NCMB418 Prelim Reviewer 1

MEDICAL-SURGICAL NURSING 3 LECTURE (NCMB418): PRELIM EXAMINATION
WEEK 1: SCOPE OF CRITICAL CARE NURSING - There are different approaches in assessing patients,
CRITICAL CARE NURSING CONCEPTS most often, the head to toe approach is used. System
- According to the AACCN (2019), the assessment of approach may also be used. In assessing critically ill
critically ill patients and their families is an essential patients, it usually starts when the nurse becomes
competency for critical care practitioners. aware of the pending admission of the patient and
Information obtained from assessment identifies the continuous until transitioning to the next phase of
immediate and future needs of the patient and family care.
so a plan of care can be initiated to address or resolve - Roles of Critical Care Nurse
these problems.  Care provider
- Critical  Educator
 Crucial – Crisis – Emergency – Serious  Manager
- Critical Care Nursing  Advocate
 Care of the seriously-ill clients from point of - Goals of Critical Care
injury/illness until discharge from intensive care  Towards the survival of the critically-ill patients
 Deals with human responses to life-threatening and restoring quality of life
problems  Helping families of critically-ill patients in coping
 Comprehensive, specialized, and individualized with stress
nursing services which are rendered to patients - Common Critical Care Unit Equipment’s
with life-threatening conditions  Cardiac Monitor
- Critical Care Nurse Task  Pulse oximeter
 Care for clients who are very ill  Swanz-Ganz Catheter
 Provide one-to-one care  Arterial lines
 Responsible of making life and death decision  Central venous catheter
 At risk of injury and illness  Nasograstic Tube
 Communication Skill is of optimum importance  Chest tubes
 At risk for actual or potential life-threatening  Endotracheal tubes
health problems  Urinary catheters
- Critically-ill Client  Tracheostomy
 Require more intensive and careful nursing care  Ventilator
 At risk for actual or potential life-threatening CODE MEANING IN HOSPITAL
health problems - Code Black
 Examples:  Bomb threat
o Post-operative clients with major surgery - Code Blue
o Illness involving vital organs  A respirator has stopped working, someone’s
o Stable clients with signs of impending doom heart has stopped or they are no longer
- Classification of Critical Care Clients breathing
 Level 0: Normal Ward Care - Code Red
 Level I: At risk of deteriorating, support from  There is a fire somewhere in the building
critical care team - Code Silver
 Level II: Needs more observation or intervention,  A person with a weapon
single failing organ or post-operative care - Code
 Level III: Advanced respiratory support or basic  A situation caused by someone’s violent or
respiratory support, Multi-system failure aggressive behavior
- Principles of Critical Care PATIENT MONITORING EQUIPMENTS
 Continuous monitoring and treatment - Acute care physiologic monitoring
 High intensity therapies - Pulse oximeter
 Expert surveillance and efficiency - Intracranial pressure monitor
 Alert to early manifestations and recognition of - Apnea monitor
parameters denoting progress and deterioration
1|CELINE
LIFE SUPPORT AND RESUSCITATIVE EQUIPMENTS Drawer 5: Cardiac, Chest Drawer 5: Bottom of crash cart
Procedures Plastic apron, Intubation tray,
- Ventilatory
ECG electrodes, Restraints, Intubation pillow, ICD
- Infusion pump Sterile gloves, Masks with face (Implantable cardioverter) set,
- Crash cart shields or masks and eye Percutaneous tracheostomy set
- Intraaortic balloon pump protection, Scalpels with blades,
Dressings, drain sponge, Commonly on the top of the
DIAGNOSTIC EQUIPMENTS Betadine solution, Sutures, silk Crash Cart:
- Mobile X-Rays with needle, Cardiac needle, Defibrillator, Inventory
- Portable clinical laboratory devices Sterile towels,3 - lumen Central Checklist/ Code Blue sheets.
Venous Pressure catheter,
- Blood analyzer Chest tubes….etc On the side of the Crash Cart:
EMERGENCY CRASH CART Oxygen Cylinder
- 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 DRAWER 1 – MEDICATIONS
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. ADULT EMERGENCY DRUGS
2. Facilitates coordination of emergency equipment. (BASED ON ACLS GUIDELINES)
3. Facilitate staff familiarity with equipment Adenosine Antiarrhythmic
4. Helps ensure a properly stocked emergency cart Amiodarone Antiarrhythmic
is readily available Atropine Agent used for symptomatic
5. Ensures a properly functioning defibrillator will bradycardia
be readily available. Dextrose Anti-hypoglycemic
6. Helps save valuable time during emergency Diazepam To relieve anxiety, muscle
TYPES OF CART ARRANGEMENTS spasms, and seizures and to
Based on Airway, Breathing Based on the Need and
control agitation
and Circulation Necessity Dobutamine Vasopressor
Drawer 1: Medications Drawer 1: Medicines Dopamine Vasopressor
Classified based on the priority Epinephrine Adrenergic agent of choice for
and a Cardiac Board cardiac arrest
Drawer 2: Breathing and Airway Drawer 2: Equipments
Ambu bag, O2 Nasal cannulae, Ryle’s tube (NGT), Macro set & Etomidate Induction of rapid hypnosis (non-
Oral airways, Intubation tray, micro set, Blood set, I.V splint, barbiturate)prior or during
suction catheters, Inner Micro pore, Gloves, Kidney tray, intubation
cannulae, Endotracheal ECG electrodes & jelly, Flumazenil Antidote for benzodiazepine
tubes,Tracheostomy,….etc Tourniquets & spirit swab
Drawer 3: Circulation Drawer 3: IV fluids
Lidocaine Antiarrhythmic
IV supplies, 3-Way, Blood set, NS 9% 500 ml, NS 9% 100 ml, Magnesium In cardiac arrest if due to
ABG kits, heparinized Isolyte P hypomagnesemia
aspirators, Needles, Alcohol Midazolam Sedative
swabs, Syringes….etc
Drawer 4: Circulation Drawer 4: Open tray on the top
Naloxone Antidote for opiate narcotics
IV solutions and tubing- LR, NS, Disposable syringes, Extension Nitroglycerin Nitrates; to prevent chest pain
D5W, IV Tubing, Macro & Micro no.10cm, 200cm, IV cannulae, Norepinephrine Vasopressor
drip, Extension tubing, Blood Needles, Intra osseous needle, Pancuronium Paralytic agent
pump tubing, Arm boards: long Defibrillator
& short…etc Procainamide Antiarrhythmic
2|CELINE
Sodium Alkalinizer used in metabolic 10. Sterile towels
Bicarbonate acidosis 11. Petroleum gauze
Succinylcholine Muscle relaxant 12. Cutdown tray
Vasopressin Antidiuretic hormone, 13. 3 – Lumen CVP Catheter Kit
vasoconstrictor 14. Chest tubes (1 each: 28 FR, 32 FR)
Verapamil Calcium channel blocker DRAWER 4 – CIRCULATION (IV AND BLOOD DRAW
DRAWER 2 – AIRWAY/BREATHING SUPPLIES SUPPLIES)
- 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)
- Contents: 5. ABG Kits (2 sets); Heparinized aspirators (2pcs)
1. AMBU Bag 6. Disposable needles (6 pcs each of 18G, 20G,
2. O2 Nasal Cannula 22G, 25G)
3. O2 Flow meter with adapter 7. Alcohol swabs
4. Oral airways (1 pc each: 10mm, 9mm, 8mm) 8. Micropore tape and Leucoplast tape
5. Intubation trays (Laryngoscope handle: Straight 9. IV Cannula (2 rach of 21G, 23G)
and curved blades; 10 cc syringe; lubricant) 10. I.V. Start kits (2 sets)
6. Stylet 11. Disposable syringes (2pcs tuberculine; 6pcs -
7. C Cell batteries (2 pcs) 3cc, 6pcs - 5cc, 6pcs – 10cc, 2pcs - 20cc, 1pc -
8. Laryngoscope light bulbs (2 pcs) 50cc)
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, DRAWER 5 – CIRCULATION: IV SOLUTIONS AND
8.5, 9.0) TUBINGS
18. Tracheostomy tubes (Size # 4, # 6, # 8) - Contents:
19. Inner cannulas (size # 4, # 6, # 8) 1. IV Solutions
20. 1 pc End-tidal CO2 detector o 1 Lactated Ringers 1-liter bottle
DRAWER 3 – CIRCULATION CARDIAC, CHEST PROCEDURE o 2 Normal Saline 1-liter bottle
- Contents: o 2 Normal Saline 250 cc bottle
1. 6pcs EKG electrodes o 2 D5W 500cc
2. Arm restraints o 2 D5W 250cc
3. Sterile gloves 2. IV Tubings
(2 pairs each size: 6, 7, 8) o 2 Macrodrip tubing
4. 2pcs Masks with face o 3 Microdrip tubing
shields or masks and eye protection o 2 Extension tubing
5. Scalpels with blades o 1 Buretrol/Soluset
6. Dressings: 4X4 10 packs o 1 Filter set/Blood tubing
7. Betadine solution 3. IV Splint/Armboards
8. Sutures (2 each: 000 Silk with needle; 0 Silk o (1 Long; 1 Short)
needle
9. Cardiac needle 20G
3|CELINE
DRAWER 6 – PROCEDURE TRAYS AND MISCELLANEOUS - Breathing
SUPPLIES  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:
- Contents: o Is the patient alert and responding?
1. Cutdown tray o Normal/Signs: The patient is alert and
2. 3 Lumen CVP Catheter Kit responding to questions in a logical manner
ASSESSMENT FRAMEWORK FOR CRITICAL NURSING when assessed (Alert/responds to
- Assessment Framework voice/responds to pain/no response,
 Starts from the awareness of the nurse of the unconscious)
client’s admission and continues until transition o Possible reasons for Unresponsiveness:
to the next phase of care  Hypoxia, Ketoacidosis (Ketone Breath)
- Stages:  Head injury, Drugs, or Stroke
 Pre-arrival assessment o Nursing Action
 Admission quick-check  Place patient in the recovery position
 Comprehensive Admission Assessment (side lying) unless a spinal injury is
 On-going Assessment suspected.
PRE-ARRIVAL ASSESSMENT - Disability Assessment
- Begins when the information is received about the  Assessment Data
pending arrival of the patient o Is there evidence of fluid loss, blood loss?
- Abbreviated report on patient o Normal signs: No signs of loss of body fluids
- Complete room set-up including verification of o Abnormal signs: Evidence of vomiting and/or
proper equipment functioning diarrhea, Blood loss, and Loss of fluid through
- Determines the possible picture of the client and his burns
or her needs. (anticipate possible resources needed o Nursing Action: Risk assessment for
by the patient) hypovolemic shock.
- Starts as soon as the nurse becomes aware of a - Exposure
patient coming in the ICU, whether from the ward,  Assessment Data
operating room or emergency room 1. Evidence of trauma/injury
- Usual documentation – abbreviated report on patient  Normal signs: (-) signs of physical
(age, gender, chief complaint, diagnosis, pertinent damage to the person, comfortable in
history, physiologic status, invasive devices, any position; calm facial expression.
equipment and status of laboratory or diagnostic  Abnormal signs: Unresponsive patient
tests) with facial grimacing, frowning signs of
ADMISSION QUICK-CHECK bruising, Physical trauma, Foreign object
- Obtained immediately after the arrival and in the person, abnormal movement of
assessment the chest; immobility.
