NCMB418-PRELIM-REVIEWER-2023-2024 UPDATE, Exams of Nursing

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CRITICAL CARE NURSING CONCEPTS

WEEK 1: SCOPE OF CRITICAL CARE NURSING

• According to the AACCN (2019), the assessment of critically ill patients and their families is an essential competency for critical care practitioners. Information obtained from assessment identifies the immediate and future needs of the patient and family so a plan of care can be initiated to address or resolve these problems.
• Critical  Crucial – Crisis – Emergency – Serious
• Critical Care Nursing  Care of the seriously-ill clients from point of injury/illness until discharge from intensive care  Deals with human responses to life-threatening problems  Comprehensive, specialized, and individualized nursing services which are rendered to patients with life-threatening conditions
• Critical Care Nurse Task  Care for clients who are very ill  Provide one-to-one care  Responsible of making life and death decision  At risk of injury and illness  Communication Skill is of optimum importance  At risk for actual or potential life-threatening health problems
• Critically-ill Client  Require more intensive and careful nursing care  At risk for actual or potential life-threatening health problems  Examples: o Post-operative clients with major surgery o Illness involving vital organs o Stable clients with signs of impending doom
• Classification of Critical Care Clients  Level 0 : Normal Ward Care  Level I : At risk of deteriorating, support from critical care team  Level II : Needs more observation or intervention, single failing organ or post-operative care  Level III : Advanced respiratory support or basic respiratory support, Multi-system failure
• Principles of Critical Care  Continuous monitoring and treatment  High intensity therapies  Expert surveillance and efficiency  Alert to early manifestations and recognition of parameters denoting progress and deterioration - There are different approaches in assessing patients, most often, the head to toe approach is used. System approach may also be used. In assessing critically ill patients, it usually starts when the nurse becomes aware of the pending admission of the patient and continuous until transitioning to the next phase of care. - Roles of Critical Care Nurse  Care provider  Educator  Manager  Advocate - Goals of Critical Care  Towards the survival of the critically-ill patients and restoring quality of life  Helping families of critically-ill patients in coping with stress - Common Critical Care Unit Equipment’s  Cardiac Monitor  Pulse oximeter  Swanz-Ganz Catheter  Arterial lines  Central venous catheter  Nasograstic Tube  Chest tubes  Endotracheal tubes  Urinary catheters  Tracheostomy  Ventilator CODE MEANING IN HOSPITAL - Code Black  Bomb threat - Code Blue  A respirator has stopped working, someone’s heart has stopped or they are no longer breathing - Code Red  There is a fire somewhere in the building - Code Silver  A person with a weapon - Code  A situation caused by someone’s violent or aggressive behavior PATIENT MONITORING EQUIPMENTS - Acute care physiologic monitoring - Pulse oximeter - Intracranial pressure monitor - Apnea monitor

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LIFE SUPPORT AND RESUSCITATIVE EQUIPMENTS

• Ventilatory
• Infusion pump
• Crash cart
• Intraaortic balloon pump DIAGNOSTIC EQUIPMENTS
• Mobile X-Rays
• Portable clinical laboratory devices
• Blood analyzer EMERGENCY CRASH CART
• The EMERGENCY CRASH CART, more commonly known as “Crash Cart” or “E Cart”, “Code Cart” or “Crash Trolley” is a wheeled cabinet or chest of drawers which contains all of the equipment necessary for emergency resuscitation.
• Stocks are routinely checked and audited to ensure that stocks are usable and those that are about to expire are replaced with new ones.
• A standard E-cart is secured with a metal lock and most often with serial numbers to restrict access to high alert drugs contained inside
• Purposes:
  1. Provides immediate access to supplies and medications.
  2. Facilitates coordination of emergency equipment.
  3. Facilitate staff familiarity with equipment
  4. Helps ensure a properly stocked emergency cart is readily available
  5. Ensures a properly functioning defibrillator will be readily available.
  6. Helps save valuable time during emergency

Drawer 5: Cardiac, Chest Procedures ECG electrodes, Restraints, Sterile gloves, Masks with face shields or masks and eye protection, Scalpels with blades, Dressings, drain sponge, Betadine solution, Sutures, silk with needle, Cardiac needle, Sterile towels,3 - lumen Central Venous Pressure catheter, Chest tubes….etc

Drawer 5: Bottom of crash cart Plastic apron, Intubation tray, Intubation pillow, ICD (Implantable cardioverter) set, Percutaneous tracheostomy set Commonly on the top of the Crash Cart: Defibrillator, Inventory Checklist/ Code Blue sheets. On the side of the Crash Cart: Oxygen Cylinder

DRAWER 1 – MEDICATIONS

TYPES OF CART ARRANGEMENTS

Based on Airway, Breathing and Circulation

Based on the Need and Necessity Drawer 1: Medications Drawer 1: Medicines Classified based on the priority and a Cardiac Board Drawer 2: Breathing and Airway Ambu bag, O2 Nasal cannulae, Oral airways, Intubation tray, suction catheters, Inner cannulae, Endotracheal tubes,Tracheostomy,….etc

Drawer 2: Equipments Ryle’s tube (NGT), Macro set & micro set, Blood set, I.V splint, Micro pore, Gloves, Kidney tray, ECG electrodes & jelly, Tourniquets & spirit swab Drawer 3: Circulation IV supplies, 3-Way, Blood set, ABG kits, heparinized aspirators, Needles, Alcohol swabs, Syringes….etc

Drawer 3: IV fluids NS 9% 500 ml, NS 9% 100 ml, Isolyte P

Drawer 4: Circulation IV solutions and tubing- LR, NS, D5W, IV Tubing, Macro & Micro drip, Extension tubing, Blood pump tubing, Arm boards: long & short…etc

Drawer 4: Open tray on the top Disposable syringes, Extension no.10cm, 200cm, IV cannulae, Needles, Intra osseous needle, Defibrillator

ADULT EMERGENCY DRUGS

(BASED ON ACLS GUIDELINES)

Adenosine Antiarrhythmic Amiodarone Antiarrhythmic Atropine Agent used for symptomatic bradycardia Dextrose Anti-hypoglycemic Diazepam To relieve anxiety, muscle spasms, and seizures and to control agitation Dobutamine Vasopressor Dopamine Vasopressor Epinephrine Adrenergic agent of choice for cardiac arrest Etomidate Induction of rapid hypnosis (non- barbiturate)prior or during intubation Flumazenil Antidote for benzodiazepine Lidocaine Antiarrhythmic Magnesium In cardiac arrest if due to hypomagnesemia Midazolam Sedative Naloxone Antidote for opiate narcotics Nitroglycerin Nitrates; to prevent chest pain Norepinephrine Vasopressor Pancuronium Paralytic agent Procainamide Antiarrhythmic

DRAWER 5 – CIRCULATION: IV SOLUTIONS

AND TUBINGS

10. Sterile towels
11. Petroleum gauze
12. Cutdown tray
13. 3 – Lumen CVP Catheter Kit
14. Chest tubes (1 each: 28 FR, 32 FR)

• Contents:

1. AMBU Bag
2. O2 Nasal Cannula
3. O2 Flow meter with adapter
4. Oral airways (1 pc each: 10mm, 9mm, 8mm)
5. Intubation trays (Laryngoscope handle: Straight and curved blades; 10 cc syringe; lubricant)
6. Stylet
7. C Cell batteries (2 pcs)
8. Laryngoscope light bulbs (2 pcs)
9. Padded tongue blades (2 pcs)
10. 1-inch Adhesive tape (1 roll) / ET holder
11. Skin prep wipes or benzoin
12. Exam gloves (2 pcs)
13. Suction catheters (2 pcs each: French 14, 16)
14. Lubricant
15. Straight connector
16. 10 cc Syringes
17. Endotracheal tubes (2 pcs each: 6.0, 7.0, 7.5, 8.0, 8.5, 9.0)
18. Tracheostomy tubes (Size # 4, # 6, # 8)
19. Inner cannulas (size # 4, # 6, # 8)
20. 1 pc End-tidal CO2 detector **DRAWER 3 – CIRCULATION CARDIAC, CHEST PROCEDURE

