Cardiovascular Nursing Part II

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Cardiovascular NursingPart II

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FYI - Hospital Language

• Code Teams
• Rapid Response Teams
• Came out of Research studies (EBP)
• SBAR
• Centers of Excellence examples (EBP)
• Primary Stroke Centers
• Heart Centers
• Magnet Hospitals
• Core Measures
• AMI, CHF, Stroke
• National Patient Safety Goals
• Lets discuss these
• What do these terms mean??

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V-O-M-I-T

• V Vital Signs
• O Oxygen
• M Monitor
• I IV Access
• T Treatment

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Cardiovascular Conditions and Disease Processes
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CV Disease Risk Factors

• Smoking
• Metabolic Syndrome
• Sedentary lifestyle, obesity
• Diabetes
• HTN
• Hyperlipidemia
• Diet, drugs
• Anger, stress, depression
• Genetics
• Gender depending on age
• Age

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Coronary Artery Disease

• Inflammatory disorder
• Atherosclerosis main cause R/T
• Endothelial injury from Inflammatory response-
  (strongest theory)
• Low density lipoproteins (LDL) and growth factor
  from platelet aggregation prevent repair of
  endothelium

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Big 4 Modifiable Risk Factors

• Elevated serum lipids (?LDL, ? HDL)
• Hypertension
• Cigarette smoking ( other)
• Physical Inactivity
• Diabetes - partially modifiable

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CAD mortality drops to non-smoker level in 12
months!
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Benefits of physical exercise

• ? HDL Levels
• ? fibrinolytic activity
• ? oxygen perfusion to muscles
• Goal 30 minutes 5X/Week
• Need to sweat
• ?HR 30-50 beats/minute
• Encourages development of collateral circulation

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Cardiology and Gender
Page 747 785
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Un-Modifiable Risk Factors

• Diabetes (partially un-modifiable!)
• Age
• Gender
• Family hx
• Heredity- Familial hypercholesterolemia

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Lipid Control

• Lipid panel every 5 years
• Treat serum cholesterol gt 200 mg/dl
• LDL gt160
• Treatment consist of
• Dietary modifications exercise
• Resins (Questran),
• Fibrins( Tricor, Lopid),
• Statins (Zocor, Lipitor, Crestor, pravachol),
• ( Zetia) Lipid Lowering agent as well

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Hypertension

• gt 140 SBP and/or gt 90 DBP over extended period of
  time
• Stress from continual elevated B/P-?rate of
  atherosclerotic development
• Atherosclerosis causes narrowed arteries,
  requiring more force to pump blood ?B/P
• Cardiac implications CAD, LVH, Heart Failure,
  Atrial hypertrophy, PVD

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Patient Teaching Focus on

• Monitor control blood glucose levels
• B/P control
• Reduction of cholesterol Triglycerides
• Eliminate all tobacco products
• Physical exercise
• Manage stressful situations
• Maintain appropriate body weight
• 
  Table 34-3

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Clinical Manifestations of
CAD/ACS

• Myocardial Infarction

• Angina Pectoris
• Stable/Unstable Angina
• Silent Ischemia
• Prinzmetals Angina
• Nocturnal Angina

VS
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Angina

• Supply vs. Demand
• Ischemia is limited and does not cause permanent
  damage
• ECG may or may not show changes
• CPK--MB will be negative
• Rest and Nitroglycerin should alleviate
• Pain is usually less than 5 minutes

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Stable vs. Unstable Angina

• Stable widespread, irregular disease in the
  coronary arteries
• Fixed Obstruction
• Usually occurs with activity
• Sufficient blood gets through when the heart
  slows down and rests
• Intermittent and sometimes predictable
• May have ST segment depression
• Unstable caused by sudden interruption of blood
  flow
• Occurs at rest, asleep, or activity

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Characteristics of Angina

• Vague pressure, ache, heaviness or tightness.
• Does not change with breathing or position
• May be anxious, a sense that someth9ing is wrong,
  sweating, nauseous, SOB or fatigued.
• Usually relieved with NTG.
• ST Segment Depression