- Based on the parameters represented by ABCDE and  Disability: Evidence of Trauma
General Appearance (General appearance of the  Nursing Action:
client is checked [i.e. consciousness or  Attempt to open the airway
responsiveness, allergies, etc.]) where safe and possible for
- Airway the patient.
 Instruct the client to talk  If you suspect the person may
 Rise and fall of chest have a cervical spine injury,
 Rate, rhythm, depth, symmetry
4|CELINE
open the airway using a jaw pH: 7.35 -7.45
PCO2: 35 - 45 mmHg
thrust rather than a head tilt.
HCO3: 22-26 meq/L
2. Is there evidence of factors that may be ECG (+) of abnormal
related to the patient’s condition? complexes and
 Normal Findings: A safe environment irregularities in rate
Urine Output Normal:
 Abnormal findings (+): Pedia: > 0.5 ml/Kg
 Causes of injury or trauma include: body wt/H
empty medication packets, empty
Adult: 1 ml/Kg body
bottles of alcohol, sharp objects, wt/H
etc.
 Nursing Action: Look for causes of injury (+) Oliguria
(+) Polyuria
or trauma Negative urine
- Quick guide when undertaking a rapid assessment balance despite
and response to clinical deterioration: rigorous fluid
replacement
Assessment Data Abnormal Signs Interpretation/
Nursing Action Fluid Balance Fluid balance < or > =
based on a minimum
Have you listened to Pt. is confused, ALWAYS listen and
input of 2 L/24 H.
the patient’s unable to give be alert to info
Central Venous Mid-axilla:
relative/s’ story of appropriate answers; regardless how
Pressure (CVP) <Hypovolemia:
the event? unresponsive, confusing it can
CVP: < 2-6 mmHg
unconscious. seem; note the
Hypovolemia/
time; It may be
cardiac failure.
important.
CVP: 2-6 mmHg
Do you know the The patient may be a If the patient is not
Level of APVU: PV-U
patient? registered DNR; for resuscitation,
Consciousness GCS: <15
dated and signed this does not mean
Pain Ax Elevated pain score
with an agreed time that active Tx has
frame. been witheld. Results of Blood Normal:
Always ask to obtain Studies Glucose: 4-8 mmol/L
Pt. admitted in the a collaborative Creatinine: 60-120
last 24 H & has no agreement of the Px micromol/L
prescribed limiting Care Plan. Na: 135-145 mmol/L
directives. K: 3.5 – 4.5
If the patient is a Mg: 1.25 – 2.5
Pt. is not known by recent admission Cl: 95 – 108
the staff. and no info is WCC: 4-12
available, then 10(9)/L
assume that all COMPREHENSIVE ADMISSION ASSESSMENT
active treatment - Determines the physiologic and psychosocial baseline
continues.
for comparing data and to determine whether the
If the patient does status is improving or deteriorating)
not have a recent - Physical assessment is usually by system approach
Hx of continuous
- Psychosocial assessment is performed, too, as this
care by the nursing
staff then ensure could determine prognosis
that a baseline of Ax - Defines the status of the patient prior to the illness
details is recorded - Assessment data includes:
for comparison.
Vital Signs Below or above the Assess the patient in  Past Medical History
normal range context:  Social History
New scores?  Psychosocial history
(+) pattern or trend
in deterioration?  Spirituality
Evidence of sepsis?  Physical Assessment
Recent history of  Psychosocial assessment
head trauma?
Arterial Blood Gas ABG: Alkalosis or
 General communication
Analysis Acidosis  Coping styles
Normal:  Anxiety and Stress
5|CELINE
 Family needs  Stage III
 Unit orientation  The area has a crater-like
 Referrals appearance due to damage below
- In-depth Assessment the skin’s surface
 Past Medical History  Stage IV
o Past hospitalizations  The area is severely damaged and a
o Medications large wound is present
o Allergies ON-GOING ASSESSMENT
 Social History - Determines response to therapy, progression of
o Interaction processes improvement of his or her condition
o Vices - Performed as long as the client is in the hospital,
 Psychosocial Assessment Continuous assessment is necessary to determine
o Behavior outcome of the client’s disease
o Emotion culture - Done periodically
- Physical Assessment - Unstable patients: every 15 mins
 Nervous System - Stable patients: every 2-4 hours
o GCS scoring - SBAR
o Pupil assessment  A structured communication tool used as a
o LOC framework for improving interprofessional
o Trauma communication and patient safety.
 Cardiovascular System  As a tool, it meets the quality requirements for
o Check for pulses safe and effective clinical documentation of care.
o Check perfusion  Situation (S)
 Respiratory System o Identify yourself, your location and the
o Breathing pattern patient.
o Arterial blood gas result o Describe the problem, your concern and
o Auscultation reason for calling.
o Secretions  Background (B)
 Urinary System o Provide the patient’s reason for admission,
o Amount diagnosis and relevant history.
o Color  Assessment (A)
o Odor o Provide both your subjective concerns and
o Dx: BUN/Crea/UA objective data.
 Gastrointestinal System o Offer provisional Dx/ clarify your concern
o Nutrition and hydration status  Recommendation/s (R)
o Contour and symmetry of abdomen o Explain what you need, when and where
o IAPePa (Inspection, Auscultation, Percussion, WEEK 2: ETHICAL AND LEGAL CONSIDERATION IN
Palpation) CRITICAL CARE NURSING
 Integumentary System FOUNDATION FOR ETHICAL DECISION MAKING
o Check the integrity 1. Professional codes and standards
o Ulcer stages: 2. Institutional policies
 Stage I 3. Legal standards
 The area looks red and feels warm 4. Principles of Ethics
to touch  Beneficence
 Stage II o Best interest of the patient remains more
 The area looks more damaged and important than self-interest
may have an open sore, scrape, or  Non-Maleficence
blister o Not only the will to do good but the equal
commitment to do no harm
6|CELINE
 Autonomy o No sedation
o Freedom from external control; acknowledge o 24 hours before elective surgery
and protect a patient’s independence o Legal age and mentally capable
 Privacy o 2 surgeons signed the consent in emergency
o Right of the patient to be free from o Emancipated minor*
unjustified access by others o Authorized representative*
 Confidentiality  Emancipated Minor:
o Protection of information; patient o A college student living away from home
information should be shared within the o In military service
healthcare team directly involved in patient o Pregnant
care o Anybody who has given birth
 Fidelity  Authorized Representative:
o Agreement to keep promises o Minor
 Veracity o Unconscious
o Being truthful or honest o Psychologically incapacitated
 Justice  Exemptions:
CONTEMPORARY ISSUES o If experts agreed that the care is an
- Informed Consent EMERGENCY, has life-threatening conditions,
 Also known as Operative permit or Surgical or patient is unconscious and authorized
consent representative cannot be reached
 Patient’s autonomous decision about whether to - Determining Capacity
undergo certain diagnostic procedure,  Reflects a medical decision on patient’s
therapeutic measures, or surgical procedure functional ability to participate in the decision-
 Purpose: making process; patients are presumed to have
o The client understands the nature of the the determining capacity
treatment and its advantages and - Advance Directives
disadvantages  Statements made by a patient with decision-
o To indicate that no coercion was made making capacity describing the care of treatment
before signing he/she wishes to receive when no longer
o To protect the client against unauthorized competent
procedure o Treatment Directives (“Living Will”)
o To protect the surgeon and the hospital  Specify in advance his/her treatment
against legal actions choices and which interventions are
 Includes: desired
o Name of Procedure o Proxy Directives
o Name of MD  Durable power of attorney for health
o Name of witness (RN) care
o Date - End-of-Life Care Issues
o Potential complication/Disfigurement  End-of-Life care includes physical, emotional,
o Obtained: MD social, and spiritual support for patients and their
o Secured: RN families
o Given: Pt  Goal:
 3 Major Elements: o To control pain and other symptoms to make
o No Coercion/Voluntary the patient as comfortable as possible;
o Sound Mind quality of life
o Ultimate Decision Maker (patient)  Decisions to forego life-sustaining
 Requisites for Validity: treatments
o Written consent made by the client  Nutrition and Hydration
o No signs of pressure
7|CELINE
 Given thru NGT, IV, or duodenal integrity. They support and respect the dignity
feedings, or gastrostomy and universal rights of all people, including
 Nutrition and hydration status patients, colleagues and families
expedites the patients return to an 3. Patient’s Bill of Rights and Obligations
acceptable level of functioning  Right to Appropriate Medical Care and Humane
 Pain Management Treatment
 One of the main components of  Right to Informed Consent
palliative care  Right to Privacy and Confidentiality
 Done if there is a decision to forego  Right to Information
life-sustaining treatment  Right to choose Health Care Provider and Facility
 “Should provide interventions to  Right to Self-Determination
relieve pain and other symptoms in  Right to Religious Belief
the dying patient even when those  Right to Medical Records
interventions entails risks of  Right to Leave
hastening death” – ANA (Code for  Right to Refuse Participation in Medical Research
Nurses)  Right to Correspondence and to Receive Visitors
 Resuscitation Decisions – DNR, DNI  Right to Express Grievances
 Do Not Resuscitate (DNR) Orders  Right to be Informed of His Rights and Obligations
 Also known as “No Code” as a Patient
 Withhold CPR - Responsibility
 No other heroic act to be perform  Keep appointments and notify clinic personnel 24
on the patient hours prior, if unable to keep scheduled
appointment.
 Nurse documents participation on
 Be involved and follow the plan of care.
the discussion
 Provide a complete medical history, medications
- Paternalism
and other matters relating to your health
 Deliberate restriction of autonomy by health care
 Inform the provider of any changes in your health
professionals based on the idea that they know
condition.
what is best for the client
 Provide a copy of your Medical Advance Directive
 Refers to instances in which the principles of
and/or Medical Power of Attorney (if applicable
beneficence overrides autonomy
and in effect)
LAWS ON CRITICAL CARE NURSING
 Ask questions about specific problems and
1. Scope of Nursing Practice based on R.A. 9173
request information when not understanding
 A person shall be deemed to be practicing
your illness or treatment.
nursing within the meaning of R.A No. 9173 when
 Accept results or consequences if you refuse
he/she singly or in collaboration with another,
treatment, do not follow the provider's
initiates and performs nursing services to
recommendations or leave the clinic against
individuals, families and communities in any
medical advice.
health care setting
4. Dying Patient’s Bill of Rights
2. Nurses’ Code of Ethics
 I have the right to participate in decisions
 The Filipino registered nurse, believing in the
concerning my care
worth and dignity of each human being,
 I have the right to expect continuing medical and
recognizes the primary responsibility to preserve
nursing attention even though “cure” goals must
health at all cost.
be changed to “comfort” goals
 This responsibility encompasses promotion of
 I have the right to not die alone
health, prevention of illness, alleviation of
 I have the right to be free of pain
suffering, and restoration of health
 Nurses demonstrate professional values such as
respect, justice, responsiveness, caring,
compassion, empathy, trustworthiness and
8|CELINE
- What is the Dying patient Bill of Rights in the WEEK 3: QUALITY AND SAFETY IN MANAGING CRITICAL
Philippines? CARE UNITS
 The Natural Death Act. also known as the Senate EVIDENCE BASED NURSING (EBN)
bill 1887, filed by former Philippine senator, - Under the umbrella of Evidence Based Practice.