• Contents:**

1. 6pcs EKG electrodes
2. Arm restraints
3. Sterile gloves (2 pairs each size: 6, 7, 8)
4. 2pcs Masks with face shields or masks and eye protection
5. Scalpels with blades
6. Dressings: 4X4 10 packs
7. Betadine solution
8. Sutures (2 each: 000 Silk with needle; 0 Silk needle
9. Cardiac needle 20G

• Contents:

1. Angiocaths (2 each: 14G, 16G, 18G, 20G, 22G)
2. 2 pcs 3-WAY Stopcocks
3. Blood tubes (3 pcs Serum Separating tubes; 1 Light blue; 1 lavender)
4. 10 cc vials Sterile Water (3 pcs)
5. ABG Kits (2 sets); Heparinized aspirators (2pcs)
6. Disposable needles (6 pcs each of 18G, 20G, 22G, 25G)
7. Alcohol swabs
8. Micropore tape and Leucoplast tape
9. IV Cannula (2 rach of 21G, 23G)
10. I.V. Start kits (2 sets)
11. Disposable syringes (2pcs tuberculine; 6pcs - 3cc, 6pcs - 5cc, 6pcs – 10cc, 2pcs - 20cc, 1pc - 50cc)

• Contents: 1. IV Solutions o 1 Lactated Ringers 1-liter bottle o 2 Normal Saline 1-liter bottle o 2 Normal Saline 250 cc bottle o 2 D5W 500cc o 2 D5W 250cc 2. IV Tubings o 2 Macrodrip tubing o 3 Microdrip tubing o 2 Extension tubing o 1 Buretrol/Soluset o 1 Filter set/Blood tubing 3. IV Splint/Armboards o (1 Long; 1 Short)

Sodium Bicarbonate

Alkalinizer used in metabolic acidosis Succinylcholine Muscle relaxant Vasopressin Antidiuretic hormone, vasoconstrictor Verapamil Calcium channel blocker DRAWER 2 – AIRWAY/BREATHING SUPPLIES

DRAWER 4 – CIRCULATION (IV AND BLOOD

DRAW SUPPLIES)

• Contents:
  1. Cutdown tray
  2. 3 Lumen CVP Catheter Kit **ASSESSMENT FRAMEWORK FOR CRITICAL NURSING
• Assessment Framework**  Starts from the awareness of the nurse of the client’s admission and continues until transition to the next phase of care
• Stages:  Pre-arrival assessment  Admission quick-check  Comprehensive Admission Assessment  On-going Assessment PRE-ARRIVAL ASSESSMENT
• Begins when the information is received about the pending arrival of the patient
• Abbreviated report on patient
• Complete room set-up including verification of proper equipment functioning
• Determines the possible picture of the client and his or her needs. (anticipate possible resources needed by the patient)
• Starts as soon as the nurse becomes aware of a patient coming in the ICU, whether from the ward, operating room or emergency room
• Usual documentation – abbreviated report on patient (age, gender, chief complaint, diagnosis, pertinent history, physiologic status, invasive devices, equipment and status of laboratory or diagnostic tests) ADMISSION QUICK-CHECK
• Obtained immediately after the arrival and assessment
• Based on the parameters represented by ABCDE and General Appearance (General appearance of the client is checked [i.e. consciousness or responsiveness, allergies, etc.])
• Airway  Instruct the client to talk  Rise and fall of chest  Rate, rhythm, depth, symmetry - Breathing  Check for tongue obstruction - Circulation/Cerebral Perfusion/Chief Complaint  Cerebral perfusion (change in LOC)  Chief complaint  Check pulse - Drugs and Diagnostic test and Disability  Disability: o Is the patient alert and responding? o Normal/Signs: The patient is alert and responding to questions in a logical manner when assessed (Alert/responds to voice/responds to pain/no response, unconscious) o Possible reasons for Unresponsiveness:  Hypoxia, Ketoacidosis (Ketone Breath)  Head injury, Drugs, or Stroke o Nursing Action  Place patient in the recovery position (side lying) unless a spinal injury is suspected. - Disability Assessment  Assessment Data o Is there evidence of fluid loss, blood loss? o Normal signs: No signs of loss of body fluids o Abnormal signs: Evidence of vomiting and/or diarrhea, Blood loss, and Loss of fluid through burns o Nursing Action: Risk assessment for hypovolemic shock. - Exposure  Assessment Data 1. Evidence of trauma/injury  Normal signs : (-) signs of physical damage to the person, comfortable in any position; calm facial expression.  Abnormal signs : Unresponsive patient with facial grimacing, frowning signs of bruising, Physical trauma, Foreign object in the person, abnormal movement of the chest; immobility.  Disability : Evidence of Trauma  Nursing Action:  Attempt to open the airway where safe and possible for the patient.  If you suspect the person may have a cervical spine injury,

DRAWER 6 – PROCEDURE TRAYS AND

MISCELLANEOUS SUPPLIES

open the airway using a jaw thrust rather than a head tilt.

2. Is there evidence of factors that may be related to the patient’s condition?  Normal Findings : A safe environment  Abnormal findings (+):  Causes of injury or trauma include: empty medication packets, empty bottles of alcohol, sharp objects, etc.  Nursing Action : Look for causes of injury or trauma

• Quick guide when undertaking a rapid assessment and response to clinical deterioration: Assessment Data Abnormal Signs Interpretation/ Nursing Action Have you listened to Pt. is confused, ALWAYS listen and the patient’s unable to give be alert to info relative/s’ story of appropriate answers; regardless how the event? unresponsive, confusing it can unconscious. seem; note the time; It may be important. Do you know the patient?

The patient may be a registered DNR; dated and signed with an agreed time frame. Pt. admitted in the last 24 H & has no prescribed limiting directives.

If the patient is not for resuscitation, this does not mean that active Tx has been witheld. Always ask to obtain a collaborative agreement of the Px Care Plan.

Pt. is not known by the staff.

If the patient is a recent admission and no info is available, then assume that all active treatment continues. If the patient does not have a recent Hx of continuous care by the nursing staff then ensure that a baseline of Ax details is recorded for comparison. Vital Signs Below or above the normal range

Assess the patient in context: New scores? (+) pattern or trend in deterioration? Evidence of sepsis? Recent history of head trauma? Arterial Blood Gas Analysis

ABG: Alkalosis or Acidosis Normal:

pH: 7.35 -7. PCO2: 35 - 45 mmHg HCO3: 22-26 meq/L ECG (+) of abnormal complexes and irregularities in rate Urine Output Normal: Pedia: > 0.5 ml/Kg body wt/H Adult: 1 ml/Kg body wt/H (+) Oliguria (+) Polyuria Negative urine balance despite rigorous fluid replacement Fluid Balance Fluid balance < or > = based on a minimum input of 2 L/24 H. Central Venous Pressure (CVP)

Mid-axilla: <Hypovolemia: CVP: < 2-6 mmHg Hypovolemia/ cardiac failure. CVP: 2-6 mmHg Level of Consciousness

APVU: PV-U GCS: < Pain Ax Elevated pain score Results of Blood Studies

Normal: Glucose: 4-8 mmol/L Creatinine: 60- micromol/L Na: 135-145 mmol/L K: 3.5 – 4. Mg: 1.25 – 2. Cl: 95 – 108 WCC: 4- 10(9)/L

• Determines the physiologic and psychosocial baseline for comparing data and to determine whether the status is improving or deteriorating)
• Physical assessment is usually by system approach
• Psychosocial assessment is performed, too, as this could determine prognosis
• Defines the status of the patient prior to the illness
• Assessment data includes:  Past Medical History  Social History  Psychosocial history  Spirituality  Physical Assessment  Psychosocial assessment  General communication  Coping styles  Anxiety and Stress