P, Q, R, S, T
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Collateral Circulation
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Treatment

• Goal ? O2 consumption
• Control the HR ?
• Initial Therapeutic intervention Includes
• Apply oxygen at 2 liters N/C
• ? Coronary Blood Flow
• Nitrates Nitro SL, Nitro paste, Nitro Spray
• Controls pain, anxiety
• Additional Treatment includes
• Anti-platelet therapy ASA for stable Angina
• Plavix for Unstable Angina
• Can reduce progression to an MI
• Beta blockers, - preferred drug for chronic
  stable angina
• ACE Inhibitors - B/P control and ?Ventricular
  Remodeling
• PCI
• PTCA/stent
• CABG

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Nitroglycerin SL (Nitrostat)

• Keep in brown bottle (sensitive to light)
• Keep away from heat
• Including body heat ( keep out of pants pocket)
• Destroys the medication
• Good for 6 months
• Instruct patient
• Should have tingling sensation
• May have Headache can take tylenol
• May feel increase in HR
• Should take effect within 3 minutes and last up
  to 30 minutes
• Caution to rise slowly causes Orthostatic
  Hypotension
• Place one under tongue allow to dissolve
• if no relief within 3-5 minutes call 911
• May also be used prophalactally prior to sexual
  activity

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Myocardial Infarction
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Myocardial Infarction

• Myocardial tissue is abruptly and severely
  deprived of oxygen
• Ischemia develops when blood flow is reduced by gt
  80--90
• Ischemia is not reversed
• Tissue necrosis occurs
• Described by the area of the heart affected
• Anterior
• Inferior
• Lateral
• Posterior
• Anterolateral
• Anteroseptal
• Subendocardial MI

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Clinical manifestations

• Pain/Pressure, not relieved by rest or nitro SL
• Nausea, vomiting
• Diaphoresis
• Vasoconstriction of peripheral nerves, BP/HR
  changes
• Fever due to necrosis of tissue
• Can start within 24 hours and last 7 days
• ST elevation of gt 1mm in two or more leads
• Elevated cardiac markers ( CKMB, Troponin, BNP,
  Myoglobin )

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Premature Ventricular Contraction
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Ventricular Tachycardia
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Multi focal PVCs
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Initial Treatment for AMI

• Goal Reduce the size of the infarct
• Remember VOMIT
• Monitor for arrhythmias--number one complication
  of MI
• Oxygen, Aspirin, Nitroglycerin, Morphine, Beta
  blockers,
• MONA plus Beta Blocker (ACLS)
• Lab tests Enzymes - CPK, Triponins
• EKG--12 lead/15 lead
• Reperfusion
• Fibrinolytic Therapy if no access to cath lab
• Cardiac Cath w/ PTCA/Stent - 90 minutes
• NEW EBP Hypothermia as endorsed by the AHA
  (ANA, 2007)

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Treatment (contd)

• Bed rest up to 48 hours depends on severity (
  usually allow BSC)
• Up to chair within 12-24 hours depends on
  severity
• Supervised OOB and ambulation activity
• Hospital stay (uncomplicated) 3-5 days
• Discharge teaching activity based on how pt.
  feels, S/S of angina MI, medication therapy,
  sexual activity (7-10 days 2 flights of
  stairs), return to work depends on occupation,
  quit smoking
• Cardiac Rehab (AMI) Mended Hearts (CABG)
• Takes 6 weeks for heart to heal (scar tissue
  replaces necrosis)
  Table 34-21

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Patient Tracking Scenario

• Emergency Department RN
• Assigned 3 patient rooms and one empty room
• One hour into your shift you receive a patient
  from the waiting room who is complaining of chest
  pain.
• Lets discuss how you will respond when the
  patient lays down on your stretcher.
• This discussion will include your
  responsibilities as a critical thinking RN and
  the reasons behind your actions!

