hemodynamic monitor

7/31/2019 Hemodynamic Monitor

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JOSEPH OMAR S. APOLINAR,RN,MANJOSEPH OMAR S. APOLINAR,RN,MAN

Davao Doctors CollegeDavao Doctors College

HemodynamicHemodynamicMonitoring SystemsMonitoring Systems

HemodynamicHemodynamicMonitoring SystemsMonitoring Systems


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HemodynamicHemodynamic

Monitoring SystemsMonitoring Systems


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Mechanical VentilatorsMechanical Ventilators


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Mechanical VentilatorsMechanical Ventilators


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Mechanical Ventilators areMechanical Ventilators are

indicated for the following patients :indicated for the following patients :

1. Patient who has a continuous decrease in Oxygenation (PaO2), increased in1. Patient who has a continuous decrease in Oxygenation (PaO2), increased inarterialarterial carbon dioxide levels (PaCO2), persistent acidosis (decreased pH), persistentcarbon dioxide levels (PaCO2), persistent acidosis (decreased pH), persistentacidosis (decreased pH).acidosis (decreased pH).

2. Conditions such as thoracic or abdominal surgery, drug overdose,2. Conditions such as thoracic or abdominal surgery, drug overdose,

neuromuscular disorders, inhalation injury, COPD, multiple trauma, shock,neuromuscular disorders, inhalation injury, COPD, multiple trauma, shock,

multisystem failure, and coma all may lead to respiratory failure.multisystem failure, and coma all may lead to respiratory failure.

3. Indications for Mechanical Ventilation :3. Indications for Mechanical Ventilation : PaO2 < 80 mm Hg with FiO2 > 0.60PaO2 < 80 mm Hg with FiO2 > 0.60 PaO2 > 80 mm Hg with pH < 7.25PaO2 > 80 mm Hg with pH < 7.25 Vital Capacity < 2 times tidal volumeVital Capacity < 2 times tidal volume Negative inspiratory force < 25 cm H2ONegative inspiratory force < 25 cm H2O Respiratory rate > 35/minRespiratory rate > 35/min


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The Positive-Pressure Ventilators -The Positive-Pressure Ventilators - inflate the lungs by exerting positiveinflate the lungs by exerting positivepressure on the airway, similar to a bellows mechanism, forcing the alveoli to expandpressure on the airway, similar to a bellows mechanism, forcing the alveoli to expand

during inspiration.during inspiration.

a. Pressure-Cycled Ventilatorsa. Pressure-Cycled Ventilators -- these ventilators ends inspiration when athese ventilators ends inspiration when apreset pressure has been reached. In other words, the ventilator cycles on, deliverspreset pressure has been reached. In other words, the ventilator cycles on, delivers

a flow of air until it reaches a predetermined pressure, then cycles off. The mosta flow of air until it reaches a predetermined pressure, then cycles off. The most

common type is the IPPB machine.common type is the IPPB machine.

b. Time-Cycled Ventilatorsb. Time-Cycled Ventilators -- these ventilators terminate or control inspirationthese ventilators terminate or control inspirationafter a preset time. The volume of air the patient receives is regulated by the lengthafter a preset time. The volume of air the patient receives is regulated by the lengthof inspiration and the flow rate of the air. These ventilators are used in newbornsof inspiration and the flow rate of the air. These ventilators are used in newborns

and infants.and infants.

c. Volume-Cycled Ventilators c. Volume-Cycled Ventilators these ventilators are by far the most commonlythese ventilators are by far the most commonlyused positive-pressure ventilators today. The volume of air to be delivered with eachused positive-pressure ventilators today. The volume of air to be delivered with each

inspiration is preset. Once this preset volume is delivered to the patient, the ventilatorinspiration is preset. Once this preset volume is delivered to the patient, the ventilatorcycles off and exhalation occurs passively.cycles off and exhalation occurs passively.

d. Noninvasive Positive-Pressure Ventilation - can be given via facemasks that coverd. Noninvasive Positive-Pressure Ventilation - can be given via facemasks that cover

the nose and mouth, nasal masks, or other nasal devices. This eliminates the need forthe nose and mouth, nasal masks, or other nasal devices. This eliminates the need for

endotracheal intubation or tracheostomy and decreases the risk for nosocomialendotracheal intubation or tracheostomy and decreases the risk for nosocomial

infections such as pneumonia. The most comfortable mode for the patient is pressure-infections such as pneumonia. The most comfortable mode for the patient is pressure-controlled ventilation with pressure support.controlled ventilation with pressure support.