COMPREHENSIVE ADMISSION ASSESSMENT

FOUNDATION FOR ETHICAL DECISION MAKING

WEEK 2: ETHICAL AND LEGAL CONSIDERATION IN CRITICAL CAR

 Family needs  Unit orientation  Referrals

• In-depth Assessment  Past Medical History o Past hospitalizations o Medications o Allergies  Social History o Interaction processes o Vices  Psychosocial Assessment o Behavior o Emotion culture
• Physical Assessment  Nervous System o GCS scoring o Pupil assessment o LOC o Trauma  Cardiovascular System o Check for pulses o Check perfusion  Respiratory System o Breathing pattern o Arterial blood gas result o Auscultation o Secretions  Urinary System o Amount o Color o Odor o Dx: BUN/Crea/UA  Gastrointestinal System o Nutrition and hydration status o Contour and symmetry of abdomen o IAPePa (Inspection, Auscultation, Percussion, Palpation)  Integumentary System o Check the integrity o Ulcer stages:  Stage I  The area looks red and feels warm to touch  Stage II  The area looks more damaged and may have an open sore, scrape, or blister

 Stage III  The area has a crater-like appearance due to damage below the skin’s surface  Stage IV  The area is severely damaged and a large wound is present ON-GOING ASSESSMENT

• Determines response to therapy, progression of improvement of his or her condition
• Performed as long as the client is in the hospital, Continuous assessment is necessary to determine outcome of the client’s disease
• Done periodically
• Unstable patients: every 15 mins
• Stable patients: every 2-4 hours
• SBAR  A structured communication tool used as a framework for improving interprofessional communication and patient safety.  As a tool, it meets the quality requirements for safe and effective clinical documentation of care.  Situation (S) o Identify yourself, your location and the patient. o Describe the problem, your concern and reason for calling.  Background (B) o Provide the patient’s reason for admission, diagnosis and relevant history.  Assessment (A) o Provide both your subjective concerns and objective data. o Offer provisional Dx/ clarify your concern  Recommendation/s (R) o Explain what you need, when and where **1. Professional codes and standards

2. Institutional policies
3. Legal standards
4. Principles of Ethics**  Beneficence o Best interest of the patient remains more important than self-interest  Non-Maleficence o Not only the will to do good but the equal commitment to do no harm

 Autonomy o Freedom from external control; acknowledge and protect a patient’s independence  Privacy o Right of the patient to be free from unjustified access by others  Confidentiality o Protection of information; patient information should be shared within the healthcare team directly involved in patient care  Fidelity o Agreement to keep promises  Veracity o Being truthful or honest  Justice CONTEMPORARY ISSUES

- Informed Consent  Also known as Operative permit or Surgical consent  Patient’s autonomous decision about whether to undergo certain diagnostic procedure, therapeutic measures, or surgical procedure  Purpose: o The client understands the nature of the treatment and its advantages and disadvantages o To indicate that no coercion was made before signing o To protect the client against unauthorized procedure o To protect the surgeon and the hospital against legal actions  Includes: o Name of Procedure o Name of MD o Name of witness (RN) o Date o Potential complication/Disfigurement o Obtained: MD o Secured: RN o Given: Pt  3 Major Elements: o No Coercion/Voluntary o Sound Mind o Ultimate Decision Maker (patient)  Requisites for Validity: o Written consent made by the client o No signs of pressure

o No sedation o 24 hours before elective surgery o Legal age and mentally capable o 2 surgeons signed the consent in emergency o Emancipated minor* o Authorized representative*  Emancipated Minor: o A college student living away from home o In military service o Pregnant o Anybody who has given birth  Authorized Representative: o Minor o Unconscious o Psychologically incapacitated  Exemptions: o If experts agreed that the care is an EMERGENCY, has life-threatening conditions, or patient is unconscious and authorized representative cannot be reached

• Determining Capacity  Reflects a medical decision on patient’s functional ability to participate in the decision- making process; patients are presumed to have the determining capacity
• Advance Directives  Statements made by a patient with decision- making capacity describing the care of treatment he/she wishes to receive when no longer competent o Treatment Directives (“Living Will”)  Specify in advance his/her treatment choices and which interventions are desired o Proxy Directives  Durable power of attorney for health care
• End-of-Life Care Issues  End-of-Life care includes physical, emotional, social, and spiritual support for patients and their families  Goal: o To control pain and other symptoms to make the patient as comfortable as possible; quality of life  Decisions to forego life-sustaining treatments  Nutrition and Hydration

 Given thru NGT, IV, or duodenal feedings, or gastrostomy  Nutrition and hydration status expedites the patients return to an acceptable level of functioning  Pain Management  One of the main components of palliative care  Done if there is a decision to forego life-sustaining treatment  “Should provide interventions to relieve pain and other symptoms in the dying patient even when those interventions entails risks of hastening death” – ANA (Code for Nurses)  Resuscitation Decisions – DNR, DNI  Do Not Resuscitate (DNR) Orders  Also known as “No Code”  Withhold CPR  No other heroic act to be perform on the patient  Nurse documents participation on the discussion

- Paternalism  Deliberate restriction of autonomy by health care professionals based on the idea that they know what is best for the client  Refers to instances in which the principles of beneficence overrides autonomy **LAWS ON CRITICAL CARE NURSING

1. Scope of Nursing Practice based on R.A. 9173**  A person shall be deemed to be practicing nursing within the meaning of R.A No. 9173 when he/she singly or in collaboration with another, initiates and performs nursing services to individuals, families and communities in any health care setting 2. Nurses’ Code of Ethics  The Filipino registered nurse, believing in the worth and dignity of each human being, recognizes the primary responsibility to preserve health at all cost.  This responsibility encompasses promotion of health, prevention of illness, alleviation of suffering, and restoration of health  Nurses demonstrate professional values such as respect, justice, responsiveness, caring, compassion, empathy, trustworthiness and

integrity. They support and respect the dignity and universal rights of all people, including patients, colleagues and families

3. Patient’s Bill of Rights and Obligations  Right to Appropriate Medical Care and Humane Treatment  Right to Informed Consent  Right to Privacy and Confidentiality  Right to Information  Right to choose Health Care Provider and Facility  Right to Self-Determination  Right to Religious Belief  Right to Medical Records  Right to Leave  Right to Refuse Participation in Medical Research  Right to Correspondence and to Receive Visitors  Right to Express Grievances  Right to be Informed of His Rights and Obligations as a Patient

• Responsibility  Keep appointments and notify clinic personnel 24 hours prior, if unable to keep scheduled appointment.  Be involved and follow the plan of care.  Provide a complete medical history, medications and other matters relating to your health  Inform the provider of any changes in your health condition.  Provide a copy of your Medical Advance Directive and/or Medical Power of Attorney (if applicable and in effect)  Ask questions about specific problems and request information when not understanding your illness or treatment.  Accept results or consequences if you refuse treatment, do not follow the provider's recommendations or leave the clinic against medical advice. 4. Dying Patient’s Bill of Rights  I have the right to participate in decisions concerning my care  I have the right to expect continuing medical and nursing attention even though “cure” goals must be changed to “comfort” goals  I have the right to not die alone  I have the right to be free of pain

EVIDENCE BASED NURSING (EBN)

WEEK 3: QUALITY AND SAFETY IN MANAGING CRITICAL CARE U

• What is the Dying patient Bill of Rights in the Philippines?  The Natural Death Act. also known as the Senate bill 1887, filed by former Philippine senator, Miriam Defensor Santiago gives a patient who is "terminally ill” or in "comatose condition" the right to die when the patient or their family refuse to pursue further medical treatment and instead allow the "natural process”
• Senate Bill 586  An act providing palliative and end-of-life care, appropriating funds therefor and for other purposes **THE PROCESS OF ETHICAL ANALYSIS (AACCN, 2019)