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Complications of MI

• Arrhythmias
• Congestive Heart Failure
• Cardiogenic Shock
• Papillary Muscle dysfunction
• Ventricular aneurysm
• Pericarditis
• Dressler Syndrome
• Pulmonary Embolism

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Myocardial Injury/Infarction

• ST abnormalities signify acute process
• ST segment returns to baseline over time
• Q wave associated with ST elevation indicates
  acute or recent injury
• Non-q wave or ST depression may indicate
  sub-endocardial injury

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Myocardial Necrosis

• 1mm wide or 1/3 amplitude of QRS complex
• Q waves may be permanent check other criteria to
  determine if infarction is old or acute

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Anterior Infarction -picture
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Inferior Infarction - picture
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Lateral Wall Infarction - picture
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Nursing Considerations
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Acute Coronary Syndrome (ACS)

• Umbrella term that encompasses
• Unstable angina
• Myocardial Infarction which may or may not have
  elevated ST segment (NSTEMI vs. STEMI)
• Goes from a stable to unstable atherosclerotic
  plaque rupture

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Care Plan Practice

• Generate 3 Nursing diagnosis and at least 3
  interventions for each diagnosis.
• Be Specific with your goals and interventions
• Do this for the patient with
• Angina
• MI/ACS

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AMI Core Measures

• Reperfusion Therapy (PTCA/Stent, Fibrinolytics)
• ASA within 24 hours of arrival to hospital
• ASA at discharge
• Beta-Blockers at discharge unless contraindicated
• ACE Inhibitor at discharge for LVF or EF lt 40
  unless contraindicated
• Lipid Control Statin
• Smoking cessation education

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Heart Failure

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Heart Failure

• Inability of the heart to pump sufficient blood
  to meet the demands of the body
• Systolic or Diastolic failure or mixed
• Can occur rapidly or over time without notice
• Can be divided into left or right ventricular
  failure
• Most common cause is CAD and Myocardial
  Infarction

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Heart Failure Society
www.hfsa.org
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Grading Heart Failure

• NYHA
• Class I No limitation
• Class II slight limitation
• Class III Marked limitation
• Class IV Inability to carry on any physical
  activity without discomfort

• AHA
• Stage A
• Stage B
• Stage C
• Stage D

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Left Ventricular Failure(most common)

• Signs and Symptoms
• Tachycardia (early sign)
• Exertional and nocturnal dyspnea
• Orthopnea
• Dry Cough
• Nocturia
• Crackles in the lungs? Pulmonary Edema
• S3 and S4 heart sounds
• ? HR (early sign)
• PMI displaced
• Fatigue
• Mental Confusion
  Table 35-3

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Right Ventricular Failure

• Tachycardia (early sign)
• By itself usually from pulmonary disease
• Most often occur 2nd-ary to Left Heart Failure
• Ascites, GI Disorders (nausea), abd. pain
• Liver and Spleen engorgement
• JVD
• Dependent bilateral edema
• Weight Gain
• Murmurs
• Anxiety
• Anorexia
• Nocturia
• Fatigue

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Jugular Vein Distention (JVD)
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Diagnostics of Acute Heart Failure

• CXR
• EKG
• MUGA Scan
• ECHO
• Pressure monitoring catheters
• PA Catheter Swan-Ganz
• Arterial line SBP, DBP, MAP

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MUGA SCAN
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MUGA SCAN Images
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Goals Treatment of HF

• ? Gas exchange/oxygenation
• ? Cardiac Function
• ? Preload
• ? Afterload
• ? Anxiety

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Treatment of Heart Failure

• Preload Low Sodium Diet (Refer to Table 35-11
  13)
• 500 - 2500 mg/day
• Preload Daily Weights
• gt 3 lbs. within 2 days should be reported to
  MD/ARNP
• Preload Fluid Restrictions typically reserved
  for Class III IV patients
• Strict I O records
• Assess for depression
• Assess for family or social support
• Cardiac Rehab for some
• Stop Smoking
• Medication diet adherence teaching
• ?Gas Exchange Oxygen

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CHF Treatment (contd.)

