Lesson 2

"Diagnosis has been described as both a process and a classification scheme, or a “pre-existing set of categories agreed upon by the
medical profession to designate a specific condition” (Jutel, 2009).
 I. ARTERIAL BLOOD GAS (ABG)
    - frequently performed in critically ill patients to assess acid-base balance, ventilation, and oxygenation. An arterial blood sample is
analyzed for oxygen tension(Pao2), carbon dioxide tension(Paco2) and pH using a blood analyzer.
     - ABG samples are obtained by direct puncture of an artery usually the radial artery, or by withdrawing blood through an
indwelling arterial catheter system.
     - A heparin syringe is used to collect the sample to prevent clotting of the blood prior to analysis.
     - Blood samples are kept on ice unless there is the ability to immediately analyze to prevent the continued transfer of CO2 and O2
in and out of the red blood cells
NURSING INTERVENTION:
1.After applying pressure to the puncture site for 3 to 5 minutes, and when bleeding stopped, taped a gauze pad firmly over it.
2.If the puncture site is on the arm, don't tape the entire circumference because this may restrict circulation.
3.If the patient is receiving anticoagulants or has a coagulopathy, apply pressure to puncture site longer than 5 minutes if necessary
4.Monitor vital signs and observe for signs of circulatory impairment.
II. EXTRACORPOREAL MEMBRANCE OXYGENATION (ECMO)
  ECMO is used in critical care situations, when your heart and lungs need help so that you can heal. It may be used in care
for COVID-19, ARDS and other infections.
This method allows the blood to "bypass" the heart and lungs, allowing these organs to rest and heal.
The blood is pumped outside of your body to a heart-lung machine that removes carbon dioxide and sends oxygen-filled blood back to
tissues in the body. Blood flows from the right side of the heart to the membrane oxygenator in the heart-lung machine, and then is
rewarmed and sent back to the body.
Some lung (pulmonary) conditions in which ECMO may be used include:
 Acute respiratory distress syndrome (ARDS)
 Blockage in a pulmonary artery in the lungs (pulmonary embolism)
 Coronavirus disease 2019 (COVID-19)
 Defect in the diaphragm (congenital diaphragmatic hernia)
 Fetus inhales waste products in the womb (meconium aspiration)
 Flu (influenza)
 Hantavirus pulmonary syndrome
 High blood pressure in the lungs (pulmonary hypertension)
 Pneumonia
 Respiratory failure
 Trauma

What you can expect

Your doctor will insert a thin, flexible tube (cannula) into a vein to draw out blood and a second tube into a vein or artery to return
warmed blood with oxygen to your body. You will receive other medications, including sedation, to make you comfortable while
receiving ECMO, and may not be able to talk during this time.
Depending on your condition, ECMO can be used for a few days to a few weeks. The amount of time you receive ECMO depends
on your condition. Your doctor will talk with you or your family about what to expect.
Lesson 3
What is Normal?
When interpreting ABG results, it is essential to know what ABG values are considered ‘normal’. From this baseline, you can then
begin to recognise significant variations in a patient’s results, which could indicate clinical deterioration.
The first value is the pH, which measures how many hydrogen ions (H+) are in the sample. This determines if the blood is acidotic or
alkalotic. Normal values for pH range from 7.35 - 7.45.
The next value is the carbon dioxide level, and this will tell you if the problem is respiratory in origin, as CO2 is regulated by the
lungs (Berman et al. 2017). The normal range for PaCO2 is 35 to 45 mmHg.
Finally, bicarbonate ions, or HCO3-, will tell you if the problem is related to metabolic changes in your patient and refers to the renal
system (Berman et al. 2017). Normal is considered to be from 22 to 26 mmol/L.
 Normal ABG Levels

pH Hydrogen 7.35 - 7.45

PaCO2 Carbon dioxide 35 - 45 mmHg

HCO3- Bicarbonate 22 - 26 mmol/L

INDICATIONS:
1. Assess ventilatory status, oxygenation and acid base status.
2. Assess the response to an intervention
3. Regulate electrolyte therapy
4. Establish perioperative baseline parameters
ABG TEST RESULT MAY SHOW:
1.  Lungs are getting enough oxygen and removing enough carbon dioxide
2.  Kidneys are working properly
PREPARATION:
1. Position patient’s arm preferably on a pillow for comfort with the wrist extended.
2. Prepare all equipment in the tray using an aseptic non touch technique
3. Palpate the radial artery on the patient’s non-dominant hand ( most pulsatile over the lateral  anterior aspect of the wrist
4. Clean the site with an alcohol wipe for 30 seconds and allow to dry before proceeding.
5. Wash hand
6.Don gloves and apron
7. Prepare and administer lidocaine subcutaneously over the planned puncture site (aspirate to ensure you are not in a blood vessel
before injecting the local anesthetic)
8. Allow the needle at least 60 seconds for the local anesthetic to work
9. Attach the needle to the ABG syringe, expel the heparin and pull the syringe plunger to the required fill level (check with your local
laboratory)
TAKING THE SAMPLE
1. Palpate the radial artery with your non dominant hand index finger around 1cm proximal to the planned puncture site (avoiding
directly touching the planned puncture site that you have just cleaned)
2. Inform the patient that you are going to insert the needle
3. Holding the syringe like a dart, insert the needle through the skin at an angle of 45 degree over the point of maximal radial artery
pulsation
4. Advance the needle into the radial artery until you observe blood flashback into the syringe
5.The syringe should then begin to self-fill in a pulsatile manner (do not pull back the syringe plunger)
6. Once the required amount of blood has been collected, remove the needle and apply pressure over the puncture site using clean
gauze.
7. Place a cap onto the syringe and label the sample
8. Dispose the materials used according to hospital policy
9. Take the ABG sample to the laboratory immediately, delay of the sample would affect the accuracy of the result (sample taken must
be sent immediately for no longer than 10 minutes.)
COMPLICATIONS RELATED TO ABG SAMPLING
1. Arteriospasm
2. Nerve Damage
3. Fainting, pallor and loss of consciousness
Lesson 4

