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

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

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

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MEDICAL-SURGICAL NURSING 3 LECTURE (NCMB418): PRELIM EXAMINATION
DRAWER 6 – PROCEDURE TRAYS AND MISCELLANEOUS
SUPPLIES
- Contents:
1. Cutdown tray
2. 3 Lumen CVP Catheter Kit
ASSESSMENT FRAMEWORK FOR CRITICAL NURSING
- Assessment Framework
 Starts from the awareness of the nurse of the
client’s admission and continues until transition
to the next phase of care
- Stages:
 Pre-arrival assessment
 Admission quick-check
 Comprehensive Admission Assessment
 On-going Assessment
PRE-ARRIVAL ASSESSMENT
- Begins when the information is received about the
pending arrival of the patient
- Abbreviated report on patient
- Complete room set-up including verification of
proper equipment functioning
- Determines the possible picture of the client and his
or her needs. (anticipate possible resources needed
by the patient)
- Starts as soon as the nurse becomes aware of a
patient coming in the ICU, whether from the ward,
operating room or emergency room
- Usual documentation – abbreviated report on patient
(age, gender, chief complaint, diagnosis, pertinent
history, physiologic status, invasive devices,
equipment and status of laboratory or diagnostic
tests)
ADMISSION QUICK-CHECK
- Obtained immediately after the arrival and
assessment
- Based on the parameters represented by ABCDE and
General Appearance (General appearance of the
client is checked [i.e. consciousness or
responsiveness, allergies, etc.])
- Airway
 Instruct the client to talk
 Rise and fall of chest
 Rate, rhythm, depth, symmetry
- Breathing
 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:
o Is the patient alert and responding?
o Normal/Signs: The patient is alert and
responding to questions in a logical manner
when assessed (Alert/responds to
voice/responds to pain/no response,
unconscious)
o Possible reasons for Unresponsiveness:
 Hypoxia, Ketoacidosis (Ketone Breath)
 Head injury, Drugs, or Stroke
o Nursing Action
 Place patient in the recovery position
(side lying) unless a spinal injury is
suspected.
- Disability Assessment
 Assessment Data
o Is there evidence of fluid loss, blood loss?
o Normal signs: No signs of loss of body fluids
o Abnormal signs: Evidence of vomiting and/or
diarrhea, Blood loss, and Loss of fluid through
burns
o Nursing Action: Risk assessment for
hypovolemic shock.
- Exposure
 Assessment Data
1. Evidence of trauma/injury
 Normal signs: (-) signs of physical
damage to the person, comfortable in
any position; calm facial expression.
 Abnormal signs: Unresponsive patient
with facial grimacing, frowning signs of
bruising, Physical trauma, Foreign object
in the person, abnormal movement of
the chest; immobility.
 Disability: Evidence of Trauma
 Nursing Action:
 Attempt to open the airway
where safe and possible for
the patient.
 If you suspect the person may
have a cervical spine injury,
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MEDICAL-SURGICAL NURSING 3 LECTURE (NCMB418): PRELIM EXAMINATION
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