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Positive-Pressure VentilatorsPositive-Pressure Ventilators


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a. Controlled Ventilation - A preset volume of gas is delivered to the patient undera. Controlled Ventilation - A preset volume of gas is delivered to the patient under

positive pressure while spontaneous patient respiratory effort is locked out.positive pressure while spontaneous patient respiratory effort is locked out.

bb. Assist/Controlled Ventilation (A/C) in this mode, a preset volume of gas is delivered. Assist/Controlled Ventilation (A/C) in this mode, a preset volume of gas is deliveredto the patient at a preset rate, but the patient may trigger a ventilator breath withto the patient at a preset rate, but the patient may trigger a ventilator breath with

negative inspiratory effort.negative inspiratory effort.

c. Synchronized Intermittent Mandatory Ventilation (SIMV) Mode - a preset minimumc. Synchronized Intermittent Mandatory Ventilation (SIMV) Mode - a preset minimumnumber of breaths are synchronously delivered to the patient but the patient may alsonumber of breaths are synchronously delivered to the patient but the patient may also

take spontaneous breaths of varying volumes. Note how inspiratory and expiratorytake spontaneous breaths of varying volumes. Note how inspiratory and expiratory

pressures differ between spontaneous and ventilator breaths.pressures differ between spontaneous and ventilator breaths.

The Ventilator is adjusted so that the patient is comfortable andThe Ventilator is adjusted so that the patient is comfortable and

breathes in sync with the machine.breathes in sync with the machine.

d. Positive End Expiratory Pressure (PEEP) - Airway pressure with varying levels ofd. Positive End Expiratory Pressure (PEEP) - Airway pressure with varying levels of

positive end-expiratory pressure (PEEP). Note that at end expiration, the airway is notpositive end-expiratory pressure (PEEP). Note that at end expiration, the airway is not

allowed to return to zero. (FRC: functional residual capacity).allowed to return to zero. (FRC: functional residual capacity).

e. Continuous Positive Airway Pressure (CPAP) - This ventilatory adjunct is used onlye. Continuous Positive Airway Pressure (CPAP) - This ventilatory adjunct is used only

with spontaneous ventilation; the patient breathes spontaneously through thewith spontaneous ventilation; the patient breathes spontaneously through the

ventilator at an elevated baseline pressure throughout the breathing cycle.ventilator at an elevated baseline pressure throughout the breathing cycle.

f. Pressure Support (PS) - Spontaneous ventilation with pressure support (PS). Thef. Pressure Support (PS) - Spontaneous ventilation with pressure support (PS). The

patient breathes spontaneously with pressure assistance to each spontaneouspatient breathes spontaneously with pressure assistance to each spontaneous

inspiration.inspiration.


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Controlled Ventilation - A preset volume of gas is delivered to theControlled Ventilation - A preset volume of gas is delivered to the

patient under positive pressure while spontaneous patient respiratorypatient under positive pressure while spontaneous patient respiratory

effort is locked out.effort is locked out.

Assist/Controlled Ventilation (A/C) in this mode, a preset volume of gas isAssist/Controlled Ventilation (A/C) in this mode, a preset volume of gas isdelivered to the patient at a preset rate, but the patient may trigger a ventilatordelivered to the patient at a preset rate, but the patient may trigger a ventilator

breath with negative inspiratory effort.breath with negative inspiratory effort.


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Positive End Expiratory Pressure (PEEP) -Positive End Expiratory Pressure (PEEP) -

mobilize bronchial secretions therapy withmobilize bronchial secretions therapy with

small volume nebulizer aerosols.small volume nebulizer aerosols.


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Continuous Positive Airway Pressure (CPAP)Continuous Positive Airway Pressure (CPAP) is a treatment that

delivers slightly pressurized air during the breathing cycle. This

keeps the windpipe open during sleep and prevents episodes of

blocked breathing in persons with obstructive sleep apnea and

other breathing problems.
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Synchronized IntermittentSynchronized Intermittent

Mandatory Ventilation (SIMV) Intensive Care UnitMandatory Ventilation (SIMV) Intensive Care Unit

with Mechanical Ventilationwith Mechanical Ventilation


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Pressure Support (PS) - Spontaneous ventilationPressure Support (PS) - Spontaneous ventilation

with pressure support (PS).with pressure support (PS).

Post-Anesthesia Care UnitPost-Anesthesia Care Unit


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1. Set the machine to deliver the tidal volume required (10 to 15 mL/kg).1. Set the machine to deliver the tidal volume required (10 to 15 mL/kg).

