Unit 2 Reading Notes

Unit 2: General Respiratory Oxygen Delivery, Mechanical Ventilation, PE/Heparin, ACF, ARDS, Chest Trauma, Chest Tubes, Anaphylaxis, and Burns/Parkland Respiratory Oxygen Delivery  Oxygen Therapy o Oxygen is an essential body nutrient necessary to life. Oxygen is a gas. Atmospheric air contains 21% oxygen. Two primary purposes of breathing include tissue perfusion and CO2 removal. The two systems that are key in the process of oxygenation are cardiac and respiratory. The three steps om the process of oxygenation are ventilation, perfusion, and diffusion.  Ventilation: air goes in and out, chest goes up and down.  Perfusion: blood goes around and around.  Diffusion: gases dosey-doe.  Surfactant: keep the alveoli open in the lungs. Surfactant is produced in the womb at about 24 weeks of gestation. o Gas exchange such as ventilation, perfusion, and diffusion all happen in the alveoli (normal CO2 is 2-3% for nonsmoker; CO2 is 7-9% for smokers). o Atelectasis: is the collapse of individual alveoli, IS/TCDB/movement/up and moving can all help prevent it.  Early Detection o Hypoxemia: low levels of oxygen in the blood. o Hypoxia: low levels of oxygen to the tissues. o Initial changes: as the patient worsens (brain does not like to be deprived of oxygen- CNS worsens).  HA, tachycardia, SOB, mental status change, impaired judgement, lack of coordination, lethargy, unresponsiveness, pale color, and in tripod position.  CO2 Capnography o Provides much more information than SpO2. o More accurate than SpO2. o Used to evaluate CPR quality and ROSC. o Provides information on ET tube placement/issues.  Hazards of Oxygen Therapy o Combustion: fire burns better in the presence of oxygen (common with smokers, need to educate patient). o Toxicity: therapy that exceeds need, can cause tissue injury (need as little as possible to see results). o Infection: have RT check function and cleanliness, give them extra tubing on discharge (or whatever supply they have in their room), change tubing based on company make recommendations. o Dry mucous membranes: any oxygen therapy over 4L should have humidification, encourage humidifier usage at home.  Low-Flow o Nasal cannula: delivers between 24-44% FiO2 with flow rates between 1-6L/min. o High-flow cannula: delivers up to 15L/min. o Simple face mask: delivers between 40-60% at flow rates of 5-8L/min. o Partial rebreather mask: delivers between 40-75% at flow rates of 6-11L/min (two-way valve). o Nonrebreather mask: delivers between 80-95% at flow rates at 10-15L/min (one-way valve air is coming from bag and not the atmosphere).  None of these are long-term usage devices.  There is high risk for aspiration.  High-Flow 1

Unit 2: General Respiratory Oxygen Delivery, Mechanical Ventilation, PE/Heparin, ACF, ARDS, Chest Trauma, Chest Tubes, Anaphylaxis, and Burns/Parkland o Venturi: delivers between 24-50% at flow rates of 4-10L/min (has a green dial, have different color valve pieces for different rates). o Oxymask: delivers between 24-90% at flow rates of 1-15+L/min (decreases claustrophobia, can have meds with a straw, do not have to take off mask to have other things done). o Vapotherm o Aerosol mask, face mask, tracheostomy collar: delivers between 24-100% at flow rates of at least 10L/min. o T-piece (for ET tube): delivers between 24-100% at flow rates of at least 10L/min.  Noninvasive Positive-Pressure Ventilation o CPAP (continuous positive airway pressure): continuous pressure. o BIPAP (bi-level positive airway pressure): different settings for inspiration and expiration.  Both can be used on patients with sleep apnea.  CPAP is one pressure while BIPAP is a two pressure.  If claustrophobic: try giving an antianxiety medication.  If assessing a patient with either of these:  Utilize yes and no questions.  Have them circle things on a piece of paper.  Have them write down information. Mechanical Ventilation  Life support treatment. The medical team needs to address and treat the underlying problem that led to the need for intubation. o Assess patient breathing partially or fully, this is not a cure, need to be intubated, still need to investigate why they need this intervention. o Continuous monitoring in ICU, OR, and ED.  Indications for Intubation and Mechanical Ventilation o Inability to maintain airway patency (facial trauma). o Inability to protect the airway against aspiration (stroke, ODs, alcohol poisoning). o Failure to ventilate (polio, brain steam issues, ALS, Parkinson’s, spinal cord injury). o Failure to oxygenate (COPD, pneumonia, pneumothorax, COVID). o Anticipation of a deteriorating course (serious trauma through ED, multiple fractures). o Surgery (any).  Angioedema: ask if this has happened before, and if so, what have we done for it?  Endotracheal Intubation o Endotracheal tubes come in a variety of sizes for a variety of ages and situations. o Who can intubate? Doctors, RT, Paramedics, and CRNAs. o Placed through the mouth-past the larynx-rests just above carina- about 2cm. o Used for short-term mechanical ventilation. o Whoever is doing the intubation will decide on what size they will need.  Tracheostomy o 10-14 days is the standard for being intubated. o This procedure can be done at the bedside.  RSI (Rapid Sequence Intubation) o Preferred method of endotracheal intubation in the ED. o RSI requires a rapid sequence of medications given based on weight. o The patient who is not given sedation should not have a gag reflex. o Selection of drugs may differ from provider to provider.  The medication given first is a sedative before a paralytic.  Nursing Role o Assess with insertion. 2