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

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

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MEDICAL-SURGICAL NURSING 3 LECTURE (NCMB418): PRELIM EXAMINATION
 Given thru NGT, IV, or duodenal
feedings, or gastrostomy
 Nutrition and hydration status
expedites the patients return to an
acceptable level of functioning
 Pain Management
 One of the main components of
palliative care
 Done if there is a decision to forego
life-sustaining treatment
 “Should provide interventions to
relieve pain and other symptoms in
the dying patient even when those
interventions entails risks of
hastening death” – ANA (Code for
Nurses)
 Resuscitation Decisions – DNR, DNI
 Do Not Resuscitate (DNR) Orders
 Also known as “No Code”
 Withhold CPR
 No other heroic act to be perform
on the patient
 Nurse documents participation on
the discussion
- Paternalism
 Deliberate restriction of autonomy by health care
professionals based on the idea that they know
what is best for the client
 Refers to instances in which the principles of
beneficence overrides autonomy
LAWS ON CRITICAL CARE NURSING
1. Scope of Nursing Practice based on R.A. 9173
 A person shall be deemed to be practicing
nursing within the meaning of R.A No. 9173 when
he/she singly or in collaboration with another,
initiates and performs nursing services to
individuals, families and communities in any
health care setting
2. Nurses’ Code of Ethics
 The Filipino registered nurse, believing in the
worth and dignity of each human being,
recognizes the primary responsibility to preserve
health at all cost.
 This responsibility encompasses promotion of
health, prevention of illness, alleviation of
suffering, and restoration of health
 Nurses demonstrate professional values such as
respect, justice, responsiveness, caring,
compassion, empathy, trustworthiness and
integrity. They support and respect the dignity
and universal rights of all people, including
patients, colleagues and families
3. Patient’s Bill of Rights and Obligations
 Right to Appropriate Medical Care and Humane
Treatment
 Right to Informed Consent
 Right to Privacy and Confidentiality
 Right to Information
 Right to choose Health Care Provider and Facility
 Right to Self-Determination
 Right to Religious Belief
 Right to Medical Records
 Right to Leave
 Right to Refuse Participation in Medical Research
 Right to Correspondence and to Receive Visitors
 Right to Express Grievances
 Right to be Informed of His Rights and Obligations
as a Patient
- Responsibility
 Keep appointments and notify clinic personnel 24
hours prior, if unable to keep scheduled
appointment.
 Be involved and follow the plan of care.
 Provide a complete medical history, medications
and other matters relating to your health
 Inform the provider of any changes in your health
condition.
 Provide a copy of your Medical Advance Directive
and/or Medical Power of Attorney (if applicable
and in effect)
 Ask questions about specific problems and
request information when not understanding
your illness or treatment.
 Accept results or consequences if you refuse
treatment, do not follow the provider's
recommendations or leave the clinic against
medical advice.
4. Dying Patient’s Bill of Rights
 I have the right to participate in decisions
concerning my care
 I have the right to expect continuing medical and
nursing attention even though “cure” goals must
be changed to “comfort” goals
 I have the right to not die alone
 I have the right to be free of pain
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MEDICAL-SURGICAL NURSING 3 LECTURE (NCMB418): PRELIM EXAMINATION
- What is the Dying patient Bill of Rights in the
Philippines?
 The Natural Death Act. also known as the Senate
bill 1887, filed by former Philippine senator,
Miriam Defensor Santiago gives a patient who is
"terminally ill” or in "comatose condition" the
right to die when the patient or their family
refuse to pursue further medical treatment and
instead allow the "natural process”
- Senate Bill 586
 An act providing palliative and end-of-life care,
appropriating funds therefor and for other
purposes
THE PROCESS OF ETHICAL ANALYSIS (AACCN, 2019)
1. Assessment
 Identify the problem
o Clarify the competing ethical claims,
conflicting obligations, and personal and
professional values; acknowledge the
emotional and communication issues
 Gather data
o Distinguish the morally relevant facts,
including medical, nursing, legal, social, and
psychological facts; clarify patient’s religious
and philosophical beliefs and values
 Identify the individuals involved in the problem’s
development and who should be involved in the
decision making; discern factors that may impede
the patient’s ability to make the decision
2. Plan
 Consider all options and avoid restricting choices
to the most obvious
 Identify the pros and cons (“harms and goods’)
 Analyze if plan is in accordance with ethical
theories and principles
 Look into institutional policies and/or procedures
that address the issue
3. Implementation
 Choose a plan and act (Anticipate Objections)
4. Evaluation
 Outline the results
 Identify what harm or good occurred as a result
 Identify necessary changes in the institutional
policy/ies or other strategies to avoid similar
issues in the future
WEEK 3: QUALITY AND SAFETY IN MANAGING CRITICAL
CARE UNITS
EVIDENCE BASED NURSING (EBN)
- Under the umbrella of Evidence Based Practice.
Definitions of evidence-based nursing have varied in
scholarly Literature.
- Scott and McSherry's extensive literature review
looked at commonalities between EBN definitions
and synthesized them to come up with the following
definition:
 "An ongoing process by which evidence, nursing
theory and the practitioners’ clinical expertise are
critically evaluated and considered, in
conjunction with patient involvement, to provide
delivery of optimum nursing care for the
individual," (Melnyk, B, Fineout-Overholt, E.,
Stillwell, S., and Williamson, K., 2010).
STEPS: (Melnyk, B, Fineout-Overholt, E., Stillwell, S., and
Williamson, K., 2015)
- Step 1: Ask clinical questions
 PICOT format
o P – atient / population of interest / problem
(start with the patient, or group of patients,
or problem)
o I – ntervention or area of interest (What is
the proposed intervention?)
o C – omparison intervention or group (What is
the main alternative, to compare with the
intervention? This might be: no intervention.)
o O – utcome (What is the anticipated or
hoped-for outcome?)
o T – ime frame (How long will it take to reach
the desired outcome?)
 P.I.C.O.T Format
o This provides an efficient outline for
searching electronic databases (to retrieve
articles relevant only to the clinical question)
 Example: "I work in MICU where
ventilator-related infections are a
common problem. I've heard that oral
care of ventilated patients even with
water can help prevent this. I wonder if
there's any evidence for that and
whether it might help our patients?"
 P (Patients in MICU)
 I (Water)
 C (Oral care with water only)
 O (Prevention of ventilator-related
infections)
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MEDICAL-SURGICAL NURSING 3 LECTURE (NCMB418): PRELIM EXAMINATION
 T (Will depend on the time frame
set)
 The S.PI.D.E.R Tool
o Can be used when dealing attitudes and
experiences rather than
o Scientifically measurable data since it focuses
less on the intervention and more on the
design
o Deals with "samples" rather than a "patient"
or "populations".
 S – ample (group of participants)
 PI – phenomenon of interest (how and
why of behaviors and experiences)
 D – esign (how the study was devised
and conducted)
 E – valuation (measurement of
outcome; might be subjective and not
necessarily empirical)
 R – esearch Type (qualitative, or
quantitative, or mixed)
o Research questions framed using the SPIDER
tool tend to begin with "What are the
experiences of ...?"
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
when questions are asked
- Step 3: Critically appraise the evidence.
 Once articles are selected for review, these must
be rapidly appraised to determine those most
relevant, valid, reliable, and applicable to the
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
decision or change
 Research evidence alone is not sufficient to
justify a change in practice. Clinical expertise,
based on patient assessments, laboratory data,
and data from outcomes management programs,
as well as patients' preferences and values are
important components of EBP
- Step 5: Evaluate the outcomes of the practice
decisions or changes based on evidence.
 To monitor and evaluate any changes in
outcomes (positive effects can be supported and
negative ones remedied)
- Note: EBP results should be disseminated.
 Leads to needless duplication of effort, and
perpetuates clinical approaches that are not
evidence based
 Examples of ways to disseminate successful
initiatives: presentations at local, regional, and
national conferences; reports in peer-reviewed
journals; professional newsletters; and
publications for general audiences
SALIENT POINTS TO CONSIDER IN USE OF EBN PRACTICE
- Promotes use of EBP among advanced practice
nurses and direct care nurses
- Identifies a network of stakeholders who are
supportive of the EBP project
- Cognitive behavioral theory underpinnings
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- Emphasis on healthcare organizational readiness and
identification of facilities and barriers
- Encompasses research, patient values, and clinical
expertise as evidence.
QUALITY AND SAFETY MONITORING
1. Care bundles
 A group of 3-5 evidence-based interventions,
when performed together, have a better
outcome than if performed individually
 Can be used to ensure the delivery of the
minimum standards of care
 Can be used as an audit tool to assess the
delivery of interventions (NOTE: cannot be used
to assess how well individual interventions are
performed)
 Encourage the review of evidence and
modification of clinical care guidelines,
engendering staff education in best practice
 Key principle = high level of adherence to all
components
 Example: The sepsis care bundle, part of the
international Surviving Sepsis campaign, is the
most widely utilized bundle.
2. Checklists
3. Continuous quality improvement
4. PDCA (Plan-Do-Check-Act) cycle (Deming Cycle,
Shewhart Cycle)
 A management tool for continuous improvement
of a business's products or processes. It can be
applied to standardize nursing management and
thus improve the nursing quality and increase the
survival rate of patients
 Uses: implementation of change, solve problems,
and continuously improve nursing management
processes
 Cyclical nature; allows it to be utilized in a
continuous manner for ongoing improvement
o P - PLAN the change or improvement
o D – DO = conduct a pilot test of the change
o C – CHECK = gather data about the pilot
change to ensure the change was successful
o A – ACT = implement the change on a
broader scale; continue to monitor the
change and repeat as necessary by repeating
the cycle
 Expertise Required: easy to use and requires little
or no training.
 Advantages:
o Makes sure that all appropriate steps are
followed.
o Offers a systematic improvement method.
o Is an effective process improvement guide.
o Informs future improvement by providing
feedback.
o Maintains order during problem solving.
 Disadvantage:
o Requires significant commitment over time.
MULTIDISCIPLINARY PLANS OF CARE
- Benefits to both patients and the hospital system:
1. Improve patient’s outcome
2. Increased quality and continuity of care
3. Improve communications and collaboration
4. Identification of hospital system problems
5. Coordination of necessary services and reduced
duplication
6. Prioritization of activities
7. Reduce length of stay and health care costs.
- Format for the Multidisciplinary Approach
Categories:
1. Discharge outcomes
2. Patient goals
3. Assessment and evaluation
4. Consultations
5. Tests
6. Medications
7. Nutrition
8. Activity
9. Education
10. Discharge planning
- Note: Primary Consideration = Patient’s Safety
INFORMATION AND COMMUNICATION TECHNOLOGIES
IN CCU
1. Clinical Information System
2. Computerized provider order entry (CPOE)
3. Hand-held Technologies
4. Tele-health Initiatives (Tele-ICU)
ADVOCACY: ACCESS TO SOCIAL CARE SERVICES
1. PhilHealth
2. DOH
3. DSWD
4. PAGCOR
5. PCSO
WEEK 3: CARE BUNDLES
- Purpose:
 Continuous Monitoring and treatment.
 Required emergency interventions.
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 Care for patients who are medically unstable or
seriously ill.
 Care for patients who do not have much chance
for recovery due to the severity of their illness or
traumatic injury.
- History:
 1854 Crimean war – Florence Nightingale
 Dr. W.E. Dandy – 3 bedded Neurosurgical unit in
US
 1927 first hospital for premature born infants in
Chicago
 2nd world war – shock wards
 Outbreak polio Epidemic – respiratory ICU
 1950 peter safar anathetist ‘Advanced support of
Life’ (sedated & ventilated)
 Nurses practice – sick patients located near the
nurse’s station receive more attention.
 Development of various specialty & ICU
significantly reduced the mortality and hopital
stay time
 Major surgeries – liver transplant, kidney
transplant and pancreatectomy
- Location:
 Should be a geographically distinct area within
the hospital, with controlled access.
 No through traffic to other departments should
occur.
 Supply and professional traffic should be
separated from public/visitor traffic.
 Location should be chosen so that the unit is
adjacent to, or within direct elevator travel to
and from, the Emergency Department, Operating
Room, Intermediate care units, and the Radiology
Department.
- Design of Unit:
- Bed Strength
 Ideally 8 to 12 beds
 Larger areas difficult to administer and smaller
areas not being cost effective
 3 to 5 beds per 100 hospital beds for a level III
ICU / 2 to 20 of the total number of hospital beds
 1 isolation bed for every 10 ICU beds
- Bed Space Beds
 150 200 square feet per open bed with 8 feet in
between beds. The beds should be 2.5 - 3 meters
(7-9 feet) apart, to allow free movement of staff
and equipment, reducing risk of cross
contamination.
 225 250 square feet per bed if in a single room.
- Infrastructure
 Patients must be situated so that direct or
indirect (e.g. by video monitor) visualization by
healthcare providers is possible at all times.
 The preferred design is to allow a direct line of
vision between the patient and the central
nursing station.
 Modular design sliding glass doors partitions to
facilitate visibility.
- Partitions
 Privacy partitions should be of material that is
easily cleaned and should be cleaned weekly and
any time that it becomes soiled or contaminated.
 If curtains are used, they should be changed
weekly and between patients.
- Central Station
 Provide a comfortable area of sufficient size to
accommodate all necessary staff functions.
 There must be adequate overhead and task
lighting, and a wall mounted clock should be
present.
 space for adequate computer terminals and
printers is essential
- Environment
 Signals alarms add to the sensory overload need
to be modulated.
 Floor coverings and ceiling with sound absorption
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
 Nurses waiting/resting room
 Doctors waiting/resting room
 Lab
 Pantry
 Visitors room
 Store room & Changing room
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- Infrastructure
1. Rails alongside the bed
2. Wall sockets for oxygen and pressurized air as
well as for suction. At least 2 oxygen and
pressurized air outlets are needed and 3
aspirators per patient.
3. A bell or intercom for calling the nurse should be
at each bed.
4. A table and a telephone with an outside line
should be at the bedside.
5. Armchairs should be on hand, preferably
adjustable ones, to allow patients to sit up if they
can.
- Types Specialized types of ICUs include:
 Neonatal intensive-care unit(NICU)
 Special Care Nursery (SCN)
 Pediatric intensive-care unit (PICU)
 Psychiatric intensive-care unit (PICU)
 Coronary care unit (CCU)
 Cardiac Surgery intensive-care unit (CSICU)
 Cardiovascular intensive-care unit (CVICU)
 Medical intensive-care unit (MICU)
 Medical Surgical intensive-care unit (MSICU)
 Surgical intensive-care unit (SICU)
 Overnight intensive recovery (OIR)
 Neurotrauma intensive-care unit (NICU)
 Neurointensive-care unit (NICU)
 Burn wound intensive-care unit (BWICU)
 Trauma Intensive Care Unit (TICU)
 Surgical Trauma intensive-care unit (STICU)
 Trauma-Neuro Critical Care (TNCC)
 Respiratory intensive-care unit (RICU)
 Geriatric intensive-care unit (GICU)
 Mobile Intensive Care Unit (MICU)
 Post Anesthesia Care Unit (PACU)
- Models
 Open ICU model is one where specialty teams
have full admitting rights and where an
intensivist is merely "consulting".
 Closed ICU model is one where the intensivist is
the admitting medical officer and the specialty
teams collaborate with ICU staff
STANDARDS OF CARE
- Healthcare workers are committed to delivering high
standards of care to all patients
- Standards of care are generally defined by evidence
based guidelines, e.g. infection control guidelines:
 SARI guidelines
 CDC guidelines (USA)
 EPIC/NICE guidelines (UK)
WHAT ARE “CARE BUNDLES”?
- A Care Bundle is a collection of interventions (usually
3-5) that are evidenced based
- All clinical staff know that these interventions are
best practice but frequently their application in
routine care is inconsistent
- A Care Bundle is a means to ensure that the
application of all the interventions is consistent for all
patients at all times thereby improving outcomes
TYPES OF CARE BUNDLES
- WHO Surgery Safety Checklist
- Urinary Catheter Care Bundle
 Insertion and Management
- Clostridium Difficile Care Bundle
- Ventilator Assisted Pneumonia (VAP) Care Bundle
- Palliative Care Bundle
- Pressure Area Care Bundle
- Sepsis Care Bundle
- PVC Care Bundle
VENTILATOR ASSOCIATED PENUMONIA (VAP) CARE
BUNDLE
- Evaluation of the head of the bed to between 30°-45°
- Daily sedative interruption and daily assessment of
readiness to extubate
- Peptic ulcer disease prophylaxis
- Deep venous thrombosis prophylaxis if not
contraindicated
URINARY CATHETER CARE BUNDLE
- Insertion
 Insert only for specific reasons
o Urinary output in critical ill
o Bladder outlet obstruction or neurogenic
bladder dysfunction
o Prevent contamination of sacral wounds
o Terminal care
 Competent HCW to insert
 Aseptic technique
 Closed system with bag below bladder
- Management
 Review need for catheter daily
 Empty when ¾ full and use clean container for
each patient
 Secure catheter to leg/abdomen
 Urine samples from sampling port only
 Hand hygiene & PPE before and after any
catheter care
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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

