 4.1

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.)


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


ET Tube Placement


Endotracheal Intubation ET tube passed through mouth or nose into tracheaUsually temporary for life support (<3 wks)Provides airway for pts who cannot maintain one on their own, for mechanical vent, & for suctioning lungsMost often used for hypoxemia & progressive alveolar hypoventilationMechanical ventilation may be lifelong in persons with chronic, progressive neuromuscular diseases that reduce effective ventilation (muscular dystrophy, multiple sclerosis, etc.)Parts of ET tube


Nursing Responsibilities for Endotrachial Intubation

Verify tube placement: X-ray, assess bilat BS, stomach distention, end-tidal CO2Stabilize the tube do not secure to lower jaw d/t to possible movement of jaw & dislodgement of ET tube


Why Patient May Need Mechanical Vent

ARDSCOPDThoracic/abdominal surgeryNeuromuscular disordersInhalation injuryStatus asthmaticusDrug overdose

Acute resp failurePulmonary edemaPulmonary embolusPneumoniaMultiple traumaShockMultisystem failureComa


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/HgInspiratory/expiratory ratio: The duration of each: ratio usually set for 1:2 to 1:1.5.Flow rate: speed of tidal volume usually 40L/minPressure limit: The maximum pressure a ventilator delivers to achieve tidal volume.


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 ResponsibilitiesMaintain cuff pressure 20-25mmHgMonitor for tracheal bleeding, ischemia, necrosis d/t continuous cuff pressureMonitor nutrition status – Labs, tube feeding and/or TPN protocols– Daily weights – Hydration status– H2 blockers

Infection monitoring: vital signs– Culture results


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.


“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.


Possible ComplicationsVentilator-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).


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.


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.


Weaning & ExtubationReadiness 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!


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.


Four Methods of Weaning1. T-piece

2. Synchronized intermittent mandatory ventilation (SIMV)

3. Pressure support ventilation (PSV)

4. Continuous positive airway pressure (CPAP)


Methods of Weaning (con’t.)

T-pieceOften 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.



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 breathingBlock 7.0 Module 4.1


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.


Signs of Weaning IntoleranceDecreased LOCSystolic BP >180 mm Hg (or increase of 20% or more) or diastolic BP >100 mm HgHeart rate >120 beats/minute (or increase of 20% or more)

Respiratory rate >30 breaths/minute (or changing 50% or more)SpO2 <90%Signs of increased work of breathing--dyspnea, accessory muscles useDiaphoresisFatigue or pain


finisThis concludes the Respiratory Nursing Presentations


Adult Health Nursing II Block 7.0

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