Unit 2: General Respiratory Oxygen Delivery, Mechanical Ventilation, PE/Heparin, ACF, ARDS, Chest Trauma, Chest Tubes, Anaphylaxis, and Burns/Parkland  Complications of Mechanical Ventilation o D: displacement of the tube. o O: obstruction of the tube. o P: pneumothorax, PE, pulse? o E: equipment failure (no oxygen, failure of the ventilator, disconnected tubing).  First assess your patient.  If there are issues with the machine, then detach the tubing and bag the patient. o Lung-  Barotrauma: distended lungs and rupture in a pneumothorax or subcutaneous emphysema (PIP alarm).  Volutrauma: lung injury that occurs when a large amount of tidal volume is delivered to one lung (was the patient recently moved?).  Atelectrauma: alveoli overworked and have shear injury.  Biotrauma: inflammatory caused by the mechanical stretching of alveoli  Lung damage.  Increased dead space (alveoli that are not involved in gas exchange). o GI-  Stress ulcers.  Malnutrition: respiratory muscle loses mass and strength.  Enteral feeding if gut working fine. o Musculoskeletal system-  Muscle atrophy. o Integumentary system-  Bed sores. o Psychosocial needs-  Experience physical and emotional stress.  Paralyzed patient being aware, long-term effects.  Delirium, agitation, anxiety. o Ventilator dependence-  Inability to be removed.  Nursing Management o Monitoring:  BP, HR, O2 saturation, RR, labs (ABGs), radiology (chest x-ray), sedation level, settings, monitor alarms, safety, communication with patient/family, frequent assessment (breath sounds, skin integrity, oral mucous membranes)  Ventilator associated pneumonia!  Weaning/Discontinue o “Weaning”: transitioning from ventilator dependence to spontaneous breathing. o Extubation: the removal of the endotracheal tube (ET).  Resources o RTs, pharmacy, providers, and nurses. USE YOUR RESOURCES! Pneumothorax  Open Pneumothorax  Tension Pneumothorax o Lung affected gets bigger and bigger, and pushes on the heart, EMERGENCY! o There is trachea deviation. o Treatment should not wait. o Needle decompression. o Need chest-tube (can be done anywhere): 4