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- Physiology of Respiration
 Mechanism of breathing
1. Phrenic nerve stimulation
2. Thorax increases in size
3. Intrathoracic and intrapulmonic pressure
decreases
4. Air rushes from positive pressure in the
atmospheres to negative pressure in the
alveoli
5. Inspiration is completed with stimulation of
the stretch receptor
6. Expiration occurs passively as a result of
recoil of elastic lung tissue
 Control of Respiration
1. Alveolar stretch receptors respond to
inspiration by sending inhibitory impulses to
inspiratory neurons in the brainstem to
prevent lung overdistention (Hering-Breur
Reflex)
2. Central and peripheral chemoreceptors
3. MO and pons-control rate and depth of
respirations
- 9. Total lung capacity; amount of air in the lungs
- Lung Volume/Body Plethysmography
1. Tidal Volume: average amount expired after
normal inspiration; approximately 500ml
2. Expiratory reserve volume (ERV): largest
additional volume of air that can be forcibly
expired after a normal inspiration and expiration;
1000-1200 ml
3. Inspiratory reserve volume(IRV): largest
additional volume of air that can be forcibly
inspired after a normal inspiration; 3000 Ml
- Pulmonary Function
4. Residual Volume: air that cannot be forcibly
expired voluntarily from the lungs; 1200 ml;
increased in COPD as lungs lose elasticity and
ability to recoil, resulting in air trapping
5. Vital Capacity (TV + IRV + ERV); amount of air that
can be forcibly expired after forcible inspiration;
4600 ml; decreases with COPD, neuromuscular
disease, atelectasis
6. Forced expiratory volume (FEV): volume of air
that can be forcibly exhaled within a specific
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
after a maximum inhalation; 5800 ml;
TV+RV+IRV+ERV; increased with COPD, decreased
with atelectasis and pneumonia
- Lung Volumes
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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

