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A. Normal ABGs
a. pH 7.35-7.45
PaCO2 35-45
>95% Base exc. +- 2.0
Bicarb 22-26
i. Tube is placed into the trachea via the mouth or nose past the
larynx with the help of a laryngoscope or bronchoscope. Placed
in at bedside
ii. A nasal ET intubation is placed in blindly through nose,
nasopharynx, and vocal cords. This is rarely done but needed if
neck and head movement is risky
1. Contraindication in pts. w/ facial fractures or suspected
fracture of skull. WOB is greater, suction and secretion
removal are difficult, and linked to increase of infection
and ventilator-associated pneumonia
iii. Indications:
1. Upper airway obstruction, apnea, high risk of aspiration,
ineffective clearance of secretions, respiratory distress
iv. Risks:
1. If head and neck mobility is limited, teeth chipped or
accidently removed, swallowing is difficult, increased
salivation,
2. Mouth care may be a challenge due to the tube
a. Use a smaller or pediatric-sized oral products for
suctioning, brushing, cleaning
3. Can become obstruct from pt. biting on tube
a. sedation and bit block is used to prevent this
v. the procedure
1. will need consent before performing, unless emergency
2. inform them how it will happen and that they wont be
able to speak
3. keep ambu bag available, suction, and IV access
4. premedicate the pt. for pain and anxiety
a. Rapid-sequence intubation (RSI)is administration of
both a sedative and paralytic agent for
emergencies.
1. A sedative-hypnotic-amnesic
(Midazolam[Versed}, etomidate
[Amidate]) is used for unconsciousness,
along w/ an opioid (fentanyl) for pain.
Paralytic (succinylcholine [Anectine]) for
muscle relaxer
5. Monitor the pts O2 during procedure and place the pt. in
supine w/ head extended and neck flexed (sniffing
position)
a. Unplanned Extubation: pt. talking, activation of lowpressure ventilator alarm, diminished or absent
breath sounds, resp. distress, gastric distention
1. soft mittens or restraints may be necessary
or sedation
b. Aspiration: prevent vomiting, NG tube on suction,
enteral feeding and keep HOB elevated at mi of 3045o
6. Provide oral care and skin integrity pg. 1617 table 66-9
7. Foster comfort and communication
a. Morphine, lorazepam, proprofol, or other sedatives
to help w/ anxiety
8. Drug therapy
a. Opioid Narcotics
1. Morphine or Fentanyl:
1. Monitor for resp. depression, ortho
hypotension, sedation ,constipation,
urinary retention, N/V
2. Toxicity can be reversed w/ Narcan
b. Muscle relaxants:
1. Succinylcholine [Anectine] is drug of
choice
1. AE: prolonged apnea due to toxicity,
malignant hyperthermia, hyperkalemia
b. Tacheostomy
i. Tube is placed into the trachea via stoma in the neck. Surgical
procedure that is performed when the need for an artificial
airway is expected to be long term
ii. Early tracheostomy (2-10 days) may have advantages over
delayed, especially when ventilation may be needed for longer
than 10-14 days.
c. Mechanical ventilation
i. Process by which FIO2 (21% room air) is moved in and out of the
lungs by a mechanical ventilator
1. It is not curative and it just a means of supporting pt until
recover.
ii. Indications: apnea, inability to breathe, acute respiratory failure,
severe hypoxia, respiratory muscle fatigue
iii. Types:
1. Negative pressure vent:
a. Involves the use of chambers that encase the chest
or body and surround it w/ intermittent
subatmospheric pressure. Expiration is passive and
is a noninvasive ventilation (does not require
artificial airway)
2. Positive pressure vent:
a. During inspiration, vent pushes air into the lungs
and expiration is passive.
b. Two different modes:
1.
C. Chest Tubes
a. Chest tube may be put in place if caused by pneumothorax or collapse
of lungs occur
i. Insertion & removal
a. Insertion: Can be put in place in ED, at pt.s bedside, or in
operating room. Pt. is positioned with arm raised on
affected side and HOB at 30-60 degrees. Chest x-ray is to
confirm placement. Occlusive dressing is used to cover
but some physician prefer petroleum gauze
2. Removal: suction is discontinued and chest drain is on
gravity draining for 24hrs before removal. Give pain meds
before removal. Tube removed by physician. Pt will hold
breath, then tube is removed. Site is immediately coved
w/ sterile dressing. Chest x-ray is performed to evaluate
pneumothorax.
ii. Whenever fluid or air accumulates in the pleural space, the
pressure becomes positive instead of negative causing the lung
to collapse. Chest tubes are put in place to relieve pressure.
a. Large are used to drain blood, Med to drain fluid, small to
drain air
b. Chest tubes are painful so monitor comfort measures
c. Flutter or Heimlick Valve is used to evacuate air from the
pleural space. The device consist of a one-way rubber
valve w/I a rigid plastic tube. It is very small and portable.
Patient is able to move w/ this device
iii. Drainage may also be put in pleural space to reestablish
negative pressure
d.
e.
f.
g.
h.
E. Cystic Fibrosis
a. Definition
i. Autosomal recessive, multisystem disease in which sodium and
chloride ions are not properly being transported in and out of
epithelial cells.