Unit 2: General Respiratory Oxygen Delivery, Mechanical Ventilation, PE/Heparin, ACF, ARDS, Chest Trauma, Chest Tubes, Anaphylaxis, and Burns/Parkland  RN role: positioning (lay on side with arm overhead), getting the chest-tube kit, consent, get order for pain medication prior to procedure, encourage to take pain medications after procedure, education on positioning, and securing the tube. Chest Trauma/Chest Tube  Flail Chest o Fracture of at least 2 neighboring ribs.  Recent CPR, MVC, victim of crime. o Causes the lung to lose its support, you can see paradoxical chest movement (sucking in during inspiration and ballooning out during expiration).  Pulmonary Contusion o “Bruised lung” often caused by blunt trauma (rapid deceleration in MVC). o Lung sounds may be normal initially but as inflammation begins and fluid accumulates you may hear crackles and wheezing on the injured side. o Can lead to ARDS, ARF, and pneumonia. o Interview and initial assessment are very important.  What if a patient comes in the day after an MVC with chest pain or SOB?  Inspect- does this patient have seatbelt marks? Were they wearing a seatbelt? Did they hit anything during the MVC? What did they get hit with during an assault?  Pneumothorax/Hemothorax o P- air in the pleural space. o H- blood in the chest cavity. o Inspect for abdominal chest movement during respirations. o Listen for- reduction of breath sounds on affected side.  Open?  From foreign object.  Closed?  Force or spontaneous.  Tension?  Air continues to collect in pleural space but does not exit during exhalation- fatal if not treated immediately by needle decompression.  Chest Tube o Wet: compartment on bottom left with water is the water-seal (check for air leaks-looking for bubbles). Amount of sterile water in the chamber regulating suction.  Spill can go into different compartments. o Dry: has a nob, quieter, can still be picked up and be ok after falling over. Knob and internal valves control suction. Suction monitor= confirmation of suction.  Water seal chamber: stops atmospheric air to enter pleural space, expect intermittent bubbles, continuous bubbles= air leak, complete suspension of air bubbles= chest re- expansion or failure in system.  No bubbles or continuous bubbles= not good!  Drainage chamber: collects drainage output, max 2100mL. Mark chamber at end of shift, to record output. o If suction chamber not at ordered amount…  Wet: add more water.  Dry: change knob settings. o Pocket for goodies: hemostats, Vaseline gauze, foam tape (or what HCP prefers), and dry 4x4. o No striping (can cause pressure in cavity). o Check for crepitus (rice-crispies: air in the subcutaneous layer, check on back). 5

Unit 2: General Respiratory Oxygen Delivery, Mechanical Ventilation, PE/Heparin, ACF, ARDS, Chest Trauma, Chest Tubes, Anaphylaxis, and Burns/Parkland  Ends with closure of the wound.  Assessment and maintenance of cardiovascular, respiratory, GI, and nutrition.  Wound care, pain control, psychosocial support, and resources. o Rehabilitative Phase:  Begins when majority of burns are healed.  End when highest level of functioning is achieved.  Priorities: psychosocial support, trying our best to prevent scars and contractures, goal is to get patient as normal as before the burn injury.  First degree burn- superficial o Involves epidermal layer only. o Appears pink or red, skin will not slough, no eschar. o Blanches with touch. o Painful and tender, sensitive to heat. o May become slightly edematous. o Heals in 3-6 days (rarely leaves a scar). o DOES NOT COUNT IN BURN CALCULATION.  Second degree burn- partial thickness o Involves epidermis and part of the dermis. o Blisters are present, skin will slough, no eschar. o Moist appearance, usually pink to red. o Blanches with touch, hair follicles present. o Very painful. o Develops mild to moderate edema. o Heals in 7-21 days with generally no scarring and minor pigment changes.  Third degree burn- full thickness o Involves entire epidermis and dermis, can extend into subcutaneous tissue, nerve damage. o Appears white, yellow, brown, or black, no blisters. o Blanching is absent, hair follicles absent. o Wound appears dry. o Elasticity is destroyed so wound becomes leathery, firm to touch. o Marked edema, circulation issues if circumferential requiring intervention. o Painless to touch. o Does not heal without surgical debridement and skin grafting, weeks to months, scars are present.  Escharotomy o Longitudinal incisions made through eschar to release constriction. o May be necessary in presence of full thickness circumferential burns of an extremity or trunk. o Performed by a physician. o Nursing:  Assess adequate of circulation.  Frequent circulation checks hourly.  Elevate o Extremity escharotomy: may be required to a circumferential extremity burn d/t compromised circulation. o Chest escharotomy: impaired chest wall movement leading to respiratory distress, performed to improve ventilation.  Fasciotomy o Deeper longitudinal incision made extending down through the fascia. 7