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 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.

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- 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
 Sputum sample is obtained by coughing and is
examined in the laboratory
 Nursing Interventions:
o Drinking a lot of water and other fluids the
night before collection may help
o Perform back tapping or chest clapping
o on client to aid in loosening the sputum
o Instruct client on proper specimen collection
o Collect morning specimen
o Gargle with water only before specimen
collection cough deeply and spit sputum in a
sterile cup
o Send specimen to lab ASAP
- MRI and CT Scan
- Chest Tubes
 Use of tubes and suction to return negative
pressure to the intrapleural space, expands the
lung by removing positive pressure from the
pleural space
 To drain air from intrapleural space, a chest tube
is placed in 2nd or 3rd ICS to drain blood or fluid,
catheter would be placed at a lower site, 8th or 9th
ICS
 Single Chamber Underwater Seal Chest Drain
o It is a single bottle, open to air. The patient's
chest tube is submerged under a level of
water (usually about 2cm) which acts as a
one-way valve. When the patient's pleural
pressure exceeds the level of water (i.e. it is
greater than 2cm H2O), the air in the tube
will bubble out and escape into the
atmosphere. When the patient takes a breath
in, the negative intrapleural pressure will
suck drain water up the tube, but no
additional air can enter.
 What are the advantages of the single bottle
pleural drain?
o Simple
o Cheap
o Easily improvised from unrelated equipment
o For simple pneumothorax, there is usually no
need for anything more sophisticated
o The fluid level (i.e. valve pressure) is
adjustable, though there are few scenarios
where one might wish to adjust it.
 The Two-Chamber Underwater Seal Pleural Drain
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
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o Pleural fluid and water seal are separate:
therefore, no froth will form.
o The collection bottle permits the drainage of
pleural fluid, so the case uses of this system
are not limited to pneumothoraces.
 The Three-Chamber Underwater Seal Drain
o This system is much like the two-bottle
system, but with an added chamber to help
regulate the suction pressure, i.e. it is
specifically designed to be used with suction.
It was apparently developed at the
Massachusetts General Hospital in 1945.
 Management:
o Provide pain relief.
 Administer narcotics/analgesics prior to
turning, coughing, and deep breathing.
 Assist with splinting while turning,
coughing, deep breathing.
o Promote adequate ventilation.
 Perform complete physical assessment
of lungs and compare with pre-op
findings.
 Auscultate lung fields every 1—2 hours.
 Encourage turning, coughing, and deep
breathing every 1—2 hours after pain
relief obtained.
o Perform tracheobronchial suctioning if
needed.
 Assess for proper maintenance of chest
drainage system (except after
pneumonectomy).
 Monitor ABGs and report significant
changes.
 Place client in semi-Fowler’s position
FROM THE CANVAS MODULE WEEK 4
- Purpose of the Respiratory System
 The lungs, in conjunction with the circulatory
system, deliver oxygen to and expel carbon
dioxide from the cells of the body.
 The upper respiratory system warms and filters
air.
 The lungs accomplish gas exchange.
- Structures of the Respiratory System:
 Parts of the Upper Respiratory System
o Nose
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
increases the space in the thoracic chamber (lowered
intrathoracic pressure causes air to enter through the
airways and inflate the lungs)
- Expiration: with relaxation, the diaphragm moves up
and intrathoracic pressure increases (pushes air out
of the lungs); expiration requires the elastic recoil of
the lungs.
 Inspiration = 1/3 of the respiratory cycle;
expiration = 2/3 of the respiratory cycle
RESPIRATION
- Oxygen diffuses from the air into the blood at the
alveoli to be transported to the cells of the body.
- Carbon dioxide diffuses from the blood into the air at
the alveoli to be removed from the body.
ASSESSMENT OF BREATH SOUNDS
- Normal Breath Sounds:
 Vesicular, Bronchovesicular, Bronchial
- Abnormal (Adventitious) Breath Sounds:
 Crackles
 Wheezes
 Friction rubs
VENTILATION PERFUSION (V/Q) RATIO
- Ventilation is the movement of air in and out of the
lungs.
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- 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.