1. Assessment**  Identify the problem o Clarify the competing ethical claims, conflicting obligations, and personal and professional values; acknowledge the emotional and communication issues  Gather data o Distinguish the morally relevant facts, including medical, nursing, legal, social, and psychological facts; clarify patient’s religious and philosophical beliefs and values  Identify the individuals involved in the problem’s development and who should be involved in the decision making; discern factors that may impede the patient’s ability to make the decision 2. Plan  Consider all options and avoid restricting choices to the most obvious  Identify the pros and cons (“harms and goods’)  Analyze if plan is in accordance with ethical theories and principles  Look into institutional policies and/or procedures that address the issue 3. Implementation  Choose a plan and act (Anticipate Objections) 4. Evaluation  Outline the results  Identify what harm or good occurred as a result  Identify necessary changes in the institutional policy/ies or other strategies to avoid similar issues in the future - Under the umbrella of Evidence Based Practice. Definitions of evidence-based nursing have varied in scholarly Literature. - Scott and McSherry's extensive literature review looked at commonalities between EBN definitions and synthesized them to come up with the following definition:  "An ongoing process by which evidence, nursing theory and the practitioners’ clinical expertise are critically evaluated and considered, in conjunction with patient involvement, to provide delivery of optimum nursing care for the individual," (Melnyk, B, Fineout-Overholt, E., Stillwell, S., and Williamson, K., 2010). - Step 1 : Ask clinical questions  PICOT format o P – atient / population of interest / problem (start with the patient, or group of patients, or problem) o I – ntervention or area of interest (What is the proposed intervention?) o C – omparison intervention or group (What is the main alternative, to compare with the intervention? This might be: no intervention.) o O – utcome (What is the anticipated or hoped-for outcome?) o T – ime frame (How long will it take to reach the desired outcome?)  P.I.C.O.T Format o This provides an efficient outline for searching electronic databases (to retrieve articles relevant only to the clinical question)  Example: "I work in MICU where ventilator-related infections are a common problem. I've heard that oral care of ventilated patients even with water can help prevent this. I wonder if there's any evidence for that and whether it might help our patients?"  P (Patients in MICU)  I (Water)  C (Oral care with water only)  O (Prevention of ventilator-related infections)

STEPS: (Melnyk, B, Fineout-Overholt, E., Stillwell, S., and Williamson, K., 2015)

 T (Will depend on the time frame set)

 The S.PI.D.E.R Tool o Can be used when dealing attitudes and experiences rather than o Scientifically measurable data since it focuses less on the intervention and more on the design o Deals with "samples" rather than a "patient" or "populations".  S – ample (group of participants)  PI – phenomenon of interest (how and why of behaviors and experiences)  D – esign (how the study was devised and conducted)  E – valuation (measurement of outcome; might be subjective and not necessarily empirical)  R – esearch Type (qualitative, or quantitative, or mixed) o Research questions framed using the SPIDER tool tend to begin with "What are the experiences of ...?" o Example: "What are the experiences of fourth year university students in using their critical care units related learning experience?"  S Fourth year university students  PI CCUs RLE  D Survey  E Experiences (of having the RLE in CCUs)  R Qualitative

• Step 2 : Search for the best evidence/Obtain the best research literature  To describe if clinical practice is streamlined when questions are asked
• Step 3 : Critically appraise the evidence.  Once articles are selected for review, these must be rapidly appraised to determine those most

relevant, valid, reliable, and applicable to the clinical question. o Guide: Are the results of the study valid? What are the results and are they important? Will the results help me care for my patients?)

• Step 4 : Integrate the evidence with clinical expertise and patient preferences and values.  Synthesize the studies to determine if they come to similar conclusions, thus supporting an EBP decision or change  Research evidence alone is not sufficient to justify a change in practice. Clinical expertise, based on patient assessments, laboratory data, and data from outcomes management programs, as well as patients' preferences and values are important components of EBP
• Step 5 : Evaluate the outcomes of the practice decisions or changes based on evidence.  To monitor and evaluate any changes in outcomes (positive effects can be supported and negative ones remedied)
• Note: EBP results should be disseminated.  Leads to needless duplication of effort, and perpetuates clinical approaches that are not evidence based  Examples of ways to disseminate successful initiatives: presentations at local, regional, and national conferences; reports in peer-reviewed journals; professional newsletters; and publications for general audiences

SALIENT POINTS TO CONSIDER IN USE OF EBN PRACTICE

• Promotes use of EBP among advanced practice nurses and direct care nurses
• Identifies a network of stakeholders who are supportive of the EBP project
• Cognitive behavioral theory underpinnings

• Emphasis on healthcare organizational readiness and identification of facilities and barriers
• Encompasses research, patient values, and clinical expertise as evidence. **QUALITY AND SAFETY MONITORING

1. Care bundles**  A group of 3-5 evidence-based interventions, when performed together, have a better outcome than if performed individually  Can be used to ensure the delivery of the minimum standards of care  Can be used as an audit tool to assess the delivery of interventions (NOTE: cannot be used to assess how well individual interventions are performed)  Encourage the review of evidence and modification of clinical care guidelines, engendering staff education in best practice  Key principle = high level of adherence to all components  Example: The sepsis care bundle, part of the international Surviving Sepsis campaign, is the most widely utilized bundle. **2. Checklists
2. Continuous quality improvement
3. PDCA (Plan-Do-Check-Act) cycle (Deming Cycle,** Shewhart Cycle)  A management tool for continuous improvement of a business's products or processes. It can be applied to standardize nursing management and thus improve the nursing quality and increase the survival rate of patients  Uses: implementation of change, solve problems, and continuously improve nursing management processes  Cyclical nature; allows it to be utilized in a continuous manner for ongoing improvement o P - PLAN the change or improvement o D – DO = conduct a pilot test of the change o C – CHECK = gather data about the pilot change to ensure the change was successful o A – ACT = implement the change on a broader scale; continue to monitor the change and repeat as necessary by repeating the cycle  Expertise Required: easy to use and requires little or no training.

 Advantages: o Makes sure that all appropriate steps are followed. o Offers a systematic improvement method. o Is an effective process improvement guide. o Informs future improvement by providing feedback. o Maintains order during problem solving.  Disadvantage: o Requires significant commitment over time. MULTIDISCIPLINARY PLANS OF CARE

- Benefits to both patients and the hospital system: 1. Improve patient’s outcome 2. Increased quality and continuity of care 3. Improve communications and collaboration 4. Identification of hospital system problems 5. Coordination of necessary services and reduced duplication 6. Prioritization of activities 7. Reduce length of stay and health care costs.

• Format for the Multidisciplinary Approach Categories: 1. Discharge outcomes 2. Patient goals 3. Assessment and evaluation 4. Consultations 5. Tests 6. Medications 7. Nutrition 8. Activity 9. Education 10. Discharge planning
• Note: Primary Consideration = Patient’s Safety

1. Clinical Information System
2. Computerized provider order entry (CPOE)
3. Hand-held Technologies
4. Tele-health Initiatives (Tele-ICU) ADVOCACY: ACCESS TO SOCIAL CARE SERVICES
5. PhilHealth
6. DOH
7. DSWD
8. PAGCOR
9. PCSO

• Purpose:  Continuous Monitoring and treatment.  Required emergency interventions.

INFORMATION AND COMMUNICATION

TECHNOLOGIES IN CCU

WEEK 3: CARE BUNDLES

 Care for patients who are medically unstable or seriously ill.  Care for patients who do not have much chance for recovery due to the severity of their illness or traumatic injury.