Miriam Defensor Santiago gives a patient who is Definitions of evidence-based nursing have varied in
"terminally ill” or in "comatose condition" the scholarly Literature.
right to die when the patient or their family - Scott and McSherry's extensive literature review
refuse to pursue further medical treatment and looked at commonalities between EBN definitions
instead allow the "natural process” and synthesized them to come up with the following
- Senate Bill 586 definition:
 An act providing palliative and end-of-life care,  "An ongoing process by which evidence, nursing
appropriating funds therefor and for other theory and the practitioners’ clinical expertise are
purposes critically evaluated and considered, in
THE PROCESS OF ETHICAL ANALYSIS (AACCN, 2019) conjunction with patient involvement, to provide
1. Assessment delivery of optimum nursing care for the
 Identify the problem individual," (Melnyk, B, Fineout-Overholt, E.,
o Clarify the competing ethical claims, Stillwell, S., and Williamson, K., 2010).
conflicting obligations, and personal and STEPS: (Melnyk, B, Fineout-Overholt, E., Stillwell, S., and
professional values; acknowledge the Williamson, K., 2015)
emotional and communication issues - Step 1: Ask clinical questions
 Gather data  PICOT format
o Distinguish the morally relevant facts, o P – atient / population of interest / problem
including medical, nursing, legal, social, and (start with the patient, or group of patients,
psychological facts; clarify patient’s religious or problem)
and philosophical beliefs and values o I – ntervention or area of interest (What is
 Identify the individuals involved in the problem’s the proposed intervention?)
development and who should be involved in the o C – omparison intervention or group (What is
decision making; discern factors that may impede the main alternative, to compare with the
the patient’s ability to make the decision intervention? This might be: no intervention.)
2. Plan o O – utcome (What is the anticipated or
 Consider all options and avoid restricting choices hoped-for outcome?)
to the most obvious o T – ime frame (How long will it take to reach
 Identify the pros and cons (“harms and goods’) the desired outcome?)
 Analyze if plan is in accordance with ethical  P.I.C.O.T Format
theories and principles o This provides an efficient outline for
 Look into institutional policies and/or procedures searching electronic databases (to retrieve
that address the issue articles relevant only to the clinical question)
3. Implementation  Example: "I work in MICU where
 Choose a plan and act (Anticipate Objections) ventilator-related infections are a
4. Evaluation common problem. I've heard that oral
 Outline the results care of ventilated patients even with
 Identify what harm or good occurred as a result water can help prevent this. I wonder if
 Identify necessary changes in the institutional there's any evidence for that and
policy/ies or other strategies to avoid similar whether it might help our patients?"
issues in the future  P (Patients in MICU)
 I (Water)
 C (Oral care with water only)
 O (Prevention of ventilator-related
infections)
9|CELINE
 T (Will depend on the time frame relevant, valid, reliable, and applicable to the
set) 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
 The S.PI.D.E.R Tool decision or change
o Can be used when dealing attitudes and  Research evidence alone is not sufficient to
experiences rather than justify a change in practice. Clinical expertise,
o Scientifically measurable data since it focuses based on patient assessments, laboratory data,
less on the intervention and more on the and data from outcomes management programs,
design as well as patients' preferences and values are
o Deals with "samples" rather than a "patient" important components of EBP
or "populations". - Step 5: Evaluate the outcomes of the practice
 S – ample (group of participants) decisions or changes based on evidence.
 PI – phenomenon of interest (how and  To monitor and evaluate any changes in
why of behaviors and experiences) outcomes (positive effects can be supported and
 D – esign (how the study was devised negative ones remedied)
and conducted) - Note: EBP results should be disseminated.
 E – valuation (measurement of  Leads to needless duplication of effort, and
outcome; might be subjective and not perpetuates clinical approaches that are not
necessarily empirical) evidence based
 R – esearch Type (qualitative, or  Examples of ways to disseminate successful
quantitative, or mixed) initiatives: presentations at local, regional, and
o Research questions framed using the SPIDER national conferences; reports in peer-reviewed
tool tend to begin with "What are the journals; professional newsletters; and
experiences of ...?" publications for general audiences
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 SALIENT POINTS TO CONSIDER IN USE OF EBN PRACTICE
when questions are asked - Promotes use of EBP among advanced practice
- Step 3: Critically appraise the evidence. nurses and direct care nurses
 Once articles are selected for review, these must - Identifies a network of stakeholders who are
be rapidly appraised to determine those most supportive of the EBP project
- Cognitive behavioral theory underpinnings
10 | C E L I N E
- Emphasis on healthcare organizational readiness and  Advantages:
identification of facilities and barriers o Makes sure that all appropriate steps are
- Encompasses research, patient values, and clinical followed.
expertise as evidence. o Offers a systematic improvement method.
QUALITY AND SAFETY MONITORING o Is an effective process improvement guide.
1. Care bundles o Informs future improvement by providing
 A group of 3-5 evidence-based interventions, feedback.
when performed together, have a better o Maintains order during problem solving.
outcome than if performed individually  Disadvantage:
 Can be used to ensure the delivery of the o Requires significant commitment over time.
minimum standards of care MULTIDISCIPLINARY PLANS OF CARE
 Can be used as an audit tool to assess the - Benefits to both patients and the hospital system:
delivery of interventions (NOTE: cannot be used 1. Improve patient’s outcome
to assess how well individual interventions are 2. Increased quality and continuity of care
performed) 3. Improve communications and collaboration
 Encourage the review of evidence and 4. Identification of hospital system problems
modification of clinical care guidelines, 5. Coordination of necessary services and reduced
engendering staff education in best practice duplication
 Key principle = high level of adherence to all 6. Prioritization of activities
components 7. Reduce length of stay and health care costs.
 Example: The sepsis care bundle, part of the - Format for the Multidisciplinary Approach
international Surviving Sepsis campaign, is the Categories:
most widely utilized bundle. 1. Discharge outcomes
2. Checklists 2. Patient goals
3. Continuous quality improvement 3. Assessment and evaluation
4. PDCA (Plan-Do-Check-Act) cycle (Deming Cycle, 4. Consultations
Shewhart Cycle) 5. Tests
 A management tool for continuous improvement 6. Medications
of a business's products or processes. It can be 7. Nutrition
applied to standardize nursing management and 8. Activity
thus improve the nursing quality and increase the 9. Education
survival rate of patients 10. Discharge planning
 Uses: implementation of change, solve problems, - Note: Primary Consideration = Patient’s Safety
and continuously improve nursing management INFORMATION AND COMMUNICATION TECHNOLOGIES
processes IN CCU
 Cyclical nature; allows it to be utilized in a 1. Clinical Information System
continuous manner for ongoing improvement 2. Computerized provider order entry (CPOE)
o P - PLAN the change or improvement 3. Hand-held Technologies
o D – DO = conduct a pilot test of the change 4. Tele-health Initiatives (Tele-ICU)
o C – CHECK = gather data about the pilot ADVOCACY: ACCESS TO SOCIAL CARE SERVICES
change to ensure the change was successful 1. PhilHealth
o A – ACT = implement the change on a 2. DOH
broader scale; continue to monitor the 3. DSWD
change and repeat as necessary by repeating 4. PAGCOR
the cycle 5. PCSO
 Expertise Required: easy to use and requires little WEEK 3: CARE BUNDLES
or no training. - Purpose:
 Continuous Monitoring and treatment.
 Required emergency interventions.
11 | C E L I N E
 Care for patients who are medically unstable or - Bed Space Beds
seriously ill.  150 200 square feet per open bed with 8 feet in
 Care for patients who do not have much chance between beds. The beds should be 2.5 - 3 meters
for recovery due to the severity of their illness or (7-9 feet) apart, to allow free movement of staff
traumatic injury. and equipment, reducing risk of cross
- History: contamination.
 1854 Crimean war – Florence Nightingale  225 250 square feet per bed if in a single room.
 Dr. W.E. Dandy – 3 bedded Neurosurgical unit in - Infrastructure
US  Patients must be situated so that direct or
 1927 first hospital for premature born infants in indirect (e.g. by video monitor) visualization by
Chicago healthcare providers is possible at all times.
 2nd world war – shock wards  The preferred design is to allow a direct line of
 Outbreak polio Epidemic – respiratory ICU vision between the patient and the central
 1950 peter safar anathetist ‘Advanced support of nursing station.
Life’ (sedated & ventilated)  Modular design sliding glass doors partitions to
 Nurses practice – sick patients located near the facilitate visibility.
nurse’s station receive more attention. - Partitions
 Development of various specialty & ICU  Privacy partitions should be of material that is
significantly reduced the mortality and hopital easily cleaned and should be cleaned weekly and
stay time any time that it becomes soiled or contaminated.
 Major surgeries – liver transplant, kidney  If curtains are used, they should be changed
transplant and pancreatectomy weekly and between patients.
- Location: - Central Station
 Should be a geographically distinct area within  Provide a comfortable area of sufficient size to
the hospital, with controlled access. accommodate all necessary staff functions.
 No through traffic to other departments should  There must be adequate overhead and task
occur. lighting, and a wall mounted clock should be
 Supply and professional traffic should be present.
separated from public/visitor traffic.  space for adequate computer terminals and
 Location should be chosen so that the unit is printers is essential
adjacent to, or within direct elevator travel to - Environment
and from, the Emergency Department, Operating  Signals alarms add to the sensory overload need
Room, Intermediate care units, and the Radiology to be modulated.
Department.  Floor coverings and ceiling with sound absorption
- Design of Unit: 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
- Bed Strength  Nurses waiting/resting room
 Ideally 8 to 12 beds  Doctors waiting/resting room
 Larger areas difficult to administer and smaller  Lab
areas not being cost effective  Pantry
 3 to 5 beds per 100 hospital beds for a level III  Visitors room
ICU / 2 to 20 of the total number of hospital beds  Store room & Changing room
 1 isolation bed for every 10 ICU beds
12 | C E L I N E
- Infrastructure  EPIC/NICE guidelines (UK)