• CF ACE inhibitors ? CO
• Preload Diuretics , NTG, Vasodilators
• Potassium-sparing Diuretics and ACE Inhibitors
  both spare potassium. Pts. Taking both types of
  meds are at risk for Hyperkalemia
• Afterload Vasodilators, ACE Inhibitors
• CF Cardiac Glycosides--Digoxin
• Inotropics/Adrenergics--Dopamine,
  Dobutamine
• Beta Blockers (Coreg is best) and ARB
• Afterload, Preload, anxiety Morphine
• Preload Position patient to ? Venous return
• Horizontal in bed or dangling at bedside
• Gas Rest-activity
• Circulatory assist devices VAD
• Cardiac Transplantation

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CHF Core Measures

• Documentation of Heart Failure education by
  nursing or case management
• ACE Inhibitor for patients with LVF or EF lt 40
  unless contraindicated
• Prior to discharge - LV Assessment by Nuclear
  Medicine, Echo or Cardiac Cath unless a valid
  documented reason why the assessment was not
  obtained.
• Smoking cessation education
• 
  Table 35-8

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Heart Failure Complications

• Pleural Effusion
• Arrhythmias
• Thrombus
• Pulmonary Edema
• Hepatomegaly
• Renal Failure

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Pleural Effusion
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CXR Pleural Effusion
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Arrhythmias - Atrial Fibrillation
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Arrhythmias - Atrial Flutter
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Pulmonary Edema

• Results from Left Heart Failure
• Signs and Symptoms
• Severe dyspnea
• Pink, blood tinged, frothy sputum
• Crackles, wheezes, rhonchi
• Anxiety
• Pale/clammy/cold skin
• Tachypnea gt 30
• Increased Heart rate

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CXR picture
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Picture- fluid shift
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Treatment of Pulmonary Edema

• Oxygen
• Morphine in small doses
• Diuretics with Potassium supplementation
• Nitrates
• High Fowlers position
• C-PaP
• Possible endotracheal intubation
• with ventilator assistance

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Nursing Care Plan Considerations

• Gas Exchange
• Fluid Balance
• Anxiety
• Activity
• Knowledge Deficit

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Discharge Teaching Focus re CHF

• Understand the cause
• Progressive disease
• Patient controls symptom management
• Daily weights, Medications, Exercise, ? Na diet
• Stop smoking
• Conserve Energy
• Support Systems important to combat depression
• Goal ? To manage the disease process outside of
  the hospital

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Cardiomyopathy
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Types

• Primary
• Secondary
• Dilated
• Hypertrophic
• Restrictive

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• Widened QRS seen with ventricular hypertrophy

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Cardiac Transplantation

• Treatment of choice for end-stage heart disease
• gt50 of patients have cardiomyopathy
• 40 In-operable CAD
• Extensive evaluation process to determine
  acceptability
• Long Wait time
• An artificial heart now exists to decrease wait
  time for transplantation

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Inflammatory Heart Diseases

• Infective Endocarditis
• Myocarditis
• Rheumatic Fever
• Rheumatic Heart Disease
• Pericarditis

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Infective Endocarditis

• Infection of the endocardium of the heart
• Etiology
• Aging process
• IV drug cocaine abusers
• Clients who have had valve replacements
• Recent dental or surgical procedures
• Signs and Symptoms
• Flu like Symptoms
• 80 develop either aortic or mitral valve murmurs
• Diagnostics
• Blood Cultures
• Cultures should be done prior to antibiotic
  administration
• New or changed murmur
• Treatment Prophlatic antibiotics prior to dental
  or surgical procedures

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Myocarditis

• Inflammation of the myocardium
• Due to infection, radiation, meds
• Most common viruses (flu)
• Associated with acute Pericarditis
• SS are benign to severe heart involvement, even
  sudden death
• Cardiac involvement can be seen 7-10 days after
  viral infection

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Myocarditis (contd)

• SS Pleuritic Chest pain, friction rub, S3,
  crackles,
• JVD
• Diagnosis ECG Lab findings are vague
• Biopsy most diagnostic
• Goal Manage the symptoms of poor cardiac
  function
• Tx Oxygen, Rest, restricted activity, Digoxin
• Nursing Mgt monitor tx for CHF