Unit 2: General Respiratory Oxygen Delivery, Mechanical Ventilation, PE/Heparin, ACF, ARDS, Chest Trauma, Chest Tubes, Anaphylaxis, and Burns/Parkland o Usually performed after an escharotomy when increased compartment syndrome occurs to an extremity or abdominal.  Rules of Nines o Front and back are each 9%. o Can use your palm. For kiddos and scattered burns, you use the patient’s palm= 1% of burn. o NEED TO KNOW PERCENTAGES!  Chemical burns to Eyes o Morgan Lens, eye irrigation. This is hooked up to NS, flush the yes out, give numbing drops to patient.  Chemical burns o Need to wear PPE to provide care.  Special Types of Burn Injury o Child abuse  History  Appearance of suspicious burns.  Documentation (document what you see, what you are assessing, what you are told from relatives, document facts).  Reporting.  Burn Center Referral Criteria o Full thickness burns (3 rd degree). o Partial thickness burns >10% (2 nd degree). o Burns to face, hands, feet, genitalia, or across major joints. o Circumferential full thickness burns of an extremity or trunk. o Electrical injuries. o Chemical injuries. o Inhalation injury in addition to burns. o Pre-existing disease. o Associated trauma with burns. o Pediatric.  Smoke Inhalation o Upper airway obstruction.  Burns of face, mouth, tongue, pharynx= massive edema formation and potential for airway obstruction. Edema will continue to develop for up to 24 hours, decrease in edema by day 3.  Treatment: intubation to maintain airway patency. o Carbon monoxide poisoning  Hemoglobin binds 200x more to CO2 than to O2.  Signs: confusion, HA, dizziness, N/V.  Treatment: 100% oxygen nonrebreather mask  Carboxie hemoglobin: <3% for nonsmokers and <10% for smokers. o Cyanide poisoning  By-product of plastic.  Cyanide hemoglobin is created, no oxygen can get in.  Can occur in under a minute.  Signs: difficulty breathing, high lactic, nausea.  Treatment: cyanide antidote which contains hydroxocobalamin, a form of B12, binds to cyanide and allows body to use oxygen again, and is excreted by the kidneys.  Fluid resuscitation o Fluid shifts. 8

Unit 2: General Respiratory Oxygen Delivery, Mechanical Ventilation, PE/Heparin, ACF, ARDS, Chest Trauma, Chest Tubes, Anaphylaxis, and Burns/Parkland o Metabolic management: manage temperature, stress, pain, allow sleep. o Nutritional support: 5000 kcal/day or greater depending on severity and normal caloric needs, vitamins, enteral nutrition vs TPN. o Pain management: IV or PO. o Psychosocial well-being: emotional support for patient and family, psych consult, evaluate and monitor for PTSD, and nightmares. o Immune system: tetanus shot, antibiotic therapy (not used unless there is an infection), isolation therapy, environmental management. o GI: monitor bowel sounds, prevent ulcers. o Renal: strict I&Os, foley cares, manage fluid and electrolyte imbalances.  Wound care  Topicals o Silver sulfadiazine (Silvadene)  Water-soluble cream, which is locally non-toxic, or mix with sterile water for slurry.  Bactericidal spectrum against a wide range on gram positive and gram-negative organisms and candida albicans.  Pain-free application.  Softens the eschar, may combine with exudate to form a gelatinous layer. o Mafenide acetate (Sulfamylon)  Water-soluble cream or powder that may be mixed with saline for slurry.  Bacterial spectrum: gram-positive, gram-negative organisms, some anaerobes, but not yeast.  Pailful application. o Bacitracin and other petroleum ointments  Effective against gram positive organisms.  Painless application. o Mupirocin (Bactroban)  Ointment used against gram negative organisms.  Used when MRSA is found in wounds.  Painless application.  Should also be applied to nares, when used.  Rehabilitation o Begins at time of admission and lasts a lifetime for some patients. o Prevention of contractures:  Exercising. 10

Unit 2: General Respiratory Oxygen Delivery, Mechanical Ventilation, PE/Heparin, ACF, ARDS, Chest Trauma, Chest Tubes, Anaphylaxis, and Burns/Parkland  Positioning.  Splinting to maintain stretch. o Minimizing scarring:  Elasticized circular bandage initially.  Custom fitted pressure garments. o Other post-hospitalization issues:  Body-image changes.  Role changes.  Uncomfortable sensations in burns.  Changes in sweating pattern.  Fatigue.  Return to work or school.  PTSD Anaphylaxis  A condition in which type I hypersensitivity reaction involves of all blood vessels and bronchiolar smooth muscle, causing widespread blood vessel dilation, decreased cardiac output, and bronchoconstriction within seconds to minutes after allergen exposure.  Symptoms: o Skin reactions (hives, itching) o Low BP (hypotension) o Constriction of airways and swollen tongue or throat) o Weak and rapid pulse o N/V/D o Dizziness or fainting  Treatment: o Might receive CPR if they stop breathing or heart stops beating. o Epinephrine (adrenaline) to reduce to body’s allergic response. o Oxygen to help breath. o IV antihistamines and cortisone to reduce inflammation of the air passages and prove breathing. o Beta-agonist (ex. Albuterol) to relieve breathing symptoms. o Can use an autoinjector. 11