1. Primarily affects the lungs, GI(pancreas and biliary tract),
and reproductive tract.
b. Patho
i. Is autosomal recessive and located on chromosome 7 as cystic
fibrosis treansmembrane regulator (CFTR) being the protein .
ii. Sodium chloride content line the passageways making mucus
abnormally thick and sticky. This can lead to plugging of glands
and eventual organ failure
iii. Progresses from being a disease of the small airway, to
involvement of the larger airways. Characterized by chronic
airways infection: bronchiolitis, bronchitis, bronchiectasis, blebs,
large cyst, hemoptysis
iv. Secrete normal volumes of seat, but unable to absorb sodium
chloride from seat as it moves through sweat ducts, so they
excrete four times the normal amount of sodium an d chloride in
their sweat.
v. Pancreatic insufficiency occurs due to mucus plugging the
pancreatic duct
1. CFRD occurs because fibrotic scarring of pancreas
c. Complication
i. CFRD(cystic fibrosis related diabetes), bone disease, sinus
disease, liver disease, pneumothorax, hemoptysis, digital
clubbing, cor pulmonale, respiratory failure
d. S&S
i. Wheezing, frequent coughing, failure to thrive, malnutrition,
steatorrhea. Productive cough with purulent or yellow/green
sputum, Delayed puberty, frequent lung infections, failure to
thrive
ii. Skin will taste salty when kissing child, mouth will also be dry
iii. Abnormally thick secretions and mucus. Decreased cilia motility,
hyperinflation of lungs, organ failure, bronchitis or bronchiolitis
are typical occurrences found
iv. Upper respiratory: chronic sinusitis and nasal polyposis
ii.
iii.
iv.
v.
vi.
F. Pulmonary Emboli
1. Definition:
i. Blockage of pulmonary arteries by a thrombus, fat or air embolus,
or tumor tissue
b. Etiology:
i. 10% of pt. die w/I the first hour and 30% die from recurrent
embolism.
i. 90% of PE arise from DVT in legs. May also be from Right heart (A
fib), upper extremities, and pelvic veins (surgery and childbirth)
c. Risks factors
i. DVTS, Immobilization, surgery, stroke, malignancy, cigarette
smoking, hypertension, oral contraceptives, heart failure,
pregnancy, clotting disorders
d. Complications
i. Pulmonary infarction (Death of lung tissue) which eventually
becomes infected, and an abscess may develop.
1. Occurs when occlusion of large/medium pulmonary vessel
2. Insufficient collateral blood flow
3. Preexisting lung disease
ii. Pulmonary hypertension does not occur unless massive PE.
Recurrent emboli may cause chronic pulmonary hypertension
e. S&S
i. Symptoms may begin slowly or suddenly
i. Dyspnea is most common symptom. Mild to moderate
hypoxemia w/ low PaCO2 is common
ii. Tachypnea, cough, chest pain, hemoptysis, crackles, wheezing,
fever, accentuation of pulmonic heart sound, tachycardia,
sudden change in mental status, petechial rash
iii. Massive emboli= low BP & shock.
Small emboli= undetected
& vague symp
f. Diagnostic studies
i. Spiral/ Helical CT scan is the most frequently used to test for PE
1. If pt. is allergic to contrast they can have a ventilationperfusion (V/Q) scan. Most accurate when these are
performed:
a. Perfusion scanning: IV injection radioisotope
b. Ventilation scanning: radioactive gas is inhaled
ii. Pulmonary angiography is most sensitive and specific test but it
is expensive and invasive.
1. Insertion of catheter into artery and contrast in injected
iii. D-dimer measure the amount of cross-linked fibrin fragment but
it is neither specific nor sensitive.
1. Abnormal: greater than 250 mcg/L
iv. Troponin: identifies right heart overload.
v. ABG analysis is important but it is not diagnostic
1. PaO2 is low, pH remains normal unless respiratory
alkalosis occurs
f. Treatment
i. Infertio vena cava filter is treatment of choice in pt. who remain
at high risk and antigcoagulation is contraindication.
1. Device is percutaneously placed at level of diaphragm and
prevent migration of large clots.
ii. Prevention with anticoagulants
ii. Pulmonary embolectomy:
1. used for pts. That are hemodynamically unstable and
contraindication for fibrinolytic therapy. Typically has high
mortality rate so last case scenario
g. Interventions
i. Key is prevention of DVT by applying sequential compression
devices, early ambulation, and anticoagulants
1. (Lovenox) is drug of choice over heparin
2. Warfarin(Coumadin) should be initiated w/I first 3 days
after heparin use and continue taking for 3-6 mo
ii. Monitor INR levels (warfarin) and aPTT(heparin)
1. Monitor green leafy vegetable intake due to vitamin K can
affect warfarin intake
iii. Objective is to prevent further growth or multiplication of thrombi
in lower extremities, prevent embolization form upper or lower
extremities, provide cardiopulmonary support if indicated
iv. Once pt. has developed a PE keep them on bed rest and in semiFowlers
v. Oxygen provided via mask or cannula
vi. Encourage turning, coughing, deep breathing, and using
incentive spirometer
vii. Diuretics may be prescribed if heart failure occurs
viii. IV fluids are admitted if manifestations of shock begins followed
by vasopressor agents