1. Rails alongside the bed WHAT ARE “CARE BUNDLES”?
2. Wall sockets for oxygen and pressurized air as - A Care Bundle is a collection of interventions (usually
well as for suction. At least 2 oxygen and 3-5) that are evidenced based
pressurized air outlets are needed and 3 - All clinical staff know that these interventions are
aspirators per patient. best practice but frequently their application in
3. A bell or intercom for calling the nurse should be routine care is inconsistent
at each bed. - A Care Bundle is a means to ensure that the
4. A table and a telephone with an outside line application of all the interventions is consistent for all
should be at the bedside. patients at all times thereby improving outcomes
5. Armchairs should be on hand, preferably TYPES OF CARE BUNDLES
adjustable ones, to allow patients to sit up if they - WHO Surgery Safety Checklist
can. - Urinary Catheter Care Bundle
- Types Specialized types of ICUs include:  Insertion and Management
 Neonatal intensive-care unit(NICU) - Clostridium Difficile Care Bundle
 Special Care Nursery (SCN) - Ventilator Assisted Pneumonia (VAP) Care Bundle
 Pediatric intensive-care unit (PICU) - Palliative Care Bundle
 Psychiatric intensive-care unit (PICU) - Pressure Area Care Bundle
 Coronary care unit (CCU) - Sepsis Care Bundle
 Cardiac Surgery intensive-care unit (CSICU) - PVC Care Bundle
 Cardiovascular intensive-care unit (CVICU) VENTILATOR ASSOCIATED PENUMONIA (VAP) CARE
 Medical intensive-care unit (MICU) BUNDLE
 Medical Surgical intensive-care unit (MSICU) - Evaluation of the head of the bed to between 30°-45°
 Surgical intensive-care unit (SICU) - Daily sedative interruption and daily assessment of
 Overnight intensive recovery (OIR) readiness to extubate
 Neurotrauma intensive-care unit (NICU) - Peptic ulcer disease prophylaxis
 Neurointensive-care unit (NICU) - Deep venous thrombosis prophylaxis if not
 Burn wound intensive-care unit (BWICU) contraindicated
 Trauma Intensive Care Unit (TICU) URINARY CATHETER CARE BUNDLE
 Surgical Trauma intensive-care unit (STICU) - Insertion
 Trauma-Neuro Critical Care (TNCC)  Insert only for specific reasons
 Respiratory intensive-care unit (RICU) o Urinary output in critical ill
 Geriatric intensive-care unit (GICU) o Bladder outlet obstruction or neurogenic
 Mobile Intensive Care Unit (MICU) bladder dysfunction
 Post Anesthesia Care Unit (PACU) o Prevent contamination of sacral wounds
- Models o Terminal care
 Open ICU model is one where specialty teams  Competent HCW to insert
have full admitting rights and where an  Aseptic technique
intensivist is merely "consulting".  Closed system with bag below bladder
 Closed ICU model is one where the intensivist is - Management
the admitting medical officer and the specialty  Review need for catheter daily
teams collaborate with ICU staff  Empty when ¾ full and use clean container for
STANDARDS OF CARE each patient
- Healthcare workers are committed to delivering high  Secure catheter to leg/abdomen
standards of care to all patients  Urine samples from sampling port only
- Standards of care are generally defined by evidence  Hand hygiene & PPE before and after any
based guidelines, e.g. infection control guidelines: catheter care
 SARI guidelines
 CDC guidelines (USA)
13 | C E L I N E
PRESSURE ULCER PREVENTION BUNDLE WEEK 4: RESPIRATORY ASSESSMENT TECHNIQUES AND
1. Risk assessment (Braden tool) MONITORING
2. Skin assessment 8 hourly FROM DOC FERRIOL’S PPT
3. Head of bed <30° unless contraindicated or - Structures:
superseded by VAP bundle  The upper portion filters, moistens, and warms
4. Incontinence skin care air during inspiration
5. Position change  Nose – for smell, aids in phonation
 Bed - 2 hourly  Paranasal Sinuses – aids in phonation
 Chair - hourly  Pharynx – helps destroy incoming bacteria
6. Heel elevation  Larynx – voice production
7. Nutritional assessment  Trachea – furnishes open passageway for air
8. Pressure relief mattresses (not a replacement for going to and from the lungs
positional change)  The lower portion consist of lungs, which enable
CLOSTRIDIUM DIFFICILE CARE BUNDLE the exchange of gases between blood and air to
- Isolate all CDI patients in a single room with clinical regulate arterial Po2, Pco2, and Ph: left lung has 2
hand washing sink and either en suite facilities or a lobes and the right lung has 3 lobes
designated toilet/commode until they are at least 48  Bronchi – right and left bronchus branches into
hours’ symptom free segmental bronchi all containing C-shaped
- Review the patient's antibiotic regimen - stop cartilage
inappropriate antibiotics  Bronchioles – secondary bronchi-terminal
- Check that all HCWs remove PPE (gloves and aprons) bronchioles, respiratory bronchioles –alveolar
immediately after each contact with CDI patient and ducts
their environment  Alveoli – squamous epithelial cell (type1) for
- Ensure that HCWs perform hand hygiene with liquid rapid gas exchange. Type II cells produce
soap and water immediately after removal of PPE surfactant to prevent alveolar collapse. Type III
- Check that the CDI patient's immediate environment are macrophages that protect against bacteria by
and all patient care equipment has been cleaned phagocytosis
today with a neutral detergent and disinfected with a  Visceral pleura that joins parietal pleura
sporicidal disinfectant - Anatomy Review: Respiratory Tract
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
14 | C E L I N E
- Physiology of Respiration - Lung Volume/Body Plethysmography
 Mechanism of breathing 1. Tidal Volume: average amount expired after
1. Phrenic nerve stimulation normal inspiration; approximately 500ml
2. Thorax increases in size 2. Expiratory reserve volume (ERV): largest
3. Intrathoracic and intrapulmonic pressure additional volume of air that can be forcibly
decreases expired after a normal inspiration and expiration;
4. Air rushes from positive pressure in the 1000-1200 ml
atmospheres to negative pressure in the 3. Inspiratory reserve volume(IRV): largest
alveoli additional volume of air that can be forcibly
5. Inspiration is completed with stimulation of inspired after a normal inspiration; 3000 Ml
the stretch receptor - Pulmonary Function
6. Expiration occurs passively as a result of 4. Residual Volume: air that cannot be forcibly
recoil of elastic lung tissue expired voluntarily from the lungs; 1200 ml;
 Control of Respiration increased in COPD as lungs lose elasticity and
1. Alveolar stretch receptors respond to ability to recoil, resulting in air trapping
inspiration by sending inhibitory impulses to 5. Vital Capacity (TV + IRV + ERV); amount of air that
inspiratory neurons in the brainstem to can be forcibly expired after forcible inspiration;
prevent lung overdistention (Hering-Breur 4600 ml; decreases with COPD, neuromuscular
Reflex) disease, atelectasis
2. Central and peripheral chemoreceptors 6. Forced expiratory volume (FEV): volume of air
3. MO and pons-control rate and depth of that can be forcibly exhaled within a specific
respirations 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
15 | C E L I N E
ADVENTITIOUS BREATH SOUNDS

DIFFUSION OF GASES BETWEEN AIR AND BLOOD BREATH SOUND DESCRIPTION ETIOLOGY
1. Ventilation-perfusion (V/Q) ratio Crackles Soft, high-pitched Fluid in the airways
2. Direction of diffusion discontinuous
popping sound
3. Low V/Q alveoli poorly ventilated but capillary blood during inspiration
is adequate, blood is shunted past the alveoli without
adequate gas exchange (atelectasis, pneumonia) - Coarse - Originating - COPD
from bronchi
4. High V/Q alveolar ventilation is adequate, but
capillary blood flow is not; adequate gas exchange - Fine - Originating - Pneumonia
does not take place because of dead space from alveoli
(pulmonary embolism, cardiogenic shock) Rhonchi Deep low-pitched Secretions or tumor

5. Absence of V/Q causes a silent unit; no gas exchange rumbling sounds
(pneumothorax) during expiration
caused by air
EFFECTS OF AGING moving out of
- Progressive loss of elastic recoil of lungs – due to narrowed airways
elastin & collagen fiber changes
Wheezes Continuous musical Bronchospasm;
- Increased respiratory muscle workload – due to
high-pitched, asthma
calcification of soft tissues in chest wall whistle-like sounds
- Total lung capacity remains constant Pleural Friction Rub Harsh, crackling Secondary to
- Increased residual lung volume – result of changes in sounds, like 2 inflammation
pieces of leather or loss of pleural
aging being rubbed fluid
AUSCULTATION OF BREATH SOUNDS together during
inspiration alone or
both inspiration &
expiration
- 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
ANTERIOR POSTERIOR large airways); result of air moving in and out of
alveoli; sounds are quiet, low- pitched, inspiration
longer than expiration
16 | C E L I N E
 Broncho-Vesicular Sounds (near main stem  Reports: numbers are absolute numbers and
bronchus) result from air moving through smaller percent predicted compared to normal healthy
air passages; sounds are moderately pitched, individuals of the same height, weight and gender
breezy, equal I and E  If the FEV1 and FVC are low and the ratio of
- Adventitious Sounds FEV1/FVC is normal, this is called restrictive lung
 Fine Crackles disease. This is seen when the lungs are small or
o Pneumonia and pulmonary edema stiff or are confined by the rib cage. If the FEV1
 Coarse Crackles and FEV1/FVC are low, this is called obstructive
o Pneumonia, COPD, pulmonary edema lung disease.
 Wheezes  The air is slowed down because of a blockage --
o Asthma or obstruction – to air flow, either because of
 Pleural Friction Rub mucus in the breathing passages (called airways)
o Inflammation of pleura that typically causes a partial obstruction, or
ASSESSMENT OF LUNG SOUNDS collapse of the tiniest airways, which blocks air
movement altogether
DIAGNOSTIC TOOLS FOR RESPIRATORY FUNCTION

- Chest X-ray
- Arterial Blood Gas (ABG) - Incentive Spirometry
 Respiratory Acidosis  Spirometry is also used to determine reversibility
o pH ↓ PaCO2 ↑ of obstruction after use of bronchodilators
 Metabolic Acidosis (Hubert & VanMeter, 2017).
o pH ↓ PaCO2 ↓  The patient demonstrates a degree of
 Respiratory Alkalosis reversibility of lung restriction / obstruction if the
o pH ↑ PaCO2 ↓ pulmonary function values improve after
 Metabolic Alkalosis administration of the bronchodilator.
o pH ↑ PaCO2 ↑  Even patients who do not show a significant
- Spirometry response to a short-acting bronchodilator, this
 The client takes as deep a breath as possible and test may benefit symptomatically from long-term
blows out the air as fast as possible until the bronchodilator treatment.
lungs are completely empty. - Bronchoscopy
 Measures the volume of air breathed out (forced  Visualization of the tracheobronchial tree via a
vital capacity or FVC) and the amount breathed scope advanced through the mouth or nose into
out in the first second (forced expiratory volume the bronchi
in 1 second or FEV1)  Performed to remove foreign body, to remove
 By looking at these 2 numbers, and the ratio of secretions or to obtain specimen of tissue or
FEV1/FVC, we can predict if the individual has mucus for further study
abnormal lung function and the type of lung
abnormally present.
17 | C E L I N E
- 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  Single Chamber Underwater Seal Chest Drain
 Sputum sample is obtained by coughing and is o It is a single bottle, open to air. The patient's
examined in the laboratory chest tube is submerged under a level of
 Nursing Interventions: water (usually about 2cm) which acts as a
o Drinking a lot of water and other fluids the one-way valve. When the patient's pleural
night before collection may help pressure exceeds the level of water (i.e. it is
o Perform back tapping or chest clapping greater than 2cm H2O), the air in the tube
o on client to aid in loosening the sputum will bubble out and escape into the
o Instruct client on proper specimen collection atmosphere. When the patient takes a breath
o Collect morning specimen in, the negative intrapleural pressure will
o Gargle with water only before specimen suck drain water up the tube, but no
collection cough deeply and spit sputum in a additional air can enter.
sterile cup  What are the advantages of the single bottle
o Send specimen to lab ASAP pleural drain?
- MRI and CT Scan o Simple
- Chest Tubes o Cheap
 Use of tubes and suction to return negative o Easily improvised from unrelated equipment
pressure to the intrapleural space, expands the o For simple pneumothorax, there is usually no
lung by removing positive pressure from the need for anything more sophisticated
pleural space o The fluid level (i.e. valve pressure) is
 To drain air from intrapleural space, a chest tube adjustable, though there are few scenarios
is placed in 2nd or 3rd ICS to drain blood or fluid, where one might wish to adjust it.
catheter would be placed at a lower site, 8th or 9th  The Two-Chamber Underwater Seal Pleural Drain
ICS 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
18 | C E L I N E
o Pleural fluid and water seal are separate: FROM THE CANVAS MODULE WEEK 4
therefore, no froth will form. - Purpose of the Respiratory System
o The collection bottle permits the drainage of  The lungs, in conjunction with the circulatory
pleural fluid, so the case uses of this system system, deliver oxygen to and expel carbon
are not limited to pneumothoraces. dioxide from the cells of the body.