2. Adjust the machine to deliver the lowest concentration of oxygen to maintain normal2. Adjust the machine to deliver the lowest concentration of oxygen to maintain normal

paO2 (80-100 mmHg). This setting may be high initially but will gradually be reducedpaO2 (80-100 mmHg). This setting may be high initially but will gradually be reduced

based on arterial blood gas results.based on arterial blood gas results.

3. Record peak inspiratory pressure.3. Record peak inspiratory pressure.

The following guide is an example of the steps involved in operating a mechanicalThe following guide is an example of the steps involved in operating a mechanical

ventilator. The nurse, in collaboration with the respiratory therapist, always reviews theventilator. The nurse, in collaboration with the respiratory therapist, always reviews the

manufucturers instructions, which vary according to the equipment, before beginningmanufucturers instructions, which vary according to the equipment, before beginning

mechanical ventilation:mechanical ventilation:

4. Set mode (assist-control or synchronized intermittent mandatory ventilation) and4. Set mode (assist-control or synchronized intermittent mandatory ventilation) and

rate according to physician order. Set PEEP and pressure support if ordered.rate according to physician order. Set PEEP and pressure support if ordered.

5. Adjust sensitivity so that the patient can trigger the ventilator with a minimal effort5. Adjust sensitivity so that the patient can trigger the ventilator with a minimal effort

(usually 2 mmHg negative inspiratory force).(usually 2 mmHg negative inspiratory force).

6. Record minute volume and measure carbon dioxide partial pressure (PCO2), pH, and6. Record minute volume and measure carbon dioxide partial pressure (PCO2), pH, andPO2 after 20 minutes of continuous mechanical ventilation.PO2 after 20 minutes of continuous mechanical ventilation.

7. Adjust setting (FiO2 and rate), according to results of arterial blood gas analysis to7. Adjust setting (FiO2 and rate), according to results of arterial blood gas analysis to

provide normal values or those set by the physician.provide normal values or those set by the physician.

8. If the patient suddenly becomes confused or agitated or begins bucking the ventilator8. If the patient suddenly becomes confused or agitated or begins bucking the ventilator

for some unexplained reason, assess for hypoxia and manually ventilate on 100%for some unexplained reason, assess for hypoxia and manually ventilate on 100%

ox en with a resuscitation ba .ox en with a resuscitation ba .


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1. Impaired Gas Exchange related to underlying illness, or ventilator setting1. Impaired Gas Exchange related to underlying illness, or ventilator settingadjustment during stabilization or weaning.adjustment during stabilization or weaning.

2. Ineffective airway clearance related to increased mucus production associated with2. Ineffective airway clearance related to increased mucus production associated with

continuous positive-pressure mechanical ventilation.continuous positive-pressure mechanical ventilation.

3. Risk for Trauma and infection related to endotracheal intubation or tracheostomy.3. Risk for Trauma and infection related to endotracheal intubation or tracheostomy.

Nursing Diagnoses based on assessment data, theNursing Diagnoses based on assessment data, the

patients major nursing diagnoses may include :patients major nursing diagnoses may include :

4. Impaired physical mobility related to ventilator-dependency.4. Impaired physical mobility related to ventilator-dependency.

5. Impaired verbal communication related to endotracheal tube and attachment to5. Impaired verbal communication related to endotracheal tube and attachment to

ventilator.ventilator.

6. Defensive coping and powerlessness related to ventilator dependency.6. Defensive coping and powerlessness related to ventilator dependency.


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Respiratory Weaning, the process of withdrawing the patient from dependence on theRespiratory Weaning, the process of withdrawing the patient from dependence on the

ventilator takes place in three stages : the patient is gradually removed from theventilator takes place in three stages : the patient is gradually removed from the

ventilator, then from the tube, and finally from oxygen.ventilator, then from the tube, and finally from oxygen.

1. Vital Capacity should be 10 - 15 mL/kg to meet the criteria for weaning. This is used to1. Vital Capacity should be 10 - 15 mL/kg to meet the criteria for weaning. This is used to

assess the patients ability to take deep breaths.assess the patients ability to take deep breaths.

5. Rapid/shallow breathing index : used to assess the breathing pattern and is calculated5. Rapid/shallow breathing index : used to assess the breathing pattern and is calculated

by dividing the respiratory rate by tidal volume. Patients with indices below 100by dividing the respiratory rate by tidal volume. Patients with indices below 100

breaths/min/L are more likely to be successful at weaning.breaths/min/L are more likely to be successful at weaning.