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Rheumatic Fever

• Inflammation that can affect up to all three
  layers of the heart
• May or may not cause permanent structural damage
  to the heart
• Occurs 2-3 weeks after Strept infection
• Other contributing Factors
• Lower socioeconomic groups (overcrowding)
• Familial tendencies
• Altered Immune response

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Diagnosing Rheumatic Fever

• No single test
• Throat cultures are usually negative by the time
  the individual seeks medical care
• CRP and ESR are indicating systemic
  inflammation
• ? WBC, Fever
• Echo valve insufficiency and pericardial fluid
• CXR enlarged heart if CHF is present
• Tx Antibiotics, NSAIDS, cortcosteroids

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Rheumatic Heart Disease

• Chronic Condition
• Results from scarring and deformity of the heart
  valves
• Term used to signify when damage has occurred to
  the heart from Rheumatic Fever

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Pericarditis

• An inflammation or alteration of the pericardium
• Signs and Symptoms
• Pain usually sharp stabbing, but can be dull
  ache is minority of cases
• Pain that radiates to shoulder or back
• Pain aggravated by breathing
• Pain aggravated by lying down
• Slow shallow breaths
• Pericardial friction rub on auscultation
• ST segment elevation in all 12 Leads

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Treatment of Pericarditis

• Identify and treat the underlying problem
• NSAIDS
• ASA
• Rest
• Overbed table for leaning forward
• Corticosteroids
• Antibiotics if bacterial
• Pericardiocentesis if there is an ? in fluid
  between the layers of the pericardial sac
• Watch for arrhythmias, pneumothorax

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Complications

• Pericardial Effusion
• Distant heart sounds
• Cough, dyspnea, tachypnea
• Cardiac Tamponade
• Agitation, confusion, restlessness
• Tachycardia, tachypnea
• Distended neck veins

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Pericardial Effusion

• When the pericardium becomes inflamed, sometimes
  the fluid between the two layers will increase
  causing a Pericardial Effusion

• MayoClinic (2005)

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Cardiac Tamponade
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Clinical Signs of Tamponade
Becks Triad Tachycardia Hypotension (although
could be normal) Narrowed Pulse Pressure
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Treatment of Pericardial Effusion or Cardiac
Tamponade

• Pericardiocentesis

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Valvular Heart Disease
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Understanding Terms

• Stenosis Constriction or narrowing of orifice
• Regurgitation Retrograde of the flow of blood
  from one chamber back into another
• Prolapse valve leaflets billow back or buckle
  back into the atrium

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Mitral Stenosis

• Mitral valve becomes narrow and constricted
• Causes ? L. Atrial pressure and volume
• Most are due to Rheumatic Heart disease
• Symptoms murmur at 5th ICS
• Extended dyspnea and fatigue

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Mitral Valve Prolapse

• Valve billows back into L. Atrium
• Cause is unknown
• Heard as a murmur
• Can be familial due to connective tissue disorder
• Most people asymptomatic, benign
• Most common valve disorder
• May lead to Mitral Valve Regurgitation
• Diagnosed by ECHO

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Mitral Regurgitation

• Retrograde blood flow from L. Ventricle to L.
  Atrium
• Etiology R/T MI, Rheumatic heart disease, MVP
• Symptoms R/T acute or chronic murmur
• Heard best at 5th ICS
• May feel a thrill
• More common in women than men

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Valvular Regurg - picture
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Aortic Stenosis

• Blood flow restricted from L. Ventricle to Aorta
• Results in LVH, ?myocardial oxygen consumption
• Causes congenital, Rheumatic Fever,
  atherosclerosis
• Symptoms - ? S1 or S2 sound
• Murmur
• S4

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Aortic Regurgitation

• Retrograde blood flow from the Ascending Aorta
  into L. Ventricle
• Results in L. Ventricle dilation LVH, leading
  to ?contractility of the heart
• murmur
• Soft S1, S3 or S4
• Causes Congenital, Rheumatic Heart Disease
• May have Orthopnea, Exertional dyspnea,
  paroxysmal nocturnal dyspnea

