critical care unit 5

8/8/2019 Critical Care Unit 5

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Critical Care NursingA Holistic Approach

Part 5

Critical Care NursingA Holistic Approach

Part 5


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Anatomy and Physiology of theRespiratory System

Anatomy and Physiology of theRespiratory System

Chapter 23


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Copyright 2005 Lippincott Williams & Wilkins. Instruc tor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.

ThoraxThorax

Thoracic cage

Ridged and flexible; protects organs

Muscles of ventilation

Diaphragm, external/internal intercostal muscles

Lungs

Pleural space

Parietal pleura, visceral pleura Mediastinum

Contains the heart, esophagus, vessels, thymus


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AirwaysAirways

Nasopharynx warms, filters, and moisturizes

Oropharynx

Trachea passageway, smooth muscle, cricoid cartilage

Bronchi right, left, carina (neuronal tissue)

Bronchioles

Terminal bronchioles

Alveoli gas exchange


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Pulmonary CirculationPulmonary Circulation

Deoxygenated blood from right ventricle

Pulmonary artery arteriole

Capillaries

Wrap around every alveoli

Thin-walled for efficient gas exchange

Venules

Pulmonary vein Left atrium


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Process of VentilationProcess of Ventilation

Movement of the diaphragm

Changes in the transpulmonary pressure

Lung compliance

Airway resistance


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Balance of Ventilation to PerfusionBalance of Ventilation to Perfusion

Alveolar dead space

Collapsed alveoli from pneumonia or atelectasis

Shunting

Anatomical

Blood moves from the right side to left side of theheart without being oxygenated

Physiological

Blood moved by alveoli without picking up oxygen


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VQ MismatchVQ Mismatch

Physiological shunt

Low ventilationperfusion ratio

Alveolar dead space

High ventilationperfusion ratio

Silent unit

Both ventilation and perfusion are decreased


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Patient Assessment:Respiratory SystemPatient Assessment:Respiratory System

Chapter 24


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HistoryHistory

Dyspnea

Chest pain

Sputum production Cough

Past history

Family history

Personal and social history


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InspectionInspection

Respiratory rate, depth, and pattern of respiration

Labored breathing, use of accessory muscles

Cyanosis of skin

A/P diameter of chest, and patient posture

Chest expansion

Chest deformities or scars

IE ratio

Clubbing of the fingers


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PalpationPalpation

Tactile fremitus

Subcutaneous emphysema Thoracic expansion

Trachea


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PercussionPercussion

Audible vibrations

Tactile vibrations


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AuscultationAuscultation

Tracheal breath sounds

Over trachea, loud and harsh

Bronchial breath sounds

Over large airways they are normal; anywhere else theyare not normal

Bronchovesicular breath sounds

Medium in pitch; heard over bronchioles

Vesicular breath sounds

Heard over distal airway; quiet, low pitched


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Pulse OximetryPulse Oximetry

Reflects the arterial oxygensaturation of hemoglobin

Saturations of 93% to 99% arenormal

Not reliable in patients

Using vasoconstrictingmeds

With knowndyshemoglobins(carboxyhemoglobin ormethemoglobin)

In shock, cardiac arrest

With severe anemia


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Arterial Blood GasesArterial Blood Gases

pH: 7.357.45

PaO2: 80100 mm Hg

PaCO2: 3545 mm Hg

HCO3: 2226 mm Hg

SaO2: 9399%


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AcidBase BalanceAcidBase Balance

Respiratory acidosis

Respiratory alkalosis

Metabolic acidosis

Metabolic alkalosis


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Patient Management:Respiratory System

Patient Management:Respiratory System

Chapter 25


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Pulmonary ToiletPulmonary Toilet

Cough and deep breathing

Chest physiotherapy

Positioning

Good lung down

Postural drainage

Percussion or vibration


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Oxygen Delivery SystemsOxygen Delivery Systems

Nasal cannula

For children, blow-by

Simple face mask

Venturi mask

Face tent

Non-rebreather mask


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Artificial AirwaysArtificial Airways

Nasopharyngeal / Oropharyngeal

Size by placing device from ear lobe to corner of mouth

Endotracheal tube

Uncuffed tubes for children younger than 10 years of age

Laryngomask airway (LMA)

Sizes 1,2,3,4, and 5

Sizes 3 and 4 for most of the population

Tracheostomies


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Chest TubesChest Tubes

Remove air and fluid fromthe pleural space

Re-expand a collapsed lung

Restore negative pressure tothe pleural space


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Reasons for a Chest TubeReasons for a Chest Tube