Criteria for Weaning Patient from the VentilatorCriteria for Weaning Patient from the Ventilator

3. Tidal Volume, the volume of air that is inhaled or exhaled from the lungs during an3. Tidal Volume, the volume of air that is inhaled or exhaled from the lungs during aneffortless breath should be normally 7 9 mL/kg.effortless breath should be normally 7 9 mL/kg.

Careful assessment is required to determine whether the patient is ready to beCareful assessment is required to determine whether the patient is ready to be

removed from the mechanical ventilation :removed from the mechanical ventilation :

4. Minute ventilation equal to the respiratory rate multiplied by the tidal volume. Normal4. Minute ventilation equal to the respiratory rate multiplied by the tidal volume. Normal

is about 6 L/min.is about 6 L/min.

2. Maximum Inspiratory Pressure (MIP) should be at least -20 cm H2O. This is used to2. Maximum Inspiratory Pressure (MIP) should be at least -20 cm H2O. This is used to

assess the patients respiratory muscle strength. Thassess the patients respiratory muscle strength. Th


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EKG MachineEKG Machine

The Electrocardiogram (ECG or EKG) rhythm strip must be analyzedThe Electrocardiogram (ECG or EKG) rhythm strip must be analyzed

in a systematic manner to determine the patients cardiac rhythmin a systematic manner to determine the patients cardiac rhythm

and detect dysrhythmias and conduction disorders, as well asand detect dysrhythmias and conduction disorders, as well as

evidence of myocardial ischemia, injury and infarctionevidence of myocardial ischemia, injury and infarction..


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V1 (Red) - 4th intercostal space, right sternal border.V1 (Red) - 4th intercostal space, right sternal border.

V2 (Yellow) - 4th intercostal space, left sternal border.V2 (Yellow) - 4th intercostal space, left sternal border.

V3 (Green) - diagonally between V2 and V4V3 (Green) - diagonally between V2 and V4

ECG Electrode Placement. The standard left precordial leads are :ECG Electrode Placement. The standard left precordial leads are :

V4 (Brown) - 5th intercostal space, left midclavicular line.V4 (Brown) - 5th intercostal space, left midclavicular line.

V5 (Black) - same level as V4 anterior axillary lineV5 (Black) - same level as V4 anterior axillary line

V6 (Lavender) - same as level V4 and V5, midaxillary line.V6 (Lavender) - same as level V4 and V5, midaxillary line.

The Limb Electrodes provide the first six leads: I, II, III, aVR, aVL and aVF.The Limb Electrodes provide the first six leads: I, II, III, aVR, aVL and aVF.

Right Limbs : Red and Black Left Limbs: Yellow and GreenRight Limbs : Red and Black Left Limbs: Yellow and Green


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Proper Placing of Precordial Leads


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The Conducting System of the HeartThe Conducting System of the Heart


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ECG WAVE FORMECG WAVE FORMNormal Sinus RhythmNormal Sinus Rhythm


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Normal Sinus RhythmNormal Sinus Rhythm


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A. Sinus-Atrial Node (SA Node)A. Sinus-Atrial Node (SA Node)1. Sinus Tachycardia1. Sinus Tachycardia

2. Sinus Bradycardia2. Sinus Bradycardia

3. Sinus Arrhythmia3. Sinus Arrhythmia

B. Atrial DysrhythmiasB. Atrial Dysrhythmias1. Premature Atrial Complex1. Premature Atrial Complex

2. Atrial Flutter2. Atrial Flutter

3. Premature Atrial Contraction3. Premature Atrial Contraction

4. Atrial Tachycardia4. Atrial Tachycardia

5. Atrial Fibrillation5. Atrial Fibrillation

CONDUCTION ABNORMALITIESCONDUCTION ABNORMALITIES

C. Atrial -Ventricular Node (AV Node) DysrhythmiasC. Atrial -Ventricular Node (AV Node) Dysrhythmias

1. First Degree AV Block1. First Degree AV Block

2. Second Degree AV Block2. Second Degree AV Block

a. Type Ia. Type I

b. Type IIb. Type II

3. Third Degree AV Block3. Third Degree AV Block

Cardiac Dysrhythmias - often called an arrhythmias, is a disruption inCardiac Dysrhythmias - often called an arrhythmias, is a disruption in

the normal events of the cardiac cycle. It may take a variety of forms.the normal events of the cardiac cycle. It may take a variety of forms.

Treatment varies depending on the type of dysrhythmia.Treatment varies depending on the type of dysrhythmia.