 The Three-Chamber Underwater Seal Drain  The upper respiratory system warms and filters
o This system is much like the two-bottle air.
system, but with an added chamber to help  The lungs accomplish gas exchange.
regulate the suction pressure, i.e. it is - Structures of the Respiratory System:
specifically designed to be used with suction.  Parts of the Upper Respiratory System
It was apparently developed at the o Nose
Massachusetts General Hospital in 1945. 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
 Management: increases the space in the thoracic chamber (lowered
o Provide pain relief. intrathoracic pressure causes air to enter through the
 Administer narcotics/analgesics prior to airways and inflate the lungs)
turning, coughing, and deep breathing. - Expiration: with relaxation, the diaphragm moves up
 Assist with splinting while turning, and intrathoracic pressure increases (pushes air out
coughing, deep breathing. of the lungs); expiration requires the elastic recoil of
o Promote adequate ventilation. the lungs.
 Perform complete physical assessment  Inspiration = 1/3 of the respiratory cycle;
of lungs and compare with pre-op expiration = 2/3 of the respiratory cycle
findings. RESPIRATION
 Auscultate lung fields every 1—2 hours. - Oxygen diffuses from the air into the blood at the
 Encourage turning, coughing, and deep alveoli to be transported to the cells of the body.
breathing every 1—2 hours after pain - Carbon dioxide diffuses from the blood into the air at
relief obtained. the alveoli to be removed from the body.
o Perform tracheobronchial suctioning if ASSESSMENT OF BREATH SOUNDS
needed. - Normal Breath Sounds:
 Assess for proper maintenance of chest  Vesicular, Bronchovesicular, Bronchial
drainage system (except after - Abnormal (Adventitious) Breath Sounds:
pneumonectomy).  Crackles
 Monitor ABGs and report significant  Wheezes
changes.  Friction rubs
 Place client in semi-Fowler’s position VENTILATION PERFUSION (V/Q) RATIO
- Ventilation is the movement of air in and out of the
lungs.
19 | C E L I N E
- Air must reach the alveoli to be available for gas - Does not replace ABGs
exchange. - Normal level is 95-100%.
- Perfusion is the filling of the pulmonary capillaries - May be unreliable
with blood. DIAGNOSTIC TESTS
- Adequate gas exchange depends upon an adequate - Imaging tests: Chest x-ray, CT scan, MRI, Fluoroscopic
V/Q ratio, a match of ventilation and perfusion. Studies and Angiography, Radioisotope procedure-
- Shunting occurs when there is an imbalance of lung Scans, Bronchoscopy, Thoracoscopy
ventilation and perfusion. This results in hypoxia. - Pulmonary function tests
LUNG CAPACITIES - Arterial blood gases
- Tidal Volume (TV): air volume of each breath - Sputum tests
- Inspiratory Reserve Volume (IRV): maximum volume - Thoracentesis
that can be inhaled after a normal inhalation. - Biopsies
- Expiratory Reserve Volume (ERV): maximum volume RESPIRATORY CONDITIONS
that exhaled after a normal exhalation. - Upper Airway Obstruction
- Vital Capacity (VC): the maximum volume of air - Causes:
exhaled from a maximal inspiration, VC = TV + IRV +  Foreign bodies/materials; enlargement of tissues
ERV. in the wall of airway, pressure on the walls of the
- Forced Expiratory Volume (FEV): volume exhaled airway, altered level of consciousness
forcefully over time in seconds. Time is indicated as a - Assessment:
subscript, usually 1 second.  Inspection (eye)
MEASUREMENT OF VOLUME AND INSPIRATORY FORCE  Palpation (touch)
- A spirometer measures volumes of air exhaled and is  Auscultation (hearing)
used to assess lung capacities. AIRWAY MANAGEMENT
- When assessing TV, measure several breaths. TV OROPHARYNGEAL AIRWAY (OPA)
varies from breath to breath. - Also known as Oral bite block
- Pulmonary function tests assess respiratory function - Temporary
and determine the extent of dysfunction. - Relieves upper airway obstruction
- Peak flow rate reflects maximal expiratory flow and is - Tongue relaxation, secretions, seizures
frequently done by patients using a home spirometer - Not recommended for alert clients
INSPIRATORY FORCE - May trigger gag and cause vomiting
- Evaluates the effort of the patient in making an - Nursing Responsibility:
inspiration.  Frequent assessment of the lips and tongue to
- A monometer which measures inspiratory effort can identify pressure areas
be attached to a mask or endotracheal tube to  Removed at least q 24 hours to check for
occlude the airway and measure pressure. pressure areas and to provide oral hygiene
- Normal inspiratory pressure is approximately 100 cm NASOPHARYNGEAL AIRWAY
H2O. - Also known as Nasal trumpet
- Force of less than 25 cm usually requires mechanical - Maintains airway patency
ventilation. - Also used to facilitate nasotracheal suctioning
ARTERIAL BLOOD GAS - Size: French 26-35
- Measurement of arterial oxygenation and carbon - Complications
dioxide levels.  Bleeding
- Used to assess the adequacy of alveolar ventilation  Sinusitis
and the ability of the lungs to provide oxygen and  Erosion of the mucus membranes
remove carbon dioxide. - Nursing Responsibility
- Also assesses acid base balance  Assessment of the pressure areas and occlusion
PULSE OXIMETRY due to secretions
- A noninvasive method to monitor the oxygen  Rotation of tube from nostril to nostril daily
saturation of the blood.
20 | C E L I N E
LARYNGEAL MASK AIRWAY POSITIVE PRESSURE VENTILLATION (PPV)
- An ET with a small mask on one end that can be - Most common form of mechanical ventilation used in
passed orally over the larynx the acute care setting
- Provides ventilatory assistance and prevent - Forces oxygen into the lungs with each breath
aspiration through an endotracheal tube or tracheostomy tube
- Combitube - Volume-cycled modes (deliver breath until preset
 Esophageal/tracheal double lumen airway tidal volume is reached with each breath)
 Used for difficult or emergency intubation - Pressured-cycled modes (deliver breath until a preset
 Permits blind placement pressure is achieved within the airway)
ENDOTRACHEAL (ET) TUBE MODES OF VENTILLATION
- Includes a 15mm adapter at the end for connection - Ways in which ventilation is triggered, allowing the
to life support equipment patient partial or complete control over their
- Distance marker on the sides for placement breathing
- Inserted into the trachea through the mouth or nose - Factors Affecting Selection of Ventilator Modes:
- Insertion of Endotracheal (ET) Tube  Underlying pulmonary status
 Using laryngoscope to visualize the upper airway  Oxygenation Presence of spontaneous breathing
 Inserted through the vocal cords into the trachea ASSIST-CONTROL VENTILATION (ACV)
 2-4 cm above the carina - Delivers a preset volume at a preset rate and
 Anchored by inflating the cuff (prevents air whenever the patient initiates a breath (i.e. if the
leakage and aspiration) patient does not initiate a breath within a preset
- Confirm Proper Placement time, the ventilator will deliver a breath)
 Presence of bilateral breath sounds - Used in patients with weak respiratory muscles
 Equal SYNCHRONIZED INTERMITTENT MANDATORY
 Suctexcursion during inspiration VENTILATION (SIMV)
 Absence of breath sounds over the stomach - Delivers a preset volume at a preset rate and is
 PETCO2: 35-40 mmHg synchronized with the patient’s effort
- Verification: CXR - Allows spontaneous breathing between ventilated
 Anchor with tape or ET fixation device breaths
 Centimeter marking at the lip is documented - Prevents competition between patient and ventilator
during each shift - Common mode for patients requiring minimal
 10-14 days of intubation: tracheostomy is usually ventilation
indicated - Used for WEANING for ventilator support
- Complications: PRESSURE-CONTROLLED VENTILATION (PCV)
 Laryngeal and tracheal damage - Delivers positive-pressure breath until a maximum
 Laryngospasm amount of airway pressure is reached, then the
 Aspiration inspiratory phase of the breath stops
 Infection and discomfort - Maximum inspiratory pressure limit is preset to help
 Vocal cord paralysis (should not be used longer minimize ventilator-induced lung injury (VILI)
than 3 week) - Settings are adjusted to achieve a goal tidal volume
MECHANICAL VENTILATOR designated by physician
- A form of assisted ventilation; takes over all part of - Tidal Volume Goal: based on patient’s weight and
the work performed by the respiratory muscles and pulmonary status
organs PRESSURE-REGULATED VOLUME CONTROL (PRVC)
- Indication: impaired patient’s ability to oxygenate - A type of PCV in which the ventilator makes pressure
and exchange carbon dioxide adjustments to aim for a predetermined tidal volume
- Main Goal: to support gas exchange until the disease - Using this mode, the ventilator senses any changes in
process is resolved lung compliance (ex. Increase in peak inspiratory
pressure) and reduces the tidal volume until airway
pressures are back within normal range
21 | C E L I N E
ADDITIONAL VENTILATORY MODES - Back Up Rate (BUR) or Respiratory Rate
POSITIVE END-EXPIRATORY PRESSURE (PEEP)  Number of breaths per minute that ventilator is
- Holds positive pressure in the alveoli during set to deliver; 4-20 breaths/minute
expiration - Fraction of Inspired Oxygen (FiO2)
- Frequently used as a supplement to most modes of  Percentage of oxygen delivered by ventilator with
ventilation each breath 21 - 100%
- Advantages: - Inspiratory to Expiratory Ratio (I:E Ratio)
 Prevents alveoli from collapsing at end-expiration  Number of breaths per minute that ventilator is
 Improves oxygenation set to deliver 1;2
 Increases functional residual capacity - Sensitivity
 Range: 2 to 24 cmH2O pressure  Determines amount of effort patient must
- Disadvantage: generate before ventilator will give a breath
 PEEP greater than 10 cmH2  Too Low: patient works harder to obtain a breath
 Increased intrathoracic pressure that causes  Too High: patient’s respiratory effort may
decreased venous return and decreased cardiac compete with ventilator
output (Hypotension) - Flow Rate
 Increase preload with fluids or vasopressors  Determines how fast VT will be delivered during
- High Levels of PEEP inspiration
 Increased airway pressure  High – increase airway pressure
 VILI, hypotension, increased ICP, alveolar  Low – decrease airway pressure
ventilation-perfusion mismatch - Pressure Limit
CONSTANT POSITIVE AIRWAY PRESSURE (CPAP)  Regulates maximum amount of pressure the
- Similar to PEEP but provides positive pressure during ventilator will generate to deliver preset VT
spontaneous breaths  Ventilated breath will stop when pressure limit is
- Increases oxygenation by preventing closure of reached
alveoli at end-expiration thereby maximizing VENTILATION TERMINOLOGIES
functional residual capacity (FRC) - Compliance
- General Range: 5-10 cmH2O; more than 10cmH20 =  Elasticity of the lung tissue
hypotension/pneumothorax  Decreased compliance = increased resistance to
- Frequently used to wean patients as a non-invasive breath
method - Peak Inspiratory Pressure (PIP)
PRESSURE SUPPORT VENTILATION (PSV)  Airway pressure at maximum inspiration
- Augments the tidal volume of spontaneous breaths  A.K.A. peak airway pressure
by delivering a preset positive pressure during - Low Pressure Alarms
inspiration  LEAK or DISCONNECTION in ventilator circuit
- Can be added to SIMV and CPAP for weaning  Patient not receiving adequate ventilation
- Range: 8-20 cmH20 - High Pressure Alarms
- Increases patient comfort by decreasing the amount  PIP has exceeded a safe limit
of work required in each spontaneous breath  Patient at risk of VILI
VENTILATOR SETTINGS - Volutrauma
- Individualized settings  Injury to the lung tissue from over distension of
- Adjustments are based on ABG measurements and alveoli
Arterial Oxygen saturations (SaO2) - Barotrauma
- VT (Tidal Volume)  Injury to the lung tissue from too much pressure
 Amount of oxygen delivered to a patient with on the airway
each preset ventilated breath; 5-15 mL/kg - Atelectrauma
(average: 10mL/kg)  VILI from a low intra-alveolar pressure causing
collapse of alveoli
22 | C E L I N E
MECHANICAL VENTILLATION COMPLICATION - In Sweden, all medical schools shut down and
- Ventilator - Associated Pneumonia (VAP) Bundles of medical students worked in 8-hour shifts as human
Care ventilators, manually inflating the lungs of afflicted
 Elevation of the head of the bed (HOB) patients.