• History:  1854 Crimean war – Florence Nightingale  Dr. W.E. Dandy – 3 bedded Neurosurgical unit in US  1927 first hospital for premature born infants in Chicago  2nd world war – shock wards  Outbreak polio Epidemic – respiratory ICU  1950 peter safar anathetist ‘Advanced support of Life’ (sedated & ventilated)  Nurses practice – sick patients located near the nurse’s station receive more attention.  Development of various specialty & ICU significantly reduced the mortality and hopital stay time  Major surgeries – liver transplant, kidney transplant and pancreatectomy
• Location:  Should be a geographically distinct area within the hospital, with controlled access.  No through traffic to other departments should occur.  Supply and professional traffic should be separated from public/visitor traffic.  Location should be chosen so that the unit is adjacent to, or within direct elevator travel to and from, the Emergency Department, Operating Room, Intermediate care units, and the Radiology Department.
• **Design of Unit:
• Bed Strength**  Ideally 8 to 12 beds  Larger areas difficult to administer and smaller areas not being cost effective  3 to 5 beds per 100 hospital beds for a level III ICU / 2 to 20 of the total number of hospital beds  1 isolation bed for every 10 ICU beds - Bed Space Beds  150 200 square feet per open bed with 8 feet in between beds. The beds should be 2.5 - 3 meters (7-9 feet) apart, to allow free movement of staff and equipment, reducing risk of cross contamination.  225 250 square feet per bed if in a single room. - Infrastructure  Patients must be situated so that direct or indirect (e.g. by video monitor) visualization by healthcare providers is possible at all times.  The preferred design is to allow a direct line of vision between the patient and the central nursing station.  Modular design sliding glass doors partitions to facilitate visibility. - Partitions  Privacy partitions should be of material that is easily cleaned and should be cleaned weekly and any time that it becomes soiled or contaminated.  If curtains are used, they should be changed weekly and between patients. - Central Station  Provide a comfortable area of sufficient size to accommodate all necessary staff functions.  There must be adequate overhead and task lighting, and a wall mounted clock should be present.  space for adequate computer terminals and printers is essential - Environment  Signals alarms add to the sensory overload need to be modulated.  Floor coverings and ceiling with sound absorption properties.  Doorways offset to minimize sound transmission.  Light soft music (except 10 pm to 6 am). - Ancillary Area  Nurses station Utility Room  Admission room  Room for specialized equipment  Conference or class room  Nurses waiting/resting room  Doctors waiting/resting room  Lab  Pantry  Visitors room  Store room & Changing room

• Infrastructure
  1. Rails alongside the bed
  2. Wall sockets for oxygen and pressurized air as well as for suction. At least 2 oxygen and pressurized air outlets are needed and 3 aspirators per patient.
  3. A bell or intercom for calling the nurse should be at each bed.
  4. A table and a telephone with an outside line should be at the bedside.
  5. Armchairs should be on hand, preferably adjustable ones, to allow patients to sit up if they can.
• Types Specialized types of ICUs include:  Neonatal intensive-care unit(NICU)  Special Care Nursery (SCN)  Pediatric intensive-care unit (PICU)  Psychiatric intensive-care unit (PICU)  Coronary care unit (CCU)  Cardiac Surgery intensive-care unit (CSICU)  Cardiovascular intensive-care unit (CVICU)  Medical intensive-care unit (MICU)  Medical Surgical intensive-care unit (MSICU)  Surgical intensive-care unit (SICU)  Overnight intensive recovery (OIR)  Neurotrauma intensive-care unit (NICU)  Neurointensive-care unit (NICU)  Burn wound intensive-care unit (BWICU)  Trauma Intensive Care Unit (TICU)  Surgical Trauma intensive-care unit (STICU)  Trauma-Neuro Critical Care (TNCC)  Respiratory intensive-care unit (RICU)  Geriatric intensive-care unit (GICU)  Mobile Intensive Care Unit (MICU)  Post Anesthesia Care Unit (PACU)
• Models  Open ICU model is one where specialty teams have full admitting rights and where an intensivist is merely "consulting".  Closed ICU model is one where the intensivist is the admitting medical officer and the specialty teams collaborate with ICU staff STANDARDS OF CARE
• Healthcare workers are committed to delivering high standards of care to all patients
• Standards of care are generally defined by evidence based guidelines, e.g. infection control guidelines:  SARI guidelines  CDC guidelines (USA)

 EPIC/NICE guidelines (UK) WHAT ARE “CARE BUNDLES”?

• A Care Bundle is a collection of interventions (usually 3-5) that are evidenced based
• All clinical staff know that these interventions are best practice but frequently their application in routine care is inconsistent
• A Care Bundle is a means to ensure that the application of all the interventions is consistent for all patients at all times thereby improving outcomes TYPES OF CARE BUNDLES
• WHO Surgery Safety Checklist
• Urinary Catheter Care Bundle  Insertion and Management
• Clostridium Difficile Care Bundle
• Ventilator Assisted Pneumonia (VAP) Care Bundle
• Palliative Care Bundle
• Pressure Area Care Bundle
• Sepsis Care Bundle
• PVC Care Bundle
• Evaluation of the head of the bed to between 30°-45°
• Daily sedative interruption and daily assessment of readiness to extubate
• Peptic ulcer disease prophylaxis
• Deep venous thrombosis prophylaxis if not contraindicated **URINARY CATHETER CARE BUNDLE
• Insertion**  Insert only for specific reasons o Urinary output in critical ill o Bladder outlet obstruction or neurogenic bladder dysfunction o Prevent contamination of sacral wounds o Terminal care  Competent HCW to insert  Aseptic technique  Closed system with bag below bladder
• Management  Review need for catheter daily  Empty when ¾ full and use clean container for each patient  Secure catheter to leg/abdomen  Urine samples from sampling port only  Hand hygiene & PPE before and after any catheter care

VENTILATOR ASSOCIATED PENUMONIA (VAP)

CARE BUNDLE

FROM DOC FERRIOL’S PPT

WEEK 4: RESPIRATORY ASSESSMENT TECHNIQUES AND MONITO

PRESSURE ULCER PREVENTION BUNDLE

1. Risk assessment (Braden tool)
2. Skin assessment 8 hourly
3. Head of bed <30° unless contraindicated or superseded by VAP bundle
4. Incontinence skin care
5. Position change  Bed - 2 hourly  Chair - hourly
6. Heel elevation
7. Nutritional assessment
8. Pressure relief mattresses (not a replacement for positional change) CLOSTRIDIUM DIFFICILE CARE BUNDLE

• Isolate all CDI patients in a single room with clinical hand washing sink and either en suite facilities or a designated toilet/commode until they are at least 48 hours’ symptom free
• Review the patient's antibiotic regimen - stop inappropriate antibiotics
• Check that all HCWs remove PPE (gloves and aprons) immediately after each contact with CDI patient and their environment
• Ensure that HCWs perform hand hygiene with liquid soap and water immediately after removal of PPE
• Check that the CDI patient's immediate environment and all patient care equipment has been cleaned today with a neutral detergent and disinfected with a sporicidal disinfectant PVC CARE BUNDLE
• Adapted from the Health Protection Scotland Care Bundle
• Management of PVC’s  Don’t put them in  Look after them properly o Sterile dressing o Hand hygiene before all contact with PVCs o At a minimum check daily for inflammation  Get them out o Remove after 72 hours or clinical decision to leave in if no signs of inflammation
• Should be adapted locally – e.g. removing after 72 hours will not apply in Pediatrics SUMMARY
• A Care bundle is a simple tool used to improve reliability in care delivery
• Elements must be evidenced based
• It can be used for different conditions or treatments and adapted locally - Structures:  The upper portion filters, moistens, and warms air during inspiration  Nose – for smell, aids in phonation  Paranasal Sinuses – aids in phonation  Pharynx – helps destroy incoming bacteria  Larynx – voice production  Trachea – furnishes open passageway for air going to and from the lungs  The lower portion consist of lungs, which enable the exchange of gases between blood and air to regulate arterial Po2, Pco2, and Ph: left lung has 2 lobes and the right lung has 3 lobes  Bronchi – right and left bronchus branches into segmental bronchi all containing C-shaped cartilage  Bronchioles – secondary bronchi-terminal bronchioles, respiratory bronchioles –alveolar ducts  Alveoli – squamous epithelial cell (type1) for rapid gas exchange. Type II cells produce surfactant to prevent alveolar collapse. Type III are macrophages that protect against bacteria by phagocytosis  Visceral pleura that joins parietal pleura - Anatomy Review: Respiratory Tract

- Physiology of Respiration  Mechanism of breathing 1. Phrenic nerve stimulation 2. Thorax increases in size 3. Intrathoracic and intrapulmonic pressure decreases 4. Air rushes from positive pressure in the atmospheres to negative pressure in the alveoli 5. Inspiration is completed with stimulation of the stretch receptor 6. Expiration occurs passively as a result of recoil of elastic lung tissue  Control of Respiration 1. Alveolar stretch receptors respond to inspiration by sending inhibitory impulses to inspiratory neurons in the brainstem to prevent lung overdistention (Hering-Breur Reflex) 2. Central and peripheral chemoreceptors 3. MO and pons-control rate and depth of respirations