E. Ventricular DysrhythmiasE. Ventricular Dysrhythmias

1. Ventricular Bradycardia1. Ventricular Bradycardia

2. Premature Ventricular Contractions (PVCs)2. Premature Ventricular Contractions (PVCs)a. Ventricular Bigeminya. Ventricular Bigeminy

b. Ventricular Trigeminyb. Ventricular Trigeminy

3. Supraventricular Tachycardia (SVT)3. Supraventricular Tachycardia (SVT)

4. Idioventricular Rhythm4. Idioventricular Rhythm

5. Ventricular Tachycardia (V-Tac)5. Ventricular Tachycardia (V-Tac)

6. Ventricular Fibrillation (V-Fib)6. Ventricular Fibrillation (V-Fib)

7. Ventricular Asystole7. Ventricular Asystole

D. Bundle of His DysrhythmiasD. Bundle of His Dysrhythmias

1. Right Bundle Block1. Right Bundle Block

2. Left Bundle Block2. Left Bundle Block

E. JUNCTIONAL DYSRHYTHMIASE. JUNCTIONAL DYSRHYTHMIAS

1. Premature Junctional Complex1. Premature Junctional Complex

2. Junctional Rhythm2. Junctional Rhythm

3. Atrioventricular Nodal Reentry3. Atrioventricular Nodal Reentry

Tachycardia.Tachycardia.


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EKG MachineEKG Machine


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Cardiac MonitorCardiac Monitor


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Cardiac MonitorCardiac Monitor


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Mobile Cardiac TelemetryMobile Cardiac Telemetry


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Oxygen InhalationOxygen Inhalation

O2 Gauge O2 Tubing O2 Mask


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Oxygen Administration DevicesOxygen Administration Devices

DevicesDevices

SuggestedSuggested

Flow RateFlow Rate

(L/min)(L/min)O2 % SettingO2 % Setting

AdvantagesAdvantages DisadvantagesDisadvantages

Low-FlowLow-Flow

SystemsSystems

1. Cannula1. Cannula

2. Oropharyngeal2. Oropharyngeal

CatheterCatheter

3. Mask, simple3. Mask, simple

4. Mask, partial4. Mask, partial

rebreatherrebreather

5. Mask, non-5. Mask, non-

rebreatherrebreather

1-21-2

3-53-5

66

1-61-6

6-86-8

8-118-11

1212

23-3023-30

30-4030-40

4242

23-4223-42

40-6040-60

50-7550-75

80-10080-100

Lightweight, comfortable,Lightweight, comfortable,

inexpensive, continuous useinexpensive, continuous use

with meals and activity.with meals and activity.

Inexpensive, does not requireInexpensive, does not require

a tracheostomy.a tracheostomy.

Simple to use, inexpensive.Simple to use, inexpensive.

Moderate O2 concentration.Moderate O2 concentration.

High O2 concentration.High O2 concentration.

Nasal Mucous dryingNasal Mucous drying

variable FiO2.variable FiO2.

Nasal Mucosa irritation;Nasal Mucosa irritation;

catheter should becatheter should be

changed frequently tochanged frequently to

alternate nostril.alternate nostril.

Poor fitting, variable FiO2,Poor fitting, variable FiO2,

must remove to eat.must remove to eat.

Warm, poorly fitting, mustWarm, poorly fitting, must

remove to eat.remove to eat.

Poorly fitting.Poorly fitting.


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Oxygen Administration DevicesOxygen Administration Devices

DevicesDevices

SuggestedSuggested

Flow RateFlow Rate

(L/min)(L/min)O2 % SettingO2 % Setting

AdvantagesAdvantages DisadvantagesDisadvantages

High-FlowHigh-Flow

SystemsSystems1. Transtracheal1. Transtracheal

cathetercatheter

2. Mask, Venturi2. Mask, Venturi

3. Mask, aerosol3. Mask, aerosol

4. Tracheostomy4. Tracheostomy

collar.collar.

5. T-piece5. T-piece

6. Face Tent6. Face Tent

1/4 - 41/4 - 4

4-64-6

6-86-8

8-108-10

8-108-10

8-108-10

8-108-10

60-10060-100

24, 26, 2824, 26, 28

30, 35, 4030, 35, 40

30-10030-100

30-10030-100

30-10030-100

30-10030-100

More comfortable, concealed byMore comfortable, concealed by

clothing, less oxygen liters perclothing, less oxygen liters per

minute needed than nasalminute needed than nasal

cannula.cannula.