 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 - In Boston, the nearby Emerson Company made
accessory muscles, decrease in LOC, available a prototype positive-pressure lung inflation
increase in CO2 levels, decrease O2 device, which was put to use at the Massachusetts
saturation and tachycardia General Hospital, and became an instant success.
 Synchronized Intermittent Mandatory Thus began the era of positive-pressure mechanical
Ventilation (SIMV) ventilation (and the era of intensive care medicine).
o Indicated for patients who satisfied weaning - Conventional Mechanical Ventilation
criteria but cannot sustain adequate  The first positive-pressure ventilators were
spontaneous ventilation for long periods designed to inflate the lungs until a preset
o As respiratory muscles strengthen, the pressure was reached.
pressure is decreased  This type of pressure-cycled ventilation fell out of
 T-piece favor because the inflation volume varied with
o Usually used when patient is awake and alert, changes in the mechanical properties of the
breathing without difficulty, and has good lungs.
gag and cough reflex  In contrast, volume-cycled ventilation, which
o Maintained on oxygen level on the same or inflates the lungs to a predetermined volume,
greater than oxygen concentration the delivers a constant alveolar volume despite
patient is receiving in mech vent changes in the mechanical properties of the
o WOF: respiratory distress and hypoxia lungs.
VENTILATION PPT COPY FROM DOC FERRIOL  For this reason, volume-cycled ventilation has
- Principles of Mechanical Ventilation: become the standard method of positive-
 “... an opening must be attempted in the trunk of pressure mechanical ventilation.
the trachea, into which a tube of reed or cane - A New Strategy for Mechanical Ventilation:
should be put; you will then blow into this, so  In the early days of positive-pressure mechanical
that the lung may rise again...and the heart ventilation, large inflation volumes were
becomes strong...” – Andrea Vesalius (1555) recommended to prevent alveolar collapse.
- Vesalius is credited with the first description of  Thus, whereas the tidal volume during
positive-pressure ventilation, but it took 400 years to spontaneous breathing is normally 5 to 7 mL/kg
apply his concept to patient care. (ideal body weight), the standard inflation
- The occasion was the polio epidemic of 1955, when volumes during volume-cycled ventilation have
the demand for assisted ventilation outgrew the been twice as large, or 10 to 15 mL/kg.
supply of negative-pressure tank ventilators (known  The large inflation volumes used in conventional
as iron lungs). mechanical ventilation can damage the lungs, and
23 | C E L I N E
can even promote injury in distant organs o A pre-determined and preset pressure
through the release of inflammatory cytokines. terminates inspiration. Pressure is constant
 The discovery of ventilator-induced lung injury is and volume is variable
drastically changing the way that mechanical  Volume Cycle
ventilation is delivered. o A pre-determined and preset volume-on
ORIGINS OF MECHANICAL VENTILATION completion of its deliver, terminates the
- The era of intensive care medicine began with inspiration. Pressure is variable and volume is
positive-pressure ventilation constant
- Negative-Pressure Ventilators (Iron Lungs)  Time Cycle
 Non-Invasive ventilation first used in Boston o Delivers air/gas over a set time (Insp. Time)
Children’s Hospital in 1928 after which the inspiration ends
 Used extensively during polio outbreaks in 1940- o Ex: Pressure controlled ventilation
1950s COMMON MODES
- Positive-Pressure Ventilators CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
 Invasive ventilation first used at Massachusetts - Given through air tight mask/ ET/Tracheostomy tube
General Hospital in 1955 - Applies continuous positive pressure to the air way.
 Now the modern standard of mechanical - Tidal volume and respiratory rate are patient
ventilation dependent
MECHANICAL VENTILATION - FiO2 & PEEP are to be set in the equipment.
- Non-Invasive: ASSIST CONTROLLED VENTILATION (ACV)
 Ventilatory support that is given without - Delivers a preset tidal volume for every breath
establishing endotracheal intubation or initiated by the machine
tracheostomy is called Non-invasive mechanical - Or triggered through the patient's effort
ventilation CONTROLLED MANDATORY VENTILATION (CMV)
 Good control of airway - Delivers a preset tidal volume/pressure at a preset
 Suitable for higher pressures rate, ignoring the patient’s own ventilatory effort.
- Invasive: INTERMITTENT MANDATORY VENTILATION (IMV)
 Ventilatory support that is given through endo- - Delivers a preset tidal volume at a preset rate while
tracheal intubation or tracheostomy is called as allowing the patient to breathe at his own rate and
 Invasive mechanical ventilation tidal volume in between.
 Avoidance of complications of intubation - Can cause breath stacking – because preset
 Avoidance of complication of invasive ventilation frequency of the machine may not occur in the same
(sinusitis) phase as the patient's own efforts.
 If tolerated, more comfortable to awake pts. SYNCHRONIZED INTERMITTENT MANDATORY
Breaks possible VENTILATION (SIMV)
 No sedation (or less sedation) - Delivers a preset, mandatory tidal volume.
- Non-Invasive: - Synchronized to the patient’s respiratory effort
 Negative Pressure INITIAL SETTINGS
o Producing negative pressure intermittently in Mode: SIMV with Pressure Support (If available)
the pleural space/around the thoracic cage FiO2: 1.0 (100%)
PEEP: 5
o Ex: Iron Lung Tidal Volume: 6-7 ml/kg
 Positive Pressure Rate : 10-15/minute
o Delivering air/gas with positive pressure to Pressure Support: 15 cm H2O/if flow assist: 0.5 sec
the airway Alarms: Max Pressure: 35 cm of H2O
Min Pressure: 10 cm of H2O
o Ex: BiPAP and CPAP
- Special consideration in the settings should be shown
- Invasive Positive Pressure:
to COPD and ARDS patients.
 Pressure Cycle
- ABG – after 1 hour and adjust the settings
- Remember that:
 PaO2 depends on FiO2 and PEEP
24 | C E L I N E
 PaCO2 depends on Tidal volume and rate - Neurological impairment
 In ICU, our primary aim is - Pulmonary impairment
o To get a PaO2 of 60-90 mmHg and PaCO2 of - Procedures requiring sedation/paralysis
30-50 mmHg GOALS
o Ensure that plateau inspiratory pressure does - Treat hypoxemia/hypercapnia
not exceed 30 cm of H2O (risk of VALI – - Relieve respiratory distress/reverse fatigue
Ventilator Associated Lung Injury) - Decrease Myocardial O2 demand
- Monitoring: - Prevention or reversal of atelectasis
 Continuous and Periodic monitoring of: - Breath for the sedated/paralysed patient
o Vital parameters such as temp, SpO2, Pulse, - Stabilise the chest wall
BP, ECG Pattern, breath rate, etc. CONTRA-INDICATIONS
o Ventilator Settings: All settings should be - Risks outweigh benefits, for example Neutropenia
recorded – as per doctor’s order - Non-invasive deemed preferable to invasive
o Sensorium ventilation
o Intake and output - Invasive ventilation considered medically futile
o Level of comfort - Contrary to the expressed wishes of the patient
o Arterial blood gas – prn or bid VENTILATION
- Precaution and Care: - Ventilators
 Tracheobronchial Hygiene  A machine that generates a controlled flow of
 Placement of Tube: blended air and oxygen into a patient’s airway.
o Chest movement - 2 categories:
o Auscultation  Volume or Pressure
o Post intubation x-ray  This refers to the mode of breath delivery rather
 Cuff Pressure than the mode itself
o If insufficient: Leak, Displacement of the - Volume
tube, Aspiration  In volume category modes of ventilation, the
o If high pressure – Tracheal stenosis machine generates flow to achieve a set volume
o Desired Pressure – 20-30 cm water known as TIDAL VOLUME
- Indications – Simplified  VT – “The volume of air that is inspired or expired
 Respiratory in a single breath during regular breathing”
o Restrictive  Volume Modes:
 ARDS o Advantages: Guaranteed Minute Ventilation
 ILD (Mv).
o Obstructive o Disadvantages: Increased monitoring of
 Bronchial asthma airway pressures. Airway pressures will
 COPD increase if lung compliance decreases. Risk of
 Central airway obstruction barotrauma.
 Non-Respiratory  Minute Ventilation (MV) – “The total volume of
o Restrictive gas in liters expelled from the lungs per minute”
 Chest wall - Pressure
 Cardiac  In pressure modes of ventilation, a pressure limit
o Normal is set, the machine generates flow until the peak
 Airway protection pressure limit is achieved- PAP or PIP (Peal
 Respiratory drive dysfunction Airway [Inspiratory] Pressure)
INDICATIONS  Peal Airway (Inspiratory) Pressure
- Respiratory Failure  PIP, PAP = PEAK
- Cardiopulmonary arrest o “is the highest level of pressure applied to
- Trauma Events the lungs during inhalation expressed in
- Cardiovascular impairment cmh2o”
25 | C E L I N E
 Pressure Modes MANDATORY ASSIST MODES OF VENTILATION
o Advantages: Greater control of airway - Synchronized Intermittent Mandatory Ventilation
pressure. Less risk of barotrauma (SIMV)
o Disadvantages: No guaranteed minute  Provides a set TIDAL VOLUME at a set RATE (F)
ventilation. Increased monitoring of VT  Patient can breathe in-between mandatory
required. Rapid changes in the compliance ventilation
can cause hypoventilation/hypoxia.  Spontaneous breaths are supported with
INSPIRATION pressure support
- Flow Trigger  Ventilator synchronises mandatory breaths and
 A breath is generated when the patient’s spontaneous breaths for increased patient
respiratory effort causes flow to reach a set level. comfort
- Pressure Trigger  Usually volume targeted but some machines offer
 A breath is generated by measuring pressure and SIMV(pc)
starting assisted ventilation when pressure  Advantages: Guaranteed Minute Ventilation
reaches a given level.  Disadvantages: Increased monitoring of airway
- Time Trigger pressures. Airway pressures will increase if lung
 A breath is generated by measuring frequency of compliance decreases. Risk of barotrauma.