-

• Lung Volume/Body Plethysmography
  1. Tidal Volume: average amount expired after normal inspiration; approximately 500ml
  2. Expiratory reserve volume (ERV): largest additional volume of air that can be forcibly expired after a normal inspiration and expiration; 1000-1200 ml
  3. Inspiratory reserve volume(IRV): largest additional volume of air that can be forcibly inspired after a normal inspiration; 3000 Ml
• Pulmonary Function
  4. Residual Volume: air that cannot be forcibly expired voluntarily from the lungs; 1200 ml; increased in COPD as lungs lose elasticity and ability to recoil, resulting in air trapping
  5. Vital Capacity (TV + IRV + ERV); amount of air that can be forcibly expired after forcible inspiration; 4600 ml; decreases with COPD, neuromuscular disease, atelectasis
  6. Forced expiratory volume (FEV): volume of air that can be forcibly exhaled within a specific time; 1-3 seconds, decreased with increased airway resistance (bronchospasm, COPD)
  7. Inspiratory capacity (TV + IRV): largest amount of air that can be inspired after a normal exhalation; 3500 ml
  8. Functional residual capacity(ERV+RV): amount of air left in the lungs after a normal exhalation; 2300 ml, increased with COPD
  9. Total lung capacity; amount of air in the lungs after a maximum inhalation; 5800 ml; TV+RV+IRV+ERV; increased with COPD, decreased with atelectasis and pneumonia
• Lung Volumes

DIFFUSION OF GASES BETWEEN AIR AND BLOOD

1. Ventilation-perfusion (V/Q) ratio
2. Direction of diffusion
3. Low V/Q alveoli poorly ventilated but capillary blood is adequate, blood is shunted past the alveoli without adequate gas exchange (atelectasis, pneumonia)
4. High V/Q alveolar ventilation is adequate, but capillary blood flow is not; adequate gas exchange does not take place because of dead space (pulmonary embolism, cardiogenic shock)
5. Absence of V/Q causes a silent unit; no gas exchange (pneumothorax) EFFECTS OF AGING

• Progressive loss of elastic recoil of lungs – due to elastin & collagen fiber changes
• Increased respiratory muscle workload – due to calcification of soft tissues in chest wall
• Total lung capacity remains constant
• Increased residual lung volume – result of changes in aging AUSCULTATION OF BREATH SOUNDS

ANTERIOR POSTERIOR

• Normal Breath Sounds  Bronchial Sounds (over trachea, larynx); result of air passing thru larger airways, sounds are loud, harsh, high-pitched; expiration longer than inspiration  Vesicular Sounds (over entire lung field except large airways); result of air moving in and out of alveoli; sounds are quiet, low- pitched, inspiration longer than expiration

ADVENTITIOUS BREATH SOUNDS

BREATH SOUND DESCRIPTION ETIOLOGY

Crackles

**- Coarse

• Fine**

Soft, high-pitched discontinuous popping sound during inspiration

• Originating from bronchi
• Originating from alveoli

Fluid in the airways

• COPD
• Pneumonia

Rhonchi Deep low-pitched rumbling sounds during expiration caused by air moving out of narrowed airways

Secretions or tumor

Wheezes Continuous musical high-pitched, whistle-like sounds

Bronchospasm; asthma Pleural Friction Rub Harsh, crackling sounds, like 2 pieces of leather being rubbed together during inspiration alone or both inspiration & expiration

Secondary to inflammation or loss of pleural fluid

 Broncho-Vesicular Sounds (near main stem bronchus) result from air moving through smaller air passages; sounds are moderately pitched, breezy, equal I and E

• Adventitious Sounds  Fine Crackles o Pneumonia and pulmonary edema  Coarse Crackles o Pneumonia, COPD, pulmonary edema  Wheezes o Asthma  Pleural Friction Rub o Inflammation of pleura ASSESSMENT OF LUNG SOUNDS

DIAGNOSTIC TOOLS FOR RESPIRATORY FUNCTION

• **Chest X-ray
• Arterial Blood Gas (ABG)**  Respiratory Acidosis o pH ↓ PaCO2 ↑  Metabolic Acidosis o pH ↓ PaCO2 ↓  Respiratory Alkalosis o pH ↑ PaCO2 ↓  Metabolic Alkalosis o pH ↑ PaCO2 ↑
• Spirometry  The client takes as deep a breath as possible and blows out the air as fast as possible until the lungs are completely empty.  Measures the volume of air breathed out (forced vital capacity or FVC) and the amount breathed out in the first second (forced expiratory volume in 1 second or FEV1)  By looking at these 2 numbers, and the ratio of FEV1/FVC, we can predict if the individual has abnormal lung function and the type of lung abnormally present.

 Reports: numbers are absolute numbers and percent predicted compared to normal healthy individuals of the same height, weight and gender  If the FEV1 and FVC are low and the ratio of FEV1/FVC is normal, this is called restrictive lung disease. This is seen when the lungs are small or stiff or are confined by the rib cage. If the FEV and FEV1/FVC are low, this is called obstructive lung disease.  The air is slowed down because of a blockage -- or obstruction – to air flow, either because of mucus in the breathing passages (called airways) that typically causes a partial obstruction, or collapse of the tiniest airways, which blocks air movement altogether

• Incentive Spirometry  Spirometry is also used to determine reversibility of obstruction after use of bronchodilators (Hubert & VanMeter, 2017).  The patient demonstrates a degree of reversibility of lung restriction / obstruction if the pulmonary function values improve after administration of the bronchodilator.  Even patients who do not show a significant response to a short-acting bronchodilator, this test may benefit symptomatically from long-term bronchodilator treatment.
• Bronchoscopy  Visualization of the tracheobronchial tree via a scope advanced through the mouth or nose into the bronchi  Performed to remove foreign body, to remove secretions or to obtain specimen of tissue or mucus for further study

• Thoracentesis  Removal of fluid or air from pleural space; diagnostic purposes, alleviate respiratory distress, needle biopsy  No more than 1000 ml of fluid should be removed at a time  Complications pneumothorax from trauma and pulmonary edema resulting from sudden fluid shift  Pre-test: Consent  Intra-test: Position the patient sitting with arms on a table or side-lying fowler’s, instruct not to cough, breathe deeply or move  Post-test: Position unaffected side to allow lung expansion of the affected side, chest x-ray is obtained, maintain pressure dressing and monitor respiratory status
• Sputum Culture  Sputum sample is obtained by coughing and is examined in the laboratory  Nursing Interventions: o Drinking a lot of water and other fluids the night before collection may help o Perform back tapping or chest clapping o on client to aid in loosening the sputum o Instruct client on proper specimen collection o Collect morning specimen o Gargle with water only before specimen collection cough deeply and spit sputum in a sterile cup o Send specimen to lab ASAP
• **MRI and CT Scan
• Chest Tubes**  Use of tubes and suction to return negative pressure to the intrapleural space, expands the lung by removing positive pressure from the pleural space  To drain air from intrapleural space, a chest tube is placed in 2nd^ or 3rd^ ICS to drain blood or fluid, catheter would be placed at a lower site, 8th^ or 9th ICS

 Single Chamber Underwater Seal Chest Drain o It is a single bottle, open to air. The patient's chest tube is submerged under a level of water (usually about 2cm) which acts as a one-way valve. When the patient's pleural pressure exceeds the level of water (i.e. it is greater than 2cm H2O), the air in the tube will bubble out and escape into the atmosphere. When the patient takes a breath in, the negative intrapleural pressure will suck drain water up the tube, but no additional air can enter.  What are the advantages of the single bottle pleural drain? o Simple o Cheap o Easily improvised from unrelated equipment o For simple pneumothorax, there is usually no need for anything more sophisticated o The fluid level (i.e. valve pressure) is adjustable, though there are few scenarios where one might wish to adjust it.  The Two-Chamber Underwater Seal Pleural Drain o This system separates the fluid collection chamber from the water seal chamber. That way, there is still an underwater seal to prevent the re-entrainment of air, and pleural fluid can collect in the first chamber without affecting the depth of the underwater seal.  Advantages o Fixed underwater seal level, therefore consistent (low) resistance to air expulsion

o Pleural fluid and water seal are separate: therefore, no froth will form. o The collection bottle permits the drainage of pleural fluid, so the case uses of this system are not limited to pneumothoraces.  The Three-Chamber Underwater Seal Drain o This system is much like the two-bottle system, but with an added chamber to help regulate the suction pressure, i.e. it is specifically designed to be used with suction. It was apparently developed at the Massachusetts General Hospital in 1945.