Provides low levels ofProvides low levels of

supplemental O2.supplemental O2.

Precise FiO2, additional humidityPrecise FiO2, additional humidity

available.available.

Good humidity, accurate Fi02.Good humidity, accurate Fi02.

Good humidity, comfortable,Good humidity, comfortable,

fairly accurate FiO2.fairly accurate FiO2.

Same as Tracheostomy collar.Same as Tracheostomy collar.

Good Humidity, fairly accurateGood Humidity, fairly accurate

FiO2.FiO2.

Requires frequent andRequires frequent and

regular cleaning, requiresregular cleaning, requires

surgical intervention.surgical intervention.

Must remove to eat.Must remove to eat.

Uncomfortable for some.Uncomfortable for some.

Heavy with tubing.Heavy with tubing.

Bulky and cumbersome.Bulky and cumbersome.


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Non-Rebreather Mask


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Rebreather Mask


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T-piece


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Aerosol Mask


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Venturi Mask


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Standard Nasal Cannula


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Tracheostomy Collar Mask


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Face Tent

O T i it h t hi h t ti f ( tOxygen Toxicity may occur when too high a concentration of oxygen (greater


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It is caused by overproduction of oxygen free radicals, which are byproducts of cellIt is caused by overproduction of oxygen free radicals, which are byproducts of cell

metabolism.metabolism.

If oxygen toxicity is untreated, these radicals can severely damage or kill cells.If oxygen toxicity is untreated, these radicals can severely damage or kill cells.

Antioxidants such as vitamin E, vitamin C, and beta-carotene may help defend againstAntioxidants such as vitamin E, vitamin C, and beta-carotene may help defend against

oxygen free radicals.oxygen free radicals.

Oxygen Toxicity may occur when too high a concentration of oxygen (greaterOxygen Toxicity may occur when too high a concentration of oxygen (greater

than 50%) is administered for an extended period.than 50%) is administered for an extended period.

(longer than 48 hours).(longer than 48 hours).

Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias,Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias,

dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, alveolardyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, alveolar

infiltrates evident on chest x-rays.infiltrates evident on chest x-rays.

Often, positive end-expiratory pressure (PEEP) or continuous positive airway pressureOften, positive end-expiratory pressure (PEEP) or continuous positive airway pressure

(CPAP) is used with oxygen therapy to reverse or prevent microatelectasis, thus(CPAP) is used with oxygen therapy to reverse or prevent microatelectasis, thus

allowing a lower percentage of oxygen to be used. The level of PEEP that allows theallowing a lower percentage of oxygen to be used. The level of PEEP that allows the

best oxygenation without hemodynamic compromise is known as best PEEP.best oxygenation without hemodynamic compromise is known as best PEEP.

Prevention of oxygen toxicity is achieved by using oxygen only as prescribed.Prevention of oxygen toxicity is achieved by using oxygen only as prescribed.


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Endotracheal TubesEndotracheal Tubes


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Endotracheal TubesEndotracheal Tubes


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Endotracheal IntubationEndotracheal Intubation

E d t h l I t b ti i l i d t h l t bEndotracheal Int bation in ol es passing an endotracheal t be


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Intubation provides a patent airway when the patient is having respiratory distressIntubation provides a patent airway when the patient is having respiratory distress

that cannot be treated with simpler methods.that cannot be treated with simpler methods.

It is the method of choice in emergency care.It is the method of choice in emergency care.

It is a means of providing an airway for patients who cannot maintain an adequateIt is a means of providing an airway for patients who cannot maintain an adequate

airway on their own (eg. comatose patients or patients with upper airway obstruction),airway on their own (eg. comatose patients or patients with upper airway obstruction),

for mechanical ventilation, and for suctioning secretions from the pulmonary tree.for mechanical ventilation, and for suctioning secretions from the pulmonary tree.

Endotracheal Intubation involves passing an endotracheal tubeEndotracheal Intubation involves passing an endotracheal tube

through the mouth or nose into the trachea.through the mouth or nose into the trachea.

Nurses should be aware that complications could occur from pressure in the cuff onNurses should be aware that complications could occur from pressure in the cuff on

the tracheal wall. Cuff pressure should be 20-25 mmHg. The cuff should be deflatedthe tracheal wall. Cuff pressure should be 20-25 mmHg. The cuff should be deflated

prior to removing the endotracheal tube.prior to removing the endotracheal tube.