respirations and starting ventilation when - Bilevel Positive Airway Pressure (BiPAP)
respirations frequency is at a given.  Provides a set P-insp at a set RATE (F)
EXPIRATION  Patient can breathe in-between mandatory
- Time Cycled ventilation
 Such in in pressure controlled ventilation  Spontaneous breaths are supported with
- Flow Cycled pressure support
 Such as in pressure support  Pt can breathe at any point of respiratory cycle,
- Volume Cycled not just between breaths
 The ventilator cycles to expiration once a set tidal  Breathing takes between two levels Pinsp and
volume has been delivered: this occurs in volume PEEP
controlled ventilation.  Advantages: Increased patient comfort. Can limit
high airway pressures. Reduce risk of barotrauma
 Disadvantages: No guaranteed Minute
Ventilation. Increased monitoring of Tidal
Volumes. Patient may hypo-ventilate and become
hypoxic if lung compliance changes suddenly
MANDATORY MODES OF VENTILATION

- Intermittent Positive Pressure Ventilation (IPPV)
 Set: TV, rate, Fi02, PEEP,
 No capacity for the patient to trigger a breath
 Uncomfortable if patient not fully sedated &/
paralysed SPONTANEOUS MODES OF VENTILATION
 Suitable only for patients who have no ability to - Spontaneous modes are:
breathe spontaneously  Triggered and Cycled by the patient
26 | C E L I N E
- Awake patients may find this more comfortable, good MONITOR
weaning tool - Do not forget:
COMPLICATIONS OF INVASIVE VENTILATION  Suctioning
- Airway  Mouth care
 Aspiration pneumonia  Nebulization
 Trauma to trachea during intubation WEANING
 Hypoxia prior to / during intubation - Factors to Consider:
 Laryngeal oedema  Awake, and off sedation (as much as possible)
 Occlusion of blood supply to trachea (if cuff  Adequate nutrition, fluid status
pressures to high)  Free of infection
 Sinus infection  Hemodynamically stable (Preferably off pressors,
- Mechanical angina controlled, no active bleeding)
 Ventilator malfunction.  Normal acid-base status
 Ventilator circuit: occlusion, kinks,  Bronchospasm controlled
bronchospasm, disconnection & biting.  Normal electrolyte balance
 Barotrauma/Volutrauma can rupture alveoli,  Oxygenation (O2 requirements <0.5 and PEEP <5
causing pneumothorax. cmH2O)
- Decreased Cardiac Output - Weaning Parameters:
 Induction agents  Inspiratory negative pressure of -25 cmH2O
 Changes intrathoracic pressure & reduces venous  RR<30
return  VT >6-8ml/kg
 Cardiac output falls, BP drops  ABG status near normal
 CVP and LV preload rise - Causes of Failure to Wean:
 This has implications for the perfusion of all vital 1. Hypoxemia
organs: brain, kidneys, GI tract o Diffuse pulmonary disease
o Focal pulmonary disease (Pneumonia)
o Pulmonary edema (removal of positive
pressure can increase preload and lead to
worsening heart failure)
2. Insufficient Ventilatory Drive
o Response to metabolic alkalosis
o Inadequate function of CNS drive (Ex:
sedatives, malnutrition)
3. Excessive Ventilatory Drive
o Excessive CO2 production (sepsis, agitation,
fever, high carbohydrate intake)
4. Respiratory Muscle Weakness
o Neuromuscular disease
o Malnutrition
POSITIVE END EXPIRATORY PRESSURE (PEEP)
o Drugs (Neuromuscular blocking agents,
- ↑ Functional residual capacity
Corticosteroids, aminoglycosides
- Move fluid from alveoli into interstitial space
5. Excessive Work of Breathing
- Improve oxygenation
o Airway obstruction
- Maintains pressure within the breathing circuit at a
o Bronchospasm
pre-set level at the end of expiration
o Secretions
- When used during spontaneous respiration it is called
o Increased Raw (ETT)
CPAP
o ETT too small
- A degree of PEEP should be applied on all ventilation
o Chest motion restriction (Pain, Bandages)
modes to minimise risk of atelectasis
27 | C E L I N E
6. Acid Base Disorders  Chest pain
7. Phrenic Nerve Injury  Tachycardia, tachypnea
o Especially with contralateral pulmonary  Anxiety, restlessness
disease)  Clammy or bluish skin
- Complication: - Diagnosis:
 Ventilation-Related Complications:  CXR – to rule out other disorders with the same
o Disconnection presenting manifestations
o Malfunction  ABG analysis
 Hemodynamic Effects:  D-dimer test – detects clot fragments from clot
o Decreased cardiac output due to impaired lysis
venous return to the right heart and  ECG
increased pulmonary venous resistance due  V/Q scan/Pulmonary angiography/spiral CT scan
to positive pressure alveolar distension - Treatment:
 Autopeep  Oxygenation (ET and mechanical ventilation)
o Barotrauma or Atelectasis  Heparin therapy until therapeutic PTT is attained;
o Oxygen toxicity sodium warfarin is used for maintenance therapy
o Respiratory alkalosis  Surgery – umbrella filter, pulmonary
o Increased intracranial pressure embolectomy
 Suctioning-Related Complications:  Prevention of development of DVT
o Hypoxemia ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
 Patients should always be pre- LUNG INJURY
oxygenated with 100% oxygen prior to - This is a syndrome with inflammation and increased
suctioning permeability of the alveolocapillary membrane that
 Suction time should be limited occurs as a result of an injury to the lungs.
o Arrhythmias - This condition is fatal when left undiagnosed or
o Nosocomial infections treated for 48hrs.
WEEK 5: NURSING CARE OF CLIENTS WITH ALTERED - Risk Factors:
VENTILATORY FUNCTION  Critically ill patients
- Respiratory emergencies may range from “shortness  Age (60y/o and above)
of breath,” or dyspnea, to complete respiratory  Malignancy (cancers)
arrest, or apnea. These conditions can result from a  Cigarette smoking, COPD
large number of causes, but most typically they - Causes:
involve the lungs.  Aspiration pneumonia or systemic illness (e.g.
PULMONARY EMBOLISM (PULMONARY EMBOLUS) burns, sepsis, drug overdose)
- This is a thrombotic or non-thrombotic embolus that - Clinical Manifestations:
lodges in the pulmonary artery system.  Signs and symptoms are often exhibited within
- It can damage part of the lung due to restricted blood 24-48 hours after initial insult to the lungs
flow, decrease oxygen levels in the blood, and affect o Subjective: restlessness, anxiety, dyspnea
other organs as well. o Objective: tachycardia, grunting respirations,
- Large or multiple blood clots can be fatal. intercostal retractions, cyanosis
- The blockage can be life-threatening o Hypoxemia
- Risk Factors: o Severe: hypotension, cyanosis, decreased UO
 Injury or damage leading to blood clot formation - Diagnostic Test:
 Inactivity for prolonged periods  Chest x-ray = reveals “white out” lungs;
 Medical conditions or treatment procedures that pulmonary edema
cause blood to clot easily (e.g. surgery, DVT, etc.) - Therapeutic Interventions:
- Clinical Manifestations:  Mechanical ventilation with positive end-
 Virchow’s Triad: venous stasis, coagulation expiratory pressure (PEEP) maintains positive
problems, vessel wall injury pressure within the lungs at the end of expiration
28 | C E L I N E
which increases the residual capacity, reducing ARDS, Pulmonary Edema,
Pneumonia,
hypoxia
Pneumothorax, PE
 Interleukin-1 receptor antagonists, surfactant - Types of Acute Respiratory Failure:
replacement therapy, antioxidants and  Type I (Hypoxemic)
corticosteroids may be used o Lung failure, respiratory insufficiency
 Maintenance of fluid volume and nutrition o Failure of lungs and heart to provide
 Goal: Improving and maintaining oxygenation adequate oxygen
and prevent respiratory and metabolic o PaCO2 < 60mmHg with normal or decreased
complications PaO2
1. Fluid management to maintain tissue o Alveolar hypoventilation
perfusion o Associated with acute diseases of the lungs
2. Corticosteroid therapy to decrease (pulmonary edema, ARDS, pneumonia)
permeability of the alveolocapillary  Type II (Hypercapnic)
membrane o Pump failure, ventilatory failure
3. Nutrition – enteral feeding o Failure of lungs to eliminate adequate CO2
4. Supplemental oxygen: Mechanical Ventilation o PaCO2 > 50mmHg
– a form of artificial ventilation that takes o Increase dead space
over all or part of the work performed by the o Drug overdose, neuromuscular disease, chest
respiratory muscles and organs wall deformity, COPD
 Modes, Settings, Alarms - Causes of Acute Respiratory Failure in Adults:
ACUTE RESPIRATORY FAILURE (ARF)  Impaired Ventilation
- It is a change in respiratory gas exchange such that o Spinal cord injury above C5
normal cellular function is jeopardized. o Phrenic nerve damage
- ARF is defined as’pO2 of less than 50 mmHg and a o Neuromuscular blockade
pCO2 of greater than 50 mmHg and a pH of less than o Guillain barre syndrome
7.30. o CNS depression
- Actual pO2 and pCO2 that define ARF vary, o Respiratory muscle fatigue
depending on the different factors that influence  Impaired Gas Exchange
patient’s normal arterial blood gasses. For example, if o Pulmonary edema
pO2 level of a 75 – year old man is 55 mmHg, o ARDS
- ARF will not be diagnosed until the pO2 have o Aspiration pneumonia
decreased to 50 mmHg or less.  Airway Obstruction
- This is a condition in which the blood doesn't have o Aspiration of foreign body
enough oxygen or has too much carbon dioxide, o Thoracic tumors
sometimes one can have both problems. o Asthma
- Respiratory Failure: o Bronchitis
 Divided into type I and type II. o Pneumonia
 Type I respiratory failure involves low oxygen,  Ventilation – perfusion abnormalities
and normal or low carbon dioxide levels. o Pulmonary embolism
 Type II respiratory failure involves low oxygen, o Emphysema
with high carbon dioxide. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
Type 1 Respiratory Failure Type 2 Respiratory Failure
- It is an umbrella term to describe various diseases
- Def - Def
PaO2 <60 mmHg PaCO2 >45 mmHg (e.g. chronic bronchitis, emphysema, chronic
PaCO2 <45 mmHg asthma).
- Etiology - Etiology - Also described as a slowly progressive and
Gas Exchange Failure Ventilatory failure
V/Q Mismatch ↓Min. Volume irreversible disease, although some patients may
Shunts show a degree of reversibility with bronchodilator
- Diseases - Diseases treatment.
COPD, Muscle Weakness,
Restrictive Diseases
29 | C E L I N E
- This usually occurs in people over 50 years of age and  Consider whether the patient is septic, and treat
smoking is a major factor in its development any signs of sepsis, severe sepsis, or septic shock
- Assessment: immediately.
 Patient’s History: - Diagnostics and Laboratory:
o Mild = a ‘smoker’s cough’ is the only  Continuous monitoring— HR, RR, and SpO2.
abnormal sign.  CXR.
o Moderate = breathlessness and/ or wheeze  ECG.
on moderate exertion, cough, and  ABG analysis as soon as possible.
generalized reduction in breath sounds.  FBC, U&E, and theophylline level (if the patient is
o Severe = breathlessness at rest, cyanosis, taking theophylline).
prominent wheeze and/ or cough, and lung  Sputum for C&S if purulent.
over inflation  Blood cultures if the patient is pyrexial.
- Clinical Findings: - Nursing Interventions:
 Subjective: anxiety, restlessness, fatigue and  Reassurance.
weakness, dyspnea, headache, impaired  Nurse the patient in an upright position.
sensorium  O2 therapy to keep saturations in the range of
 Objective: orthopnea, expiratory wheezing, 88– 92%
stertorous breathing sounds, cough  Nebulizers (may need to be continuous).
 Barrel chest, cyanosis, clubbing of fingers, use of  Steroids.
accessory muscles, purse lip breathing (COPD)  IV theophylline (for patients who do not respond
 Distended neck veins, peripheral edema (RSHF) to nebulizers).
- Consider and Record the following too:  Assessment for NIV.