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Tricuspid Valve Disease

• Stenosis Regurgitation
• Tricuspid Stenosis is uncommon
• R. Atrium enlargement ?systemic venous pressure
• Tricuspid Regurgitation
• Volume overload in R. Atrium and Ventricle occurs
• Causes R. Ventricular dysfunction, or pulmonary
  HTN

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Diagnosing Valve Disease

• History and Physical Exam
• Echocardiography
• Cardiac Catheterization
• ECG

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Collaborative Care for Valvular Disease

• Ask about history of Rheumatic Heart Disease
• Use of antibiotic prophylaxis
• Digitalis
• Diuretics
• Anticoagulation (ASA, Coumadin)
• Surgical repair or replacement

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Nursing Management/Goals

• Maintaining normal cardiac function
• Monitoring Cardiac output, fluid volume excess
• Improving activity tolerance
• Educating patients on the disease process and
  preventative measures

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Mitral Valve repair
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Valve Replacement

• Mechanical/Biologic
• Antibiotics
• Lifelong anticoagulation therapy
• mechanical
• Good oral hygiene
• Prevent infections

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Cardiovascular Interventions
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Synchronized Cardioversion
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Procedure Requirements

• Consent
• Conscious sedation , Propofol/Diprivan
• 50 -100 joules initially
• Usually performed in procedure room/cath lab
• Can be performed in ER/ICU/Step-down unit/PCU

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Defibrillation

• Treatment for Pulseless Ventricular Tachycardia
  Ventricular Fibrillation
• Defibrillator 2 Types
• Monophasic delivers energy in one direction
• 360 joules
• Biphasic delivers energy in two directions
• 150 or 200 joules

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Percutaneous Transluminal Coronary Angioplasty
(PTCA)/Stent

• Previously discussed under diagnostic cardiac
  cath
• An invasive but technically nonsurgical technique
• Used to reduce frequency and severity of chest
  discomfort for clients with angina
• Also used with client with an evolving acute MI
  to reperfuse myocardium

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PTCA(cont)

• Catheter is introduced through a guide wire
• Balloon is inflated to compress plaque
• Success rate can be as high as 90 upon initial
  reopening

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Balloon Angioplasty - picture
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Blockages - picture
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Stents
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Coronary Artery Bypass Graft Surgery (CABG)

• Most common type of Cardiac Surgery
• Occluded coronary arteries are bypassed with
  clients own blood vessels or synthetic grafts
• Saphenous Vein66 patency rate _at_ 10 yrs
• Internal Mammary Artery
• Patency rate-90 _at_ 10 yrs

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CABG (cont)

• Pre-Op care
• May be elective or emergency
• Pre-Op teaching
• Check administration of cardiac meds,
  anticoagulants
• NPO after midnight
• Explain Post-Op procedure
• Teach Sternal Precautions

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Cardiac Bypass- picture
Harvested vessels are connected to the blocked
arteries. Several medical centers are now
offering minimally invasive coronary artery
surgery. Less invasive technique for 1 or 2
clogged arteries.
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Cardiac bypass - picture
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CABG (cont)

• Post-Op ICU for at least 24 hours
• Monitor for arrhythmias
• Monitor Vital Signs and Electrolytes
• Emotional status
• Discharge Planning and teaching

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Intra-Aortic Balloon Pump

• Purpose Provides temporary circulatory
  assistance to a compromised heart
• Indications
• Cardiac Bypass surgery
• Acute Myocardial infarction with complications
• Awaiting cardiac transplantation
• Effects
• Increased coronary perfusion
• Improved oxygen delivery
• Decreases anginal pain
• Decreases Afterload
• Decreases Preload
• Increases Stroke Volume
• Facilitates left ventricular emptying

116
Intra-Aortic Balloon Pump Procedure

• Catheter is inserted into femoral artery
• Advanced into descending Aorta
• Balloon inflates during Diastole
• Balloon deflates during Systole