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LARYNGEAL MASK AIRWAY
- An ET with a small mask on one end that can be
passed orally over the larynx
- Provides ventilatory assistance and prevent
aspiration
- Combitube
 Esophageal/tracheal double lumen airway
 Used for difficult or emergency intubation
 Permits blind placement
ENDOTRACHEAL (ET) TUBE
- Includes a 15mm adapter at the end for connection
to life support equipment
- Distance marker on the sides for placement
- Inserted into the trachea through the mouth or nose
- Insertion of Endotracheal (ET) Tube
 Using laryngoscope to visualize the upper airway
 Inserted through the vocal cords into the trachea
 2-4 cm above the carina
 Anchored by inflating the cuff (prevents air
leakage and aspiration)
- Confirm Proper Placement
 Presence of bilateral breath sounds
 Equal
 Suctexcursion during inspiration
 Absence of breath sounds over the stomach
 PETCO2: 35-40 mmHg
- Verification: CXR
 Anchor with tape or ET fixation device
 Centimeter marking at the lip is documented
during each shift
 10-14 days of intubation: tracheostomy is usually
indicated
- Complications:
 Laryngeal and tracheal damage
 Laryngospasm
 Aspiration
 Infection and discomfort
 Vocal cord paralysis (should not be used longer
than 3 week)
MECHANICAL VENTILATOR
- A form of assisted ventilation; takes over all part of
the work performed by the respiratory muscles and
organs
- Indication: impaired patient’s ability to oxygenate
and exchange carbon dioxide
- Main Goal: to support gas exchange until the disease
process is resolved
POSITIVE PRESSURE VENTILLATION (PPV)
- Most common form of mechanical ventilation used in
the acute care setting
- Forces oxygen into the lungs with each breath
through an endotracheal tube or tracheostomy tube
- Volume-cycled modes (deliver breath until preset
tidal volume is reached with each breath)
- Pressured-cycled modes (deliver breath until a preset
pressure is achieved within the airway)
MODES OF VENTILLATION
- Ways in which ventilation is triggered, allowing the
patient partial or complete control over their
breathing
- Factors Affecting Selection of Ventilator Modes:
 Underlying pulmonary status
 Oxygenation Presence of spontaneous breathing
ASSIST-CONTROL VENTILATION (ACV)
- Delivers a preset volume at a preset rate and
whenever the patient initiates a breath (i.e. if the
patient does not initiate a breath within a preset
time, the ventilator will deliver a breath)
- Used in patients with weak respiratory muscles
SYNCHRONIZED INTERMITTENT MANDATORY
VENTILATION (SIMV)
- Delivers a preset volume at a preset rate and is
synchronized with the patient’s effort
- Allows spontaneous breathing between ventilated
breaths
- Prevents competition between patient and ventilator
- Common mode for patients requiring minimal
ventilation
- Used for WEANING for ventilator support
PRESSURE-CONTROLLED VENTILATION (PCV)
- Delivers positive-pressure breath until a maximum
amount of airway pressure is reached, then the
inspiratory phase of the breath stops
- Maximum inspiratory pressure limit is preset to help
minimize ventilator-induced lung injury (VILI)
- Settings are adjusted to achieve a goal tidal volume
designated by physician
- Tidal Volume Goal: based on patient’s weight and
pulmonary status
PRESSURE-REGULATED VOLUME CONTROL (PRVC)
- A type of PCV in which the ventilator makes pressure
adjustments to aim for a predetermined tidal volume
- Using this mode, the ventilator senses any changes in
lung compliance (ex. Increase in peak inspiratory
pressure) and reduces the tidal volume until airway
pressures are back within normal range
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ADDITIONAL VENTILATORY MODES
POSITIVE END-EXPIRATORY PRESSURE (PEEP)
- Holds positive pressure in the alveoli during
expiration
- Frequently used as a supplement to most modes of
ventilation
- Advantages:
 Prevents alveoli from collapsing at end-expiration
 Improves oxygenation
 Increases functional residual capacity
 Range: 2 to 24 cmH2O pressure
- Disadvantage:
 PEEP greater than 10 cmH2
 Increased intrathoracic pressure that causes
decreased venous return and decreased cardiac
output (Hypotension)
 Increase preload with fluids or vasopressors
- High Levels of PEEP
 Increased airway pressure
 VILI, hypotension, increased ICP, alveolar
ventilation-perfusion mismatch
CONSTANT POSITIVE AIRWAY PRESSURE (CPAP)
- Similar to PEEP but provides positive pressure during
spontaneous breaths
- Increases oxygenation by preventing closure of
alveoli at end-expiration thereby maximizing
functional residual capacity (FRC)
- General Range: 5-10 cmH2O; more than 10cmH20 =
hypotension/pneumothorax
- Frequently used to wean patients as a non-invasive
method
PRESSURE SUPPORT VENTILATION (PSV)
- Augments the tidal volume of spontaneous breaths
by delivering a preset positive pressure during
inspiration
- Can be added to SIMV and CPAP for weaning
- Range: 8-20 cmH20
- Increases patient comfort by decreasing the amount
of work required in each spontaneous breath
VENTILATOR SETTINGS
- Individualized settings
- Adjustments are based on ABG measurements and
Arterial Oxygen saturations (SaO2)
- VT (Tidal Volume)
 Amount of oxygen delivered to a patient with
each preset ventilated breath; 5-15 mL/kg
(average: 10mL/kg)
- Back Up Rate (BUR) or Respiratory Rate
 Number of breaths per minute that ventilator is
set to deliver; 4-20 breaths/minute
- Fraction of Inspired Oxygen (FiO2)
 Percentage of oxygen delivered by ventilator with
each breath 21 - 100%
- Inspiratory to Expiratory Ratio (I:E Ratio)
 Number of breaths per minute that ventilator is
set to deliver 1;2
- Sensitivity
 Determines amount of effort patient must
generate before ventilator will give a breath
 Too Low: patient works harder to obtain a breath
 Too High: patient’s respiratory effort may
compete with ventilator
- Flow Rate
 Determines how fast VT will be delivered during
inspiration
 High – increase airway pressure
 Low – decrease airway pressure
- Pressure Limit
 Regulates maximum amount of pressure the
ventilator will generate to deliver preset VT
 Ventilated breath will stop when pressure limit is
reached
VENTILATION TERMINOLOGIES
- Compliance
 Elasticity of the lung tissue
 Decreased compliance = increased resistance to
breath
- Peak Inspiratory Pressure (PIP)
 Airway pressure at maximum inspiration
 A.K.A. peak airway pressure
- Low Pressure Alarms
 LEAK or DISCONNECTION in ventilator circuit
 Patient not receiving adequate ventilation
- High Pressure Alarms
 PIP has exceeded a safe limit
 Patient at risk of VILI
- Volutrauma
 Injury to the lung tissue from over distension of
alveoli
- Barotrauma
 Injury to the lung tissue from too much pressure
on the airway
- Atelectrauma
 VILI from a low intra-alveolar pressure causing
collapse of alveoli
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MECHANICAL VENTILLATION COMPLICATION
- Ventilator - Associated Pneumonia (VAP) Bundles of
Care
 Elevation of the head of the bed (HOB)
 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
accessory muscles, decrease in LOC,
increase in CO2 levels, decrease O2
saturation and tachycardia
 Synchronized Intermittent Mandatory
Ventilation (SIMV)
o Indicated for patients who satisfied weaning
criteria but cannot sustain adequate
spontaneous ventilation for long periods
o As respiratory muscles strengthen, the
pressure is decreased
 T-piece
o Usually used when patient is awake and alert,
breathing without difficulty, and has good
gag and cough reflex
o Maintained on oxygen level on the same or
greater than oxygen concentration the
patient is receiving in mech vent
o WOF: respiratory distress and hypoxia
VENTILATION PPT COPY FROM DOC FERRIOL
- Principles of Mechanical Ventilation:
 “... an opening must be attempted in the trunk of
the trachea, into which a tube of reed or cane
should be put; you will then blow into this, so
that the lung may rise again...and the heart
becomes strong...” – Andrea Vesalius (1555)
- Vesalius is credited with the first description of
positive-pressure ventilation, but it took 400 years to
apply his concept to patient care.
- The occasion was the polio epidemic of 1955, when
the demand for assisted ventilation outgrew the
supply of negative-pressure tank ventilators (known
as iron lungs).
- In Sweden, all medical schools shut down and
medical students worked in 8-hour shifts as human
ventilators, manually inflating the lungs of afflicted
patients.
- In Boston, the nearby Emerson Company made
available a prototype positive-pressure lung inflation
device, which was put to use at the Massachusetts
General Hospital, and became an instant success.
Thus began the era of positive-pressure mechanical
ventilation (and the era of intensive care medicine).
- Conventional Mechanical Ventilation
 The first positive-pressure ventilators were
designed to inflate the lungs until a preset
pressure was reached.
 This type of pressure-cycled ventilation fell out of
favor because the inflation volume varied with
changes in the mechanical properties of the
lungs.
 In contrast, volume-cycled ventilation, which
inflates the lungs to a predetermined volume,
delivers a constant alveolar volume despite
changes in the mechanical properties of the
lungs.
 For this reason, volume-cycled ventilation has
become the standard method of positive-
pressure mechanical ventilation.
- A New Strategy for Mechanical Ventilation:
 In the early days of positive-pressure mechanical
ventilation, large inflation volumes were
recommended to prevent alveolar collapse.
 Thus, whereas the tidal volume during
spontaneous breathing is normally 5 to 7 mL/kg
(ideal body weight), the standard inflation
volumes during volume-cycled ventilation have
been twice as large, or 10 to 15 mL/kg.
 The large inflation volumes used in conventional
mechanical ventilation can damage the lungs, and
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can even promote injury in distant organs
through the release of inflammatory cytokines.
 The discovery of ventilator-induced lung injury is
drastically changing the way that mechanical
ventilation is delivered.
ORIGINS OF MECHANICAL VENTILATION
- The era of intensive care medicine began with
positive-pressure ventilation
- Negative-Pressure Ventilators (Iron Lungs)
 Non-Invasive ventilation first used in Boston
Children’s Hospital in 1928
 Used extensively during polio outbreaks in 1940-
1950s
- Positive-Pressure Ventilators
 Invasive ventilation first used at Massachusetts
General Hospital in 1955
 Now the modern standard of mechanical
ventilation
MECHANICAL VENTILATION
- Non-Invasive:
 Ventilatory support that is given without
establishing endo- tracheal intubation or
tracheostomy is called Non-invasive mechanical
ventilation
 Good control of airway
 Suitable for higher pressures
- Invasive:
 Ventilatory support that is given through endo-
tracheal intubation or tracheostomy is called as
 Invasive mechanical ventilation
 Avoidance of complications of intubation
 Avoidance of complication of invasive ventilation
(sinusitis)
 If tolerated, more comfortable to awake pts.
Breaks possible
 No sedation (or less sedation)
- Non-Invasive:
 Negative Pressure
o Producing negative pressure intermittently in
the pleural space/around the thoracic cage
o Ex: Iron Lung
 Positive Pressure
o Delivering air/gas with positive pressure to
the airway
o Ex: BiPAP and CPAP
- Invasive Positive Pressure:
 Pressure Cycle
o A pre-determined and preset pressure
terminates inspiration. Pressure is constant
and volume is variable
 Volume Cycle
o A pre-determined and preset volume-on
completion of its deliver, terminates the
inspiration. Pressure is variable and volume is
constant
 Time Cycle
o Delivers air/gas over a set time (Insp. Time)
after which the inspiration ends
o Ex: Pressure controlled ventilation
COMMON MODES
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
- Given through air tight mask/ ET/Tracheostomy tube
- Applies continuous positive pressure to the air way.
- Tidal volume and respiratory rate are patient
dependent
- FiO2 & PEEP are to be set in the equipment.
ASSIST CONTROLLED VENTILATION (ACV)
- Delivers a preset tidal volume for every breath
initiated by the machine
- Or triggered through the patient's effort
CONTROLLED MANDATORY VENTILATION (CMV)
- Delivers a preset tidal volume/pressure at a preset
rate, ignoring the patient’s own ventilatory effort.
INTERMITTENT MANDATORY VENTILATION (IMV)
- Delivers a preset tidal volume at a preset rate while
allowing the patient to breathe at his own rate and
tidal volume in between.
- Can cause breath stacking – because preset
frequency of the machine may not occur in the same
phase as the patient's own efforts.
SYNCHRONIZED INTERMITTENT MANDATORY
VENTILATION (SIMV)
- Delivers a preset, mandatory tidal volume.
- Synchronized to the patient’s respiratory effort
INITIAL SETTINGS
Mode: SIMV with Pressure Support (If available)
FiO2: 1.0 (100%)
PEEP: 5
Tidal Volume: 6-7 ml/kg
Rate : 10-15/minute
Pressure Support: 15 cm H2O/if flow assist: 0.5 sec
Alarms: Max Pressure: 35 cm of H2O
Min Pressure: 10 cm of H2O
- Special consideration in the settings should be shown
to COPD and ARDS patients.
- ABG – after 1 hour and adjust the settings
- Remember that:
 PaO2 depends on FiO2 and PEEP
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 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”