Unintentional or premature removal of the tube is a potentially life-threateningUnintentional or premature removal of the tube is a potentially life-threatening

complication of endotracheal intubation. It can cause laryngeal swelling, hypoxemia,complication of endotracheal intubation. It can cause laryngeal swelling, hypoxemia,

bradycardia, hypotension, and even death. Measures must be taken to preventbradycardia, hypotension, and even death. Measures must be taken to prevent

premature and inadvetent removal. Removal of the tube is a frequent problem inpremature and inadvetent removal. Removal of the tube is a frequent problem inintensive care are units and occurs mainly during nursing care or by the patient.intensive care are units and occurs mainly during nursing care or by the patient.

Endotracheal tube may be used for no more than 3 weeks, by which time a tracheostomyEndotracheal tube may be used for no more than 3 weeks, by which time a tracheostomy

must be considered to decrease irritation of and trauma to the tracheal lining, to reduce themust be considered to decrease irritation of and trauma to the tracheal lining, to reduce theincidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decreaseincidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease

the work of breathing.the work of breathing.

C f th P ti t ith E d t h l T bC f th P ti t ith E d t h l T b


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Care of the Patient with an Endotracheal TubeCare of the Patient with an Endotracheal Tube

Immediately after IntubationImmediately after Intubation

ExtubationExtubation

(Removal of Endotracheal Tube)(Removal of Endotracheal Tube) Care of Patient FollowingCare of Patient Following

ExtubationExtubation

1. Check symmetry of chest expansion.1. Check symmetry of chest expansion. 1. Explain procedure.1. Explain procedure. 1. Give heated humidity and oxygen by1. Give heated humidity and oxygen by

face mask.face mask.

2. Ensure high humidity; visible mist2. Ensure high humidity; visible mist

should appear in the T-piece orshould appear in the T-piece or

ventilator tubing.ventilator tubing.

2. Have self-inflating bag and mask ready2. Have self-inflating bag and mask ready

in case ventilatory assistance is requiredin case ventilatory assistance is required

immediately after extubation.immediately after extubation.

2. Monitor respiratory rate and quality2. Monitor respiratory rate and quality

of chest excursions. Note stridor, colorof chest excursions. Note stridor, color

change, and change in mental alertnesschange, and change in mental alertness

or behavior.or behavior.

3. Administer oxygen concentration as3. Administer oxygen concentration as

prescribed by physician.prescribed by physician.3. Suction the tracheobronchial tree and3. Suction the tracheobronchial tree and

oropharynx, remove tape, and thenoropharynx, remove tape, and then

deflate the cuff.deflate the cuff.

3. Monitor the patients oxygen level3. Monitor the patients oxygen level

using a pulse oximeter.using a pulse oximeter.

4. Secure the tube to the patients face4. Secure the tube to the patients face

with tape, and mark the proximal end forwith tape, and mark the proximal end for

position maintenance.position maintenance.

4. Give oxygen for a few breaths, then4. Give oxygen for a few breaths, then

insert a new, sterile suction catheterinsert a new, sterile suction catheter

inside tube.inside tube.

4. Keep NPO or give only ice chips for4. Keep NPO or give only ice chips for

next few hours.next few hours.

5. Use sterile suction technique and5. Use sterile suction technique and

airway care to prevent iatrogenicairway care to prevent iatrogenic

contamination and infection.contamination and infection.

5. Have the patient inhale. At peak5. Have the patient inhale. At peak

inspiration remove the tube, suctioninginspiration remove the tube, suctioning

the airway through the tube as it is pulledthe airway through the tube as it is pulled

out.out.

5. Provide mouth care.5. Provide mouth care.

6. Continue to reposition patient every 26. Continue to reposition patient every 2

hours and as needed to preventhours and as needed to prevent

atelectasis and to optimize lungatelectasis and to optimize lung

expansion.expansion.

6. Teach patient how to perform6. Teach patient how to perform

coughing and deep-breathingcoughing and deep-breathing

exercises.exercises.

7. Provide oral hygiene and suction the7. Provide oral hygiene and suction the

oropharynx whenever necessary.oropharynx whenever necessary.


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Tracheostomy TubeTracheostomy Tube

Foam Cuff Inner Cannula

ObturatorBalloon

Neck Plate

Side Port

Connector

Cannula


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TracheostomyTracheostomy

A tracheostomy is a surgical procedure in which an opening is madeA tracheostomy is a surgical procedure in which an opening is made


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The indwelling tube inserted into the trachea is called a tracheostomy tube. AThe indwelling tube inserted into the trachea is called a tracheostomy tube. A

tracheostomy may be either temporary or permanent.tracheostomy may be either temporary or permanent.