Indications
1. Acute Respiratory Failure
2.  Airway compromise
3.Severe Hypoxia
4. Respiratory muscle fatigue.
5. Cardiac Insufficiency.
6. Neurological problems
7. Acute Lung Injury
CLINICAL PARAMETERS:

          Respiratory Rate > 35/min

          Tidal Volume         6 - 10ml/kg
          Vital Capacity       <(15ml/kg/body wt)
          PaO2.                    >50mm of Hg with FiO2 >0.60
          PaCO2.                 > 55mm of Hg with pH >7.25

TYPES OF MECHANICAL VENTILATOR

1. Pressure - cycle ventilator : the ventilator pushes air into the lungs until a specific airway pressure is reached; it is used for short
periods, as in PACU.
2. Time -cycled ventilator : ventilator pushes air into lungs until a preset time has lapsed; it is used for pediatric or neonatal client.
3. Volume - cycled ventilator : 
     - ventilator pushes air into lungs until a pre-set volume is delivered
     - A constant tidal volume is delivered regardless of the changing compliance of the lungs and chest wall or the airway resistance in
the client or ventilator.
4. Microprocessor ventilator:
     - built into the ventilator to allow continous monitoring of ventilator functions, alarms, and client parameters
     - more responsive to clients who have severe lung disease or require prolonged weaning.
Modes of ventilation
1. CONTROLLED -
          a. client receives a set tidal volume at a set rate
          b. used for clients who cannot initiate respiratory effort
          c. least used mode: if the client attempts to initiate a breath,  the ventilator blocks the effort
  2. ASSIST CONTROL 
          - most commonly used mode; tidal  volume and ventilatory rate are preset  on the ventilator.
  3. SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV)
      - allows the client to breathe spontaneously at his or her own rate and tidal volume between ventilator breaths.
      -  can be used as a primary ventilator  mode or  as a weaning mode.
      - when used as a weaning mode, the simv  breaths decreased gradually, and the client gradually resumes spontaneous
breathing.
        CONTROL AND SETTINGS
   TIDAL VOLUME : volume of air that the client receives with each breath
    RATE: number of ventilator breaths delivered per minute
    SIGHS: volumes of air that are 1.5 to 2 times the set tidal volume, delivered 6- 10 times per hour; may be used to
prevent atelectasis.
   FI02 : oxygen concentratio delivered to the client; determined by client's condition and ABG levels
   PEAK AIRWAY INSPIRED PRESSURE: pressure needed by ventilator to deliver a set tidal volumeat a given compliance; 
monitoring PAIP reflects changes in compliance of the lungs and resistance in the ventilator or client
  CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) : application for spontaneously breathing clients; keeps the
alveoli open during inspiration and prevents alveolar collapse; used primarily as a weaning modality 
    COMPLICATIONS OF VENTILATOR:
1. Hypotension - caused by application of positive pressure, which increases intrathoracic pressure and inhibits blood return
to the heart.
2. Respiratory complications such as PNEUMOTHORAX or SUBCUTANEOUS EMPHYSEMA 
3. GI alteratiosn such as stress ulcers
4. Malnutrition
5.Infections
6. Muscular deconditioning
7.Ventilator dependence 
8.Ventilator associated pneumonia
9. Baro Trauma
WEANING : process of going from ventilator depedence to spontaneous breathing
1. SIMV
2.T- PIECE
3.PRESSURE SUPPORT
Nursing responsibilities
 1. Assess vital signs, lung sounds, respiratory status and breathing pattern 
      2. Monitor skin color, (lips and nail beds)
      3. Monitor chest bilateral expansion
      4. Obtain pulse oximetry readings
      5. Monitor ABG results
      6. Assess need for suctioning and observe the type, color and amount of secretions
      7. Assess ventilator settings
      8. Assess level of water in the humidifier and the temperature of the humidification system because extremes temperature
can damage the mucosa in. the airway.
      9. Ensure that the alarms are set.
     10. If a cause of alarm cannot be determined, ventilate the client manually with a resuscitation bag until the problem is
corrected.