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 Pressure Modes
o Advantages: Greater control of airway
pressure. Less risk of barotrauma
o Disadvantages: No guaranteed minute
ventilation. Increased monitoring of VT
required. Rapid changes in the compliance
can cause hypoventilation/hypoxia.
INSPIRATION
- Flow Trigger
 A breath is generated when the patient’s
respiratory effort causes flow to reach a set level.
- Pressure Trigger
 A breath is generated by measuring pressure and
starting assisted ventilation when pressure
reaches a given level.
- Time Trigger
 A breath is generated by measuring frequency of
respirations and starting ventilation when
respirations frequency is at a given.
EXPIRATION
- Time Cycled
 Such in in pressure controlled ventilation
- Flow Cycled
 Such as in pressure support
- Volume Cycled
 The ventilator cycles to expiration once a set tidal
volume has been delivered: this occurs in volume
controlled ventilation.
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
 Suitable only for patients who have no ability to
breathe spontaneously
MANDATORY ASSIST MODES OF VENTILATION
- Synchronized Intermittent Mandatory Ventilation
(SIMV)
 Provides a set TIDAL VOLUME at a set RATE (F)
 Patient can breathe in-between mandatory
ventilation
 Spontaneous breaths are supported with
pressure support
 Ventilator synchronises mandatory breaths and
spontaneous breaths for increased patient
comfort
 Usually volume targeted but some machines offer
SIMV(pc)
 Advantages: Guaranteed Minute Ventilation
 Disadvantages: Increased monitoring of airway
pressures. Airway pressures will increase if lung
compliance decreases. Risk of barotrauma.
- Bilevel Positive Airway Pressure (BiPAP)
 Provides a set P-insp at a set RATE (F)
 Patient can breathe in-between mandatory
ventilation
 Spontaneous breaths are supported with
pressure support
 Pt can breathe at any point of respiratory cycle,
not just between breaths
 Breathing takes between two levels Pinsp and
PEEP
 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
SPONTANEOUS MODES OF VENTILATION
- Spontaneous modes are:
 Triggered and Cycled by the patient
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- 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