A tracheostomy is used to bypass an upper airway obstruction, to allow removal ofA tracheostomy is used to bypass an upper airway obstruction, to allow removal of

tracheobronchial secretions, to permit the long-term use of mechanical ventilation, totracheobronchial secretions, to permit the long-term use of mechanical ventilation, to

prevent aspiration of oral or gastric secretions in the unconscious or paralyzed patientprevent aspiration of oral or gastric secretions in the unconscious or paralyzed patient

(by closing off the trachea from the esophagus).(by closing off the trachea from the esophagus).

The surgical procedure is usually performed in the operating room or in an intensiveThe surgical procedure is usually performed in the operating room or in an intensive

care unit, where the patients ventilation can be well controlled and optimal asepticcare unit, where the patients ventilation can be well controlled and optimal aseptic

technique can be maintained.technique can be maintained.

A tracheostomy is a surgical procedure in which an opening is madeA tracheostomy is a surgical procedure in which an opening is made

into the trachea.into the trachea.

A surgical opening is made in the second and third tracheal rings. After the trachea isA surgical opening is made in the second and third tracheal rings. After the trachea is

exposed, a cuffed tracheostomy tube of an appropriate size is inserted. The cuff is anexposed, a cuffed tracheostomy tube of an appropriate size is inserted. The cuff is an

inflatable attachment to the tracheostomy tube of an appropriate size is inserted.inflatable attachment to the tracheostomy tube of an appropriate size is inserted.

Long term complications include airway obstruction from accumulations of secretionsLong term complications include airway obstruction from accumulations of secretions

or protrusion of the cuff over the opening of the tube, infection, rupture of theor protrusion of the cuff over the opening of the tube, infection, rupture of the

innominate artery, dysphagia, tracheosophageal fistula, tracheal dilation, and trachealinnominate artery, dysphagia, tracheosophageal fistula, tracheal dilation, and tracheal

ischemia and necrosis. Tracheal stenosis may develop after the tube is removed.ischemia and necrosis. Tracheal stenosis may develop after the tube is removed.

Complications may occur early or late in the course of tracheostomy tube management.Complications may occur early or late in the course of tracheostomy tube management.Early complications include bleeding, pneumothorax, air embolism, aspiration,Early complications include bleeding, pneumothorax, air embolism, aspiration,

subcutaneous or mediastinal emphysema, recurrent laryngeal nerve damage and posteriorsubcutaneous or mediastinal emphysema, recurrent laryngeal nerve damage and posterior

tracheal wall penetration.tracheal wall penetration.

Preventing Complications Associated With Endotracheal andPreventing Complications Associated With Endotracheal and


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Administer adequate warmed humidity.Administer adequate warmed humidity.

Maintain cuff around tube.Maintain cuff around tube.

Suction as needed per assessment findings.Suction as needed per assessment findings.

Preventing Complications Associated With Endotracheal andPreventing Complications Associated With Endotracheal and

Tracheostomy Tubes :Tracheostomy Tubes :

Maintain skin integrity. Change tape and dressing as needed or per protocol.Maintain skin integrity. Change tape and dressing as needed or per protocol.

Monitor for signs and symptoms of infection, including temperature and whine bloodMonitor for signs and symptoms of infection, including temperature and whine blood

cell count.cell count.

Auscultate lung sounds.Auscultate lung sounds.

Administer prescribed oxygen and monitor oxygen saturation.Administer prescribed oxygen and monitor oxygen saturation.

Monitor for cyanosis.Monitor for cyanosis.

Maintain adequate hydration of the patient.Maintain adequate hydration of the patient.

Use sterile technique when suctioning and performing tracheostomy care.Use sterile technique when suctioning and performing tracheostomy care.


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Cardio-Pulmonary Resuscitation (CPR)Cardio-Pulmonary Resuscitation (CPR)


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Cardio-Pulmonary Resuscitation (CPR)Cardio-Pulmonary Resuscitation (CPR)


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Chest Tube Thoracostomy (CTT)Chest Tube Thoracostomy (CTT)


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Water Seal Drainage - Three BottlesWater Seal Drainage - Three Bottles


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Chest Tube Water Seal DrainageChest Tube Water Seal Drainage

One, Two Three BottlesOne, Two Three Bottles


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Hemovac Chest Tube DrainageHemovac Chest Tube Drainage


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Hemovac Chest Tube DrainageHemovac Chest Tube Drainage

hemodynamic monitor

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