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Intraaoritc pump
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Ventricular Assist Devices(VAD)

• Purpose Provides longer term support for a
  decompensated heart
• Assist or replace the action of the ventricle
• May be implanted or external
• Indications
• Ventricular failure associated with an MI
• Waiting for a donor or artificial heart

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Pacemakers

• Triggers electrical activity.
• Used in place of SA node
• Permanent or Temporary
• Single and Dual Chamber Permanent Pacemakers
• Atrial or Ventricular single chamber
• Atrial and Ventricular dual chambers (AV)
• CRT pacing technique that paces both ventricles
• Malfunctions can occur
• -R/T sensing or capture

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Pacemaker Malfunction
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Pacemaker Malfunction
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Indications for Permanent pacing

• Symptomatic Brady arrhythmias
• Sick Sinus Syndrome
• Third Degree Heart Block
• Tachy arrhythmias
• Chronic A-Fib with a slow Ventricular rate
• See Table 35-10

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Care and Considerations

• Keep incision w/ staples dry
• No pushing, pulling, lifting or raising arm for 2
  weeks
• Encourage use of sling
• Watch for s/s of infection
• Keep wallet card
• Avoid large electrical generators,
• and large magnets like MRI
• Teach pulse taking daily with log daily till MD
  visit

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Pacemaker Insertion
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Types of Pacemakers
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External Pacemaker

• Indications
• Used for Temporary pacing
• Pt waiting for permanent pacemaker surgery
• Post CABG surgery using Epicardial pacing wires
• Post MI
• See Table 35-11

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Internal Automated Defibrillators
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AICD
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AICDs

• Treats life threatening arrhythmias
• Detects abnormally fast rhythm and deliver small
  electrical charge to convert the heart into a
  normal rhythm.
• Leads placed via sub-clavian catheter into
  endocarium

130
Patient Teaching

• Lie down when it fires
• If pt. loses consciousness, call 911
• Airport security should be alerted
• Do not allow for wanding to go over the site

131
Artificial Airways

• Oral or nasal ET (endotracheal tube) intubation
• Indications
• Airway obstruction
• Respiratory distress
• Ineffective clearance of secretions
• High risk for aspiration
• Insertions
• Physician (ED or Pulmonologist)
• Credentialed Respiratory Therapist

132
ET Tubes

• Oral

• Nasal

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Goal of Mechanical Ventilation

• ? Work of breathing
• Assure patient comfort
• Patient breathing works with ventilator not
  against
• Maintain adequate oxygenation
• Protect the airway

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Nursing Responsibilitiesfor Mechanical
Ventilation

• Maintain correct tube placement
• Checked every 2-4 hours
• Ascultates for bilateral breath sounds
• Maintain proper cuff inflation
• Maintains at 20-25mm Hg
• Monitor oxygenation and ventilation
• Assess clinical data for ABGs, SpO2
• Assess for S/S of hypoxemia
• Confusion, anxiety, arrhythmias and dusky skin
  color)
• Assess for complications
• Maintain tube patency
• Open or Closed suctioning
• Provide oral care
• Maintain skin integrity
• Watch for skin breakdown on the face and lips
• Provide skin care daily and re-tape and secure ET
  tube

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The Ventilated Patient
137
Ventilators

• Not a cure but a means to support patient
  breathing
• Negative pressure
• Positive Pressure most common for acutely ill
  patients
• Several manufacturers
• Several types/modes
• Controlled
• Assist-controlled
• Intermittent
• Positive End-Expiratory (PEEP)
• CPAP
• High frequency/flow
• Process for weaning and extubation

138
Considerations for Mechanical Ventilation

• Consider the implications for short term-versus
  long-term need
• What is the long term goal for the patient/family
• Is the patient needing ventilation for acute
  reasons or for a chronic illness/disease
• Patients and families should discuss the
  implications for removal of ventilation support

139
Remote Intensive Care Units
140
Resources

• www.theheart.org
• www.societyofcriticalcaremedicine.org
• www.guoideline.gov