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6. Acid Base Disorders
7. Phrenic Nerve Injury
o Especially with contralateral pulmonary
disease)
- Complication:
 Ventilation-Related Complications:
o Disconnection
o Malfunction
 Hemodynamic Effects:
o Decreased cardiac output due to impaired
venous return to the right heart and
increased pulmonary venous resistance due
to positive pressure alveolar distension
 Autopeep
o Barotrauma or Atelectasis
o Oxygen toxicity
o Respiratory alkalosis
o Increased intracranial pressure
 Suctioning-Related Complications:
o Hypoxemia
 Patients should always be pre-
oxygenated with 100% oxygen prior to
suctioning
 Suction time should be limited
o Arrhythmias
o Nosocomial infections
WEEK 5: NURSING CARE OF CLIENTS WITH ALTERED
VENTILATORY FUNCTION
- Respiratory emergencies may range from “shortness
of breath,” or dyspnea, to complete respiratory
arrest, or apnea. These conditions can result from a
large number of causes, but most typically they
involve the lungs.
PULMONARY EMBOLISM (PULMONARY EMBOLUS)
- This is a thrombotic or non-thrombotic embolus that
lodges in the pulmonary artery system.
- It can damage part of the lung due to restricted blood
flow, decrease oxygen levels in the blood, and affect
other organs as well.
- Large or multiple blood clots can be fatal.
- The blockage can be life-threatening
- Risk Factors:
 Injury or damage leading to blood clot formation
 Inactivity for prolonged periods
 Medical conditions or treatment procedures that
cause blood to clot easily (e.g. surgery, DVT, etc.)
- Clinical Manifestations:
 Virchow’s Triad: venous stasis, coagulation
problems, vessel wall injury
 Chest pain
 Tachycardia, tachypnea
 Anxiety, restlessness
 Clammy or bluish skin
- Diagnosis:
 CXR – to rule out other disorders with the same
presenting manifestations
 ABG analysis
 D-dimer test – detects clot fragments from clot
lysis
 ECG
 V/Q scan/Pulmonary angiography/spiral CT scan
- Treatment:
 Oxygenation (ET and mechanical ventilation)
 Heparin therapy until therapeutic PTT is attained;
sodium warfarin is used for maintenance therapy
 Surgery – umbrella filter, pulmonary
embolectomy
 Prevention of development of DVT
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
LUNG INJURY
- This is a syndrome with inflammation and increased
permeability of the alveolocapillary membrane that
occurs as a result of an injury to the lungs.
- This condition is fatal when left undiagnosed or
treated for 48hrs.
- Risk Factors:
 Critically ill patients
 Age (60y/o and above)
 Malignancy (cancers)
 Cigarette smoking, COPD
- Causes:
 Aspiration pneumonia or systemic illness (e.g.
burns, sepsis, drug overdose)
- Clinical Manifestations:
 Signs and symptoms are often exhibited within
24-48 hours after initial insult to the lungs
o Subjective: restlessness, anxiety, dyspnea
o Objective: tachycardia, grunting respirations,
intercostal retractions, cyanosis
o Hypoxemia
o Severe: hypotension, cyanosis, decreased UO
- Diagnostic Test:
 Chest x-ray = reveals “white out” lungs;
pulmonary edema
- Therapeutic Interventions:
 Mechanical ventilation with positive end-
expiratory pressure (PEEP) maintains positive
pressure within the lungs at the end of expiration
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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