 Current treatment— inhalers, nebulizers,  Mouth care.
antibiotics, steroids, O2, and theophyllines;  IV fluids if the patient is dehydrated.
 Exercise tolerance;  Analgesia.
 High protein soft diet in small, frequent feedings  AVPU and GCS scores.
 Pneumococcal and influenza vaccines - Management:
 Surgery for end-stage emphysema: lung volume 1. Non-Invasive Ventilation (NIV)
reduction; lung transplant o Increasingly used in ED resuscitation rooms
 Previous admissions, especially intensive care or (evidence suggests that using NIV in patients
treatment with NIV; the reason for ED with COPD reduces mortality and the need
attendance— it is important to identify whether for invasive ventilation)
the exacerbation has been accompanied by an o NIV should be considered in patients who
increase in the amount or type of sputum meet the following criteria:
produced; a recent fall or chest injury may be the  Respiratory acidosis (pH <7.35, PaCO2
cause of the symptoms. >6kPa) that persists despite maximal
- In the ED, Assess for the following: medical therapy;
 Cough; sputum— color and amount;  Not moribund, GCS score >8
 Cyanosis;  Able to protect the airway;
 Tachypnea; wheeze;  Cooperative and conscious;
 Accessory muscle usage; lip pursing on  Few co- morbidities;
expiration;  Hemodynamically stable;
 Chest expansion (which is often poor);  No excess respiratory secretions;
 Fever;  Potential for recovery to a quality of life
 Dehydration; acceptable to the patient.
 Confusion or reduction in conscious level; o Ideally, patients should have an anesthetic
 Pain assessment prior to the commencement of
NIV, in order to determine their suitability
and outline what the ceiling treatment
30 | C E L I N E
should be. A ‘do not attempt resuscitation’  Expansion is reduced on the affected side.
(DNAR) order may be completed at this time  There is percussion dullness over the area of
if the patient is not suitable for invasive consolidation.
ventilation.  Breath sounds are bronchial; adventitious
2. Intensive Care crackles.
o Patients with exacerbations of COPD should  Tachypnea and central cyanosis.
not be automatically excluded from invasive  Fever, sweats, and rigors.
ventilation if all other treatments are failing.  Cough and sputum.
o The following will have to be considered: - Diagnostics and Laboratory:
 Quality of life (ideally involving the family  Sputum microscopy, culture, and sensitivity.
in the discussion);  CXR
 O2 requirements when stable;  ABG (if SpO2 is <93% on room air) and pulse
 Co-morbidities; oximetry
 Forced expiratory volume in 1s (FEV1);  FBC, U&E, C-Reactive Protein, and Liver Function
 Body mass index (BMI). Tests.
PNEUMONIA - Management:
- Pneumonia is an inflammation of the lung, which is  Initial (ED) Management:
characterized by exudation into the alveoli. It can be o Supplemental O2 to maintain saturations at
classified anatomically as lobar or by etiology. >93%
- It is most commonly caused by bacteria. o IV fluids (if the patient is dehydrated)
- The terms ‘pneumonia’ and ‘chest infection’ are often o Medications: IV antibiotics, analgesia,
used interchangeably. antipyretic
- Causes: o Bronchoalveloar lavage may be used for
 Pneumonia can be caused by any of over 100 patients who are immunocompromised,
microorganisms. Therefore, the treatment should those who do not respond to antimicrobial
be started before the causative organism has therapy, or those from whom a sputum
been identified. sample cannot be obtained
- Common microorganisms that can cause - Nursing Management:
Pneumonia:  Positioning (upright)
 Streptococcus pneumoniae (90% of cases)  Ensure timely antimicrobial therapy.
 Haemophilus influenzae  Monitor hemodynamics, fluid and electrolytes
 Staphylococcus aureus and imbalances
 Legionella species  Adherence to infection prevention and control.
- Types of Pneumonia:  Ventilator-associated pneumonia care bundle
 Community Acquired – not hospitalized or VENTILATOR-ASSOCIATED PNEUMONIA (VAP)
residing in a long-term care facility for ≥ 14 days - Ventilator-associated pneumonia (VAP) develops 48 h
prior to onset of symptoms. or later after commencement of mechanical
 Hospital Acquired – more than 48 h between ventilation via endotracheal tube or tracheostomy.
admission and onset of symptoms. - It develops as a result of colonization of the lower
 Ventilator Associated – more than 48–72 h respiratory tract and lung tissue by pathogens.
between intubation and onset of symptoms. - Intubation compromises the integrity of the
 Aspiration – micro-aspiration of bacteria oropharynx and trachea, allowing oral and gastric
colonizing the upper respiratory tract, secretions to enter the airways.
macroaspiration of gastric contents, indirect - VAP is the most frequent post-admission infection in
transmission from staff, inhaled aerosols. critical care patients, and significantly increases the
 Atypical number of mechanical ventilation days, the length of
- Assessment Findings: critical care stays, and the length of hospital stay
 The clinical findings are often referred to as overall.
consolidation.
31 | C E L I N E
- Risk Factors:  Scoring the Severity of Pneumonia
 Immunocompromised, the elderly, and those o Validated CURB- 65 score to assess severity,
with chronic illnesses (e.g. lung disease, risk of death, and risk of ICU admission
malnutrition, obesity). o Scoring can also guide subsequent
- Diagnosis is difficult due to the number of differential treatment and the decision about the need
diagnoses that present with the same signs and for hospital admission
symptoms (e.g. sepsis, ARDS, cardiac failure, lung CURB- CLINICAL FEATURE POINTS
atelectasis); radiological changes = consolidation and 65
new or progressive infiltrates) C Confusion 1
- Clinical Signs: U Urea >7mmol 1
 Pyrexia > 38°C R RR >/ = 30 1
 Raised or reduced white blood cell (WBC) count B SBP <90/= mmHg or 1
 New-onset purulent sputum DBP <60/=mmHg
 Increased respiratory secretions/suctioning 65 Age >65 1
CURB-65 RISK 30-DAY MANAGEMENT
requirements SCORE GROUP MORTALITY
 Worsening gas exchange. 0-1 1 1.5% Low risk, consider home
- Management: treatment
 Care Bundle approach for the prevention of 2 2 9.2% Probably admission vs
close outpatient
ventilator-associated pneumonia management
o Demonstrated to be an effective preventive 3-5 3 22% Admission, manage as
strategy. severe
o 6 Elements for the Prevention (Should be - CURB-65 Scoring Interpretation:
reviewed daily):  0 or 1 – relatively mild symptoms with good
1. Elevation of the head of the bed to 30– social support and no other significant health
45° (unless contraindicated) problems can usually be discharged home.
2. Sedation Level Assessment – unless the  2 – more severe symptoms; at higher risk; for
patient is awake and comfortable, admission
sedation is reduced or held for  ≥3 – associated with a 17% risk of death.
assessment at least daily (unless PNEUMONIA AND SEPSIS
contraindicated). - The elderly is particularly vulnerable to developing
3. Oral Hygiene – clean with chlorhexidine sepsis from pneumonia, and general assessment of
gluconate (≥ 1–2% gel or liquid) q6h; the breathless patient should identify any signs of
teeth are brushed q12h with standard sepsis
toothpaste. COVID-19
4. Subglottic Aspiration – a tracheal tube - COVID-19 affects different people in different ways.
(endotracheal or tracheostomy) that has - Most infected people will develop mild to moderate
a subglottic secretion drainage port is illness and recover without hospitalization; zoonotic
used if the patient is expected to be (passed between animals and people)
intubated for > 72 h. Secretions are 1. Severe Acute Respiratory Syndrome-2 (SARS-
aspirated via the subglottic secretion COV-2) = COVID-19
port 1- to 2-hourly. o New (novel) strain of coronavirus
5. Tube Cuff Pressure – cuff pressure is o Not previously identified in humans
measured q4h, and maintained in the 2. Middle East Respiratory Syndrome (MERS-CoV) =
range 20–30 cmH2O (or 2 cmH2O above 2012
peak inspiratory pressure). 3. Severe Acute Respiratory Syndrome (SARS-CoV)
6. Stress Ulcer Prophylaxis – stress ulcer =2003
prophylaxis is prescribed only for high- - Incubation period – 2-14 days; symptoms usually
risk patients, according to locally begin around 5th day
developed guidelines. - Origin of COVID-19
 Bats or pangolins
32 | C E L I N E
 Transmitted to humans directly or through an  Keep the room well-ventilated; choose open,
intermediate host well-ventilated spaces over closed ones. Open a
 Source Location: large live animal market in window if indoors
Wuhan, Hubei Province  If sharing a room with another person, place beds
 Human – to – human spread at least 1 meter apart.
- Variants of Concerns: WHO as of August 13, 2021  Stay home if you feel unwell and call COVID
 Increase in transmissibility or detrimental change hotlines; monitor self for any symptoms for 14
in COVID-19 epidemiology; OR days.
 Increase in virulence or change in clinical disease  Call a health care provider immediately if any of
presentation; OR the danger signs are observed: difficulty
 Decrease in effectiveness of public health and breathing, loss of speech or mobility, confusion
social measures or available diagnostics, vaccines, or chest pain.
therapeutics.  Stay positive by keeping in touch with loved ones
- Clinical Manifestations: by phone or online, and by exercising at home.
 Most Common Symptoms:  To prevent the spread of COVID-19:
o Fever (83% - 99%) o Maintain a safe distance from others, even if
o Dry cough (59% - 92%) they don’t appear to be sick.
o Shortness of breath (31% - 40%) o Wear a mask in public, especially indoors or
 Less Common Symptoms: when physical distancing is not possible.
o Aches and Pains o Choose open, well-ventilated spaces over
o Sore Throat closed ones. Open a window if indoors.
o Diarrhea - Medical Treatments:
o Conjunctivitis  WHO does not recommend self-medication with
o Headache any medicines, including antibiotics, as a
o Loss of Taste or Smell (Anosmia or Ageusia) prevention or cure for COVID-19.
o A rash on skin, or discoloration of fingers or o Optimal supportive care includes oxygen for
toes severely ill patients and those who are at
 Serious Symptoms: risk for severe disease and more advanced
o Difficulty breathing or shortness of breath, respiratory support such as ventilation for
chest pain or pressure, loss of speech or patients who are critically ill.
movement o Dexamethasone is a corticosteroid that can
- Diagnostic Tests: help reduce the length of time on a
 Chest X-ray ventilator and save lives of patients with
 CT Scan severe and critical illness.
 ECG - Other Medications used in COVID-19:
- Laboratory Tests:  Anti-viral agents
 CBC with differential, metabolic profile, o Remdesivir
inflammatory markers (CRP, D-dimer, ferritin) o Tocilizumab
- Prevention: o Bamlanivimab and Casirivimab and
 Keep at least a 1-meter distance from others, Imdevimab
even from family members. o Baricitinib in combination with remdesivir
 Wear a medical mask to protect others, including
if/when seeking for medical care.
 Clean hands frequently. Use soap and water, or
an alcohol-based hand rub.
 When possibly exposed, stay in a separate room
from other family members, and if not possible,
wear a medical mask.
33 | C E L I N E

NCMB418 Prelim Reviewer 1

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MEDICAL-SURGICAL NURSING 3 LECTURE (NCMB418): PRELIM EXAMINATION

ADVENTITIOUS BREATH SOUNDS

(pulmonary embolism, cardiogenic shock) Rhonchi Deep low-pitched Secretions or tumor

DIAGNOSTIC TOOLS FOR RESPIRATORY FUNCTION

MANDATORY MODES OF VENTILATION

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