 Management: o Provide pain relief.  Administer narcotics/analgesics prior to turning, coughing, and deep breathing.  Assist with splinting while turning, coughing, deep breathing. o Promote adequate ventilation.  Perform complete physical assessment of lungs and compare with pre-op findings.  Auscultate lung fields every 1—2 hours.  Encourage turning, coughing, and deep breathing every 1—2 hours after pain relief obtained. o Perform tracheobronchial suctioning if needed.  Assess for proper maintenance of chest drainage system (except after pneumonectomy).  Monitor ABGs and report significant changes.  Place client in semi-Fowler’s position

FROM THE CANVAS MODULE WEEK 4

- Purpose of the Respiratory System  The lungs, in conjunction with the circulatory system, deliver oxygen to and expel carbon dioxide from the cells of the body.  The upper respiratory system warms and filters air.  The lungs accomplish gas exchange.

• Structures of the Respiratory System:  Parts of the Upper Respiratory System o Nose o Sinuses and nasal passages o Pharynx, Tonsils and adenoids o Larynx: epiglottis, glottis, vocal cords, and cartilages  Parts of the Lower Respiratory System o Lungs, Pleura and mediastinum o Lobes of the lungs: Left (upper & lower); right (upper, middle, lower) o Bronchi & bronchioles and the alveoli (gas exchange) VENTILLATION
• Inspiration: contraction of the diaphragm and contraction of the external intercostal muscles increases the space in the thoracic chamber (lowered intrathoracic pressure causes air to enter through the airways and inflate the lungs)
• Expiration: with relaxation, the diaphragm moves up and intrathoracic pressure increases (pushes air out of the lungs); expiration requires the elastic recoil of the lungs.  Inspiration = 1/3 of the respiratory cycle; expiration = 2/3 of the respiratory cycle RESPIRATION
• Oxygen diffuses from the air into the blood at the alveoli to be transported to the cells of the body.
• Carbon dioxide diffuses from the blood into the air at the alveoli to be removed from the body. **ASSESSMENT OF BREATH SOUNDS
• Normal Breath Sounds:**  Vesicular, Bronchovesicular, Bronchial
• Abnormal (Adventitious) Breath Sounds:  Crackles  Wheezes  Friction rubs VENTILATION PERFUSION (V/Q) RATIO
• Ventilation is the movement of air in and out of the lungs.

• Air must reach the alveoli to be available for gas exchange.
• Perfusion is the filling of the pulmonary capillaries with blood.
• Adequate gas exchange depends upon an adequate V/Q ratio, a match of ventilation and perfusion.
• Shunting occurs when there is an imbalance of ventilation and perfusion. This results in hypoxia. LUNG CAPACITIES
• Tidal Volume (TV) : air volume of each breath
• Inspiratory Reserve Volume (IRV) : maximum volume that can be inhaled after a normal inhalation.
• Expiratory Reserve Volume (ERV) : maximum volume that exhaled after a normal exhalation.
• Vital Capacity (VC) : the maximum volume of air exhaled from a maximal inspiration, VC = TV + IRV + ERV.
• Forced Expiratory Volume (FEV) : volume exhaled forcefully over time in seconds. Time is indicated as a subscript, usually 1 second. MEASUREMENT OF VOLUME AND INSPIRATORY FORCE
• A spirometer measures volumes of air exhaled and is used to assess lung capacities.
• When assessing TV, measure several breaths. TV varies from breath to breath.
• Pulmonary function tests assess respiratory function and determine the extent of dysfunction.
• Peak flow rate reflects maximal expiratory flow and is frequently done by patients using a home spirometer INSPIRATORY FORCE
• Evaluates the effort of the patient in making an inspiration.
• A monometer which measures inspiratory effort can be attached to a mask or endotracheal tube to occlude the airway and measure pressure.
• Normal inspiratory pressure is approximately 100 cm H2O.
• Force of less than 25 cm usually requires mechanical ventilation. ARTERIAL BLOOD GAS
• Measurement of arterial oxygenation and carbon dioxide levels.
• Used to assess the adequacy of alveolar ventilation and the ability of the lungs to provide oxygen and remove carbon dioxide.
• Also assesses acid base balance PULSE OXIMETRY
• A noninvasive method to monitor the oxygen saturation of the blood. - Does not replace ABGs - Normal level is 95-100%. - May be unreliable DIAGNOSTIC TESTS - Imaging tests: Chest x-ray, CT scan, MRI, Fluoroscopic Studies and Angiography, Radioisotope procedure- lung Scans, Bronchoscopy, Thoracoscopy - Pulmonary function tests - Arterial blood gases - Sputum tests - Thoracentesis - Biopsies RESPIRATORY CONDITIONS - Upper Airway Obstruction - Causes:  Foreign bodies/materials; enlargement of tissues in the wall of airway, pressure on the walls of the airway, altered level of consciousness - Assessment:  Inspection (eye)  Palpation (touch)  Auscultation (hearing) AIRWAY MANAGEMENT OROPHARYNGEAL AIRWAY (OPA) - Also known as Oral bite block - Temporary - Relieves upper airway obstruction - Tongue relaxation, secretions, seizures - Not recommended for alert clients - May trigger gag and cause vomiting - Nursing Responsibility:  Frequent assessment of the lips and tongue to identify pressure areas  Removed at least q 24 hours to check for pressure areas and to provide oral hygiene NASOPHARYNGEAL AIRWAY - Also known as Nasal trumpet - Maintains airway patency - Also used to facilitate nasotracheal suctioning - Size : French 26-35 - Complications  Bleeding  Sinusitis  Erosion of the mucus membranes - Nursing Responsibility  Assessment of the pressure areas and occlusion due to secretions  Rotation of tube from nostril to nostril daily

LARYNGEAL MASK AIRWAY

• An ET with a small mask on one end that can be passed orally over the larynx
• Provides ventilatory assistance and prevent aspiration
• Combitube  Esophageal/tracheal double lumen airway  Used for difficult or emergency intubation  Permits blind placement ENDOTRACHEAL (ET) TUBE
• Includes a 15mm adapter at the end for connection to life support equipment
• Distance marker on the sides for placement
• Inserted into the trachea through the mouth or nose
• Insertion of Endotracheal (ET) Tube  Using laryngoscope to visualize the upper airway  Inserted through the vocal cords into the trachea  2-4 cm above the carina  Anchored by inflating the cuff (prevents air leakage and aspiration)
• Confirm Proper Placement  Presence of bilateral breath sounds  Equal  Suctexcursion during inspiration  Absence of breath sounds over the stomach  PETCO2: 35-40 mmHg
• Verification: CXR  Anchor with tape or ET fixation device  Centimeter marking at the lip is documented during each shift  10-14 days of intubation: tracheostomy is usually indicated
• Complications:  Laryngeal and tracheal damage  Laryngospasm  Aspiration  Infection and discomfort  Vocal cord paralysis (should not be used longer than 3 week) MECHANICAL VENTILATOR
• A form of assisted ventilation; takes over all part of the work performed by the respiratory muscles and organs
• Indication : impaired patient’s ability to oxygenate and exchange carbon dioxide
• Main Goal : to support gas exchange until the disease process is resolved

POSITIVE PRESSURE VENTILLATION (PPV)