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- This usually occurs in people over 50 years of age and
smoking is a major factor in its development
- Assessment:
 Patient’s History:
o Mild = a ‘smoker’s cough’ is the only
abnormal sign.
o Moderate = breathlessness and/ or wheeze
on moderate exertion, cough, and
generalized reduction in breath sounds.
o Severe = breathlessness at rest, cyanosis,
prominent wheeze and/ or cough, and lung
over inflation
- Clinical Findings:
 Subjective: anxiety, restlessness, fatigue and
weakness, dyspnea, headache, impaired
sensorium
 Objective: orthopnea, expiratory wheezing,
stertorous breathing sounds, cough
 Barrel chest, cyanosis, clubbing of fingers, use of
accessory muscles, purse lip breathing (COPD)
 Distended neck veins, peripheral edema (RSHF)
- Consider and Record the following too:
 Current treatment— inhalers, nebulizers,
antibiotics, steroids, O2, and theophyllines;
 Exercise tolerance;
 High protein soft diet in small, frequent feedings
 Pneumococcal and influenza vaccines
 Surgery for end-stage emphysema: lung volume
reduction; lung transplant
 Previous admissions, especially intensive care or
treatment with NIV; the reason for ED
attendance— it is important to identify whether
the exacerbation has been accompanied by an
increase in the amount or type of sputum
produced; a recent fall or chest injury may be the
cause of the symptoms.
- In the ED, Assess for the following:
 Cough; sputum— color and amount;
 Cyanosis;
 Tachypnea; wheeze;
 Accessory muscle usage; lip pursing on
expiration;
 Chest expansion (which is often poor);
 Fever;
 Dehydration;
 Confusion or reduction in conscious level;
 Pain
 Consider whether the patient is septic, and treat
any signs of sepsis, severe sepsis, or septic shock
immediately.
- Diagnostics and Laboratory:
 Continuous monitoring— HR, RR, and SpO2.
 CXR.
 ECG.
 ABG analysis as soon as possible.
 FBC, U&E, and theophylline level (if the patient is
taking theophylline).
 Sputum for C&S if purulent.
 Blood cultures if the patient is pyrexial.
- Nursing Interventions:
 Reassurance.
 Nurse the patient in an upright position.
 O2 therapy to keep saturations in the range of
88– 92%
 Nebulizers (may need to be continuous).
 Steroids.
 IV theophylline (for patients who do not respond
to nebulizers).
 Assessment for NIV.
 Mouth care.
 IV fluids if the patient is dehydrated.
 Analgesia.
 AVPU and GCS scores.
- Management:
1. Non-Invasive Ventilation (NIV)
o Increasingly used in ED resuscitation rooms
(evidence suggests that using NIV in patients
with COPD reduces mortality and the need
for invasive ventilation)
o NIV should be considered in patients who
meet the following criteria:
 Respiratory acidosis (pH <7.35, PaCO2
>6kPa) that persists despite maximal
medical therapy;
 Not moribund, GCS score >8
 Able to protect the airway;
 Cooperative and conscious;
 Few co- morbidities;
 Hemodynamically stable;
 No excess respiratory secretions;
 Potential for recovery to a quality of life
acceptable to the patient.
o Ideally, patients should have an anesthetic
assessment prior to the commencement of
NIV, in order to determine their suitability
and outline what the ceiling treatment
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should be. A ‘do not attempt resuscitation’
(DNAR) order may be completed at this time
if the patient is not suitable for invasive
ventilation.
2. Intensive Care
o Patients with exacerbations of COPD should
not be automatically excluded from invasive
ventilation if all other treatments are failing.
o The following will have to be considered:
 Quality of life (ideally involving the family
in the discussion);
 O2 requirements when stable;
 Co-morbidities;
 Forced expiratory volume in 1s (FEV1);
 Body mass index (BMI).
PNEUMONIA
- Pneumonia is an inflammation of the lung, which is
characterized by exudation into the alveoli. It can be
classified anatomically as lobar or by etiology.
- It is most commonly caused by bacteria.
- The terms ‘pneumonia’ and ‘chest infection’ are often
used interchangeably.
- Causes:
 Pneumonia can be caused by any of over 100
microorganisms. Therefore, the treatment should
be started before the causative organism has
been identified.
- Common microorganisms that can cause
Pneumonia:
 Streptococcus pneumoniae (90% of cases)
 Haemophilus influenzae
 Staphylococcus aureus
 Legionella species
- Types of Pneumonia:
 Community Acquired – not hospitalized or
residing in a long-term care facility for ≥ 14 days
prior to onset of symptoms.
 Hospital Acquired – more than 48 h between
admission and onset of symptoms.
 Ventilator Associated – more than 48–72 h
between intubation and onset of symptoms.
 Aspiration – micro-aspiration of bacteria
colonizing the upper respiratory tract,
macroaspiration of gastric contents, indirect
transmission from staff, inhaled aerosols.
 Atypical
- Assessment Findings:
 The clinical findings are often referred to as
consolidation.
 Expansion is reduced on the affected side.
 There is percussion dullness over the area of
consolidation.
 Breath sounds are bronchial; adventitious
crackles.
 Tachypnea and central cyanosis.
 Fever, sweats, and rigors.
 Cough and sputum.
- Diagnostics and Laboratory:
 Sputum microscopy, culture, and sensitivity.
 CXR
 ABG (if SpO2 is <93% on room air) and pulse
oximetry
 FBC, U&E, C-Reactive Protein, and Liver Function
Tests.
- Management:
 Initial (ED) Management:
o Supplemental O2 to maintain saturations at
>93%
o IV fluids (if the patient is dehydrated)
o Medications: IV antibiotics, analgesia,
antipyretic
o Bronchoalveloar lavage may be used for
patients who are immunocompromised,
those who do not respond to antimicrobial
therapy, or those from whom a sputum
sample cannot be obtained
- Nursing Management:
 Positioning (upright)
 Ensure timely antimicrobial therapy.
 Monitor hemodynamics, fluid and electrolytes
and imbalances
 Adherence to infection prevention and control.
 Ventilator-associated pneumonia care bundle
VENTILATOR-ASSOCIATED PNEUMONIA (VAP)
- Ventilator-associated pneumonia (VAP) develops 48 h
or later after commencement of mechanical
ventilation via endotracheal tube or tracheostomy.
- It develops as a result of colonization of the lower
respiratory tract and lung tissue by pathogens.
- Intubation compromises the integrity of the
oropharynx and trachea, allowing oral and gastric
secretions to enter the airways.
- VAP is the most frequent post-admission infection in
critical care patients, and significantly increases the
number of mechanical ventilation days, the length of
critical care stays, and the length of hospital stay
overall.
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- 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

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 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.

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