Hemothorax

Pneumothorax

Tension pneumothorax or hemothorax

Fistula


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PharmacologicalInterventionsPharmacologicalInterventions

Bronchodilators

Anti-inflammatory agents

Antibiotics Sedative agents


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50/50 Rule of Respiratory Failure50/50 Rule of Respiratory Failure

pH less than 7.25

PaCO2 greater than 50 mm Hg

PaO2 less than 50 mm Hg


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Mechanical VentilatorsMechanical Ventilators

Negativepressureventilator

Positivepressureventilator

Pressure ventilator

High-frequency ventilator


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Modes of VentilationModes of Ventilation

Assist-control

Synchronized intermittent mandatory ventilation (SIMV)

Pressure-support

Pressure-controlled ventilation

Volume-guaranteed pressure option

Continuous positive airway pressure (CPAP)

Positive end-expiratory pressure (PEEP)


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Ventilator SettingsVentilator Settings

FiO2

Respiratory rate

Tidal volume

Peak flow

Pressure limit

PEEP

Sensitivity


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ComplicationsComplications

Aspiration

Barotrauma

Ventilatorassociated Pneumonia (VAP)

Decreased cardiac output


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Common Respiratory DisordersCommon Respiratory Disorders

Chapter 26


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PneumoniaPneumonia

Community-acquired pneumonia

Hospital-acquired pneumonia

Bacteria

Viruses

Mycoplasma

Fungi

Chemical


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Pneumonia

is an inflammatory response

to the uncontrolledmultiplication of

microorganisms invading the

lower respiratory tract.


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PneumoniaPneumonia

Studies

CXR, sputum culture, bronchoalveolar lavage

Management

Antibiotics, oxygen, pulmonary toilet

Supportive care

Nutrition, hydration, rest

Prevention

Pneumococcal and influenza vaccines


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PleuralE

ffusionPleuralEffusion

Accumulation of pleural fluid secondary to increased fluidformation

Increased capillary permeability

Deceased colloid osmotic pressure of the blood

Increased intrapleural negative pressure

Impaired lymphatic drainage

Increased pressure in the capillaries or lymphatics


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Assessment of Pleural FluidAssessment of Pleural Fluid H/P finding

Shortness of breath, chest pain

Tachypnea, hypoxemia, pleural rub Diagnostic studies

CXR lateral decubitus

Thoracentesis


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PneumothoraxPneumothorax

Sudden onset of pleuritic chest pain

Dyspnea, shortness of breath, increased work ofbreathing

Diagnostic test

CXR

Management

Oxygen Possible placement of chest tube


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PulmonaryE

mbolismPulmonaryE

mbolism Part of a deep vein thrombosis that has traveled and

lodged in the pulmonary arteries

Severity depends on the extent of occlusion

Mismatch of ventilation and perfusion

Testing

VQ scan or a pulmonary angiogram

Management

Anticoagulation


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COPDCOPD

History

Exposure to risk factors, comorbidities, currentmedical treatment (beta blockers)

Tests

Spirometry, ABGs

Management

Oxygen, education, drug therapy, nutrition, exercise,surgical intervention


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AsthmaAsthma

A chronic inflammatory disease of the airways

Airway hyperresponsiveness

Variable airway obstruction

Resolves spontaneously or after using a bronchodilator


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AsthmaAsthma

Testing

Spirometry

Pulmonary function testing

Management

Education, prevent exacerbation, optimizepharmacotherapy


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Acute Respiratory FailureAcute Respiratory Failure

A sudden and lifethreatening deterioration in gasexchange

Type I Acute hypoxemic respiratory failure

Type II - Acute hypercapnic respiratory failure

Type III Combined hypoxemic and hypercapnic failure


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Acute Respiratory FailureAcute Respiratory Failure

Tests

ABGs, CXR, PFTs, CT, thoracentesis

Management

Correction of gases, oxygen therapy

Reversal of any narcotics

Possible mechanical ventilation


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Acute Respiratory DistressSyndrome

Acute Respiratory DistressSyndrome

Chapter 27


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ARDSARDS

Complex clinical syndrome

Acute hypoxic injury

Caused by direct or indirect pulmonary injury

Direct injury - aspiration, pulmonary infection, neardrowning, thoracic trauma or toxic inhalation

Indirect injury shock, sepsis, hypothermia, DIC,multiple transfusion eclampsia, pancreatitis, burns


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Phases of ARDSPhases of ARDS


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Diagnostic StudiesDiagnostic Studies

Blood cultures

Bronchoalveolar lavage detection of interleukin-1 andtumor necrosis factor-E

Blood gas

CXR

Lung compliance, airway resistance, and pressure


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