• Most common form of mechanical ventilation used in the acute care setting
• Forces oxygen into the lungs with each breath through an endotracheal tube or tracheostomy tube
• Volume-cycled modes (deliver breath until preset tidal volume is reached with each breath)
• Pressured-cycled modes (deliver breath until a preset pressure is achieved within the airway) MODES OF VENTILLATION
• Ways in which ventilation is triggered, allowing the patient partial or complete control over their breathing
• Factors Affecting Selection of Ventilator Modes:  Underlying pulmonary status  Oxygenation Presence of spontaneous breathing ASSIST-CONTROL VENTILATION (ACV)
• Delivers a preset volume at a preset rate and whenever the patient initiates a breath (i.e. if the patient does not initiate a breath within a preset time, the ventilator will deliver a breath)
• Used in patients with weak respiratory muscles
• Delivers a preset volume at a preset rate and is synchronized with the patient’s effort
• Allows spontaneous breathing between ventilated breaths
• Prevents competition between patient and ventilator
• Common mode for patients requiring minimal ventilation
• Used for WEANING for ventilator support PRESSURE-CONTROLLED VENTILATION (PCV)
• Delivers positive-pressure breath until a maximum amount of airway pressure is reached, then the inspiratory phase of the breath stops
• Maximum inspiratory pressure limit is preset to help minimize ventilator-induced lung injury (VILI)
• Settings are adjusted to achieve a goal tidal volume designated by physician
• Tidal Volume Goal : based on patient’s weight and pulmonary status PRESSURE-REGULATED VOLUME CONTROL (PRVC)
• A type of PCV in which the ventilator makes pressure adjustments to aim for a predetermined tidal volume
• Using this mode, the ventilator senses any changes in lung compliance (ex. Increase in peak inspiratory pressure) and reduces the tidal volume until airway pressures are back within normal range

SYNCHRONIZED INTERMITTENT

MANDATORY VENTILATION

POSITIVE END-EXPIRATORY PRESSURE (PEEP)

ADDITIONAL VENTILATORY MODES

• Holds positive pressure in the alveoli during expiration
• Frequently used as a supplement to most modes of ventilation
• Advantages:  Prevents alveoli from collapsing at end-expiration  Improves oxygenation  Increases functional residual capacity  Range: 2 to 24 cmH2O pressure
• Disadvantage:  PEEP greater than 10 cmH2  Increased intrathoracic pressure that causes decreased venous return and decreased cardiac output (Hypotension)  Increase preload with fluids or vasopressors
• High Levels of PEEP  Increased airway pressure  VILI, hypotension, increased ICP, alveolar ventilation-perfusion mismatch CONSTANT POSITIVE AIRWAY PRESSURE (CPAP)
• Similar to PEEP but provides positive pressure during spontaneous breaths
• Increases oxygenation by preventing closure of alveoli at end-expiration thereby maximizing functional residual capacity (FRC)
• General Range : 5-10 cmH2O; more than 10cmH20 = hypotension/pneumothorax
• Frequently used to wean patients as a non-invasive method PRESSURE SUPPORT VENTILATION (PSV)
• Augments the tidal volume of spontaneous breaths by delivering a preset positive pressure during inspiration
• Can be added to SIMV and CPAP for weaning
• Range : 8-20 cmH20
• Increases patient comfort by decreasing the amount of work required in each spontaneous breath VENTILATOR SETTINGS
• Individualized settings
• Adjustments are based on ABG measurements and Arterial Oxygen saturations (SaO2)
• VT (Tidal Volume)  Amount of oxygen delivered to a patient with each preset ventilated breath; 5-15 mL/kg (average: 10mL/kg) - Back Up Rate (BUR) or Respiratory Rate  Number of breaths per minute that ventilator is set to deliver; 4-20 breaths/minute - Fraction of Inspired Oxygen (FiO2)  Percentage of oxygen delivered by ventilator with each breath 21 - 100% - Inspiratory to Expiratory Ratio (I:E Ratio)  Number of breaths per minute that ventilator is set to deliver 1;2 - Sensitivity  Determines amount of effort patient must generate before ventilator will give a breath  Too Low : patient works harder to obtain a breath  Too High : patient’s respiratory effort may compete with ventilator - Flow Rate  Determines how fast VT will be delivered during inspiration  High – increase airway pressure  Low – decrease airway pressure - Pressure Limit  Regulates maximum amount of pressure the ventilator will generate to deliver preset VT  Ventilated breath will stop when pressure limit is reached VENTILATION TERMINOLOGIES - Compliance  Elasticity of the lung tissue  Decreased compliance = increased resistance to breath - Peak Inspiratory Pressure (PIP)  Airway pressure at maximum inspiration  A.K.A. peak airway pressure - Low Pressure Alarms  LEAK or DISCONNECTION in ventilator circuit  Patient not receiving adequate ventilation - High Pressure Alarms  PIP has exceeded a safe limit  Patient at risk of VILI - Volutrauma  Injury to the lung tissue from over distension of alveoli - Barotrauma  Injury to the lung tissue from too much pressure on the airway - Atelectrauma  VILI from a low intra-alveolar pressure causing collapse of alveoli

MECHANICAL VENTILLATION COMPLICATION

- Ventilator - Associated Pneumonia (VAP) Bundles of Care  Elevation of the head of the bed (HOB)  Daily sedation vacations and assessment of readiness to extubate  Peptic ulcer disease prophylaxis  Deep vein thrombosis (DVT) prophylaxis  Daily oral care with chlorhexidine (added in 2010) **WEANING PATIENT FROM MECHANICAL VENTILLATION

• Methods of Weaning**  Assist-Control (A/C) Ventilation o Control rate is decreased; patient strengthens respiratory muscle by triggering more progressive respirations o Nursing Management:  WOF: rapid or shallow breathing, use of accessory muscles, decrease in LOC, increase in CO2 levels, decrease O2 saturation and tachycardia  Synchronized Intermittent Mandatory Ventilation (SIMV) o Indicated for patients who satisfied weaning criteria but cannot sustain adequate spontaneous ventilation for long periods o As respiratory muscles strengthen, the pressure is decreased  T-piece o Usually used when patient is awake and alert, breathing without difficulty, and has good gag and cough reflex o Maintained on oxygen level on the same or greater than oxygen concentration the patient is receiving in mech vent o WOF: respiratory distress and hypoxia **VENTILATION PPT COPY FROM DOC FERRIOL
• Principles of Mechanical Ventilation:**  “... an opening must be attempted in the trunk of the trachea, into which a tube of reed or cane should be put; you will then blow into this, so that the lung may rise again...and the heart becomes strong...” – Andrea Vesalius (1555)
• Vesalius is credited with the first description of positive-pressure ventilation, but it took 400 years to apply his concept to patient care.
• The occasion was the polio epidemic of 1955, when the demand for assisted ventilation outgrew the supply of negative-pressure tank ventilators (known as iron lungs). - In Sweden, all medical schools shut down and medical students worked in 8-hour shifts as human ventilators, manually inflating the lungs of afflicted patients. - In Boston, the nearby Emerson Company made available a prototype positive-pressure lung inflation device, which was put to use at the Massachusetts General Hospital, and became an instant success. Thus began the era of positive-pressure mechanical ventilation (and the era of intensive care medicine). - Conventional Mechanical Ventilation  The first positive-pressure ventilators were designed to inflate the lungs until a preset pressure was reached.  This type of pressure-cycled ventilation fell out of favor because the inflation volume varied with changes in the mechanical properties of the lungs.  In contrast, volume-cycled ventilation, which inflates the lungs to a predetermined volume, delivers a constant alveolar volume despite changes in the mechanical properties of the lungs.  For this reason, volume-cycled ventilation has become the standard method of positive- pressure mechanical ventilation. - A New Strategy for Mechanical Ventilation:  In the early days of positive-pressure mechanical ventilation, large inflation volumes were recommended to prevent alveolar collapse.  Thus, whereas the tidal volume during spontaneous breathing is normally 5 to 7 mL/kg (ideal body weight), the standard inflation volumes during volume-cycled ventilation have been twice as large, or 10 to 15 mL/kg.  The large inflation volumes used in conventional

mechanical ventilation can damage the lungs, and