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a positive or negative pressure breathing device that can maintain ventilation and oxygen delivery for a prolonged period. used when patient is unable to maintain safe levels of oxygen or CO2 by spontaneous breathing even with the assistance of other oxygen delivery devices. used to control patients respirations during surgery to oxygenate blood when patients ventilator efforts are inadequate to rest the respiratory muscle- pts may be spontaneous breathers but effort needed to to breathing maybe very exhausting for the patient
continous decrease in O2, Increase PaCO2 persistent acidosis Conditions: thoracic, abdominal surgery, drug overdose, neuromuscular disorder, inhalation injury COPD, multiple trauma, shock, multi system failure and coma.=====all lead to respiratory failure apnea
PARAMETERS FOR MECHANICAL VENTILATION
Pa O2 < 50mmhg with FiO2 > 0.60 PaO2 > 50 mmhg with pH < 7.25 Vital capacity < 2 times tidal volume RR > 35 cpm
CLASSIFICATIONS OF MECHANICAL VENTILATOR
NEGATIVE PRESSURE-exert negative pressure on the external chest, drawing air into the lungs similar to spontaneous ventilation
Decreasing intrathoracic pressure during inspiration, allow air to flow into lungs, filling its volume
TYPES OF NEGATIVE PRESSURE
LUNG)---extensively used for neuromuscular d.o. machine enables the person to breathe when normal muscle control has been lost or work of breathing exceeds person·s ability.
BODY WRAP (PNEUMOWRAP)-patient lies supine on the plate which extends the length of the thoracic spine. -the grid is placed over the patients thorax and a separate power source is connected to the mid portion of the suit by a plastic tube. -The grid causes negative pressure generated with in the suit to be applied predominantly to the thorax since plastic is sucked tightly against all other body parts. -only used on patients who are not totally dependent on ventilator support and generally only provides modest tidal volumes.
. CHEST CUIRASS (TORTOISE SHELL)
consist of rigid shell, some consist of shells of either reinforced plastic or fiber glass which extend from symphysis pubis to supra sterna notch. - Must be connected to a power source capable of generating -25 to -30 cmH2O pressure. Since the cuirass only covers the chest area, the patient can be ventilated in either the sitting or supine position.
PRESSURE-inflate the lung by exerting positive pressure on the airway, forcing the alveoli to expand during inspiration, expiration occurs passively
TYPES OF POSITIVE- PRESSURE VENTILATORS (CLASSIFIED BY THE METHOD OF ENDING THE INSPIRATORY PHASE OF RESPIRATION) 1.PRESSURE CYCLED 2. TIME CYCLED 3. VOLUME CYCLED
PRESSURE CYCLED-the ventilator cycles on, delivers a flow of air until a predetermined pressure is reached and then cycles off
TIME CYCLED-terminate or control inspiration after a preset time., for newborns, and infants
VOLUME ²CYCLED- commonly used PPV, the volume of air to be delivered with each inspiration is preset. Once this preset volume is delivered to the patient, the ventilator cycles off and exhalation occurs passively.
MODES OF OPERATION
CONTROLLED VENTILATION ASSIST/CONTROL INTERMITTENT MANDATORY VENTILATION SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV) PRESSURE SUPPORT
1. Cycles automatically at rate selected by operator 2. Provides fixed level of ventilation, but will not cycle or have a gas available in the circuitry to respond to pts own inspiratory efforts. This typically increases work of breathing for patients attempting to breath spontaneously. 3. Possible indicated for patients whose respiratory drive is absent
Inspiratory cycle ventilator is activated by patients voluntary inspiratory efforts and delivers a preset volume or pressure. Ventilators also cycles at a rate predetermined by the operator. Should the patient stop breathing, or breathe so weakly that the ventilator cannot function as an assistor, this mandatory baseline rate will prevent apnea. Indicated for patients who are breathing spontaneously, but who have a potential to lose their respiratory drive or muscular control of ventilation. In this mode the persons work of breathing is greatly reduced.
INTERMITTENT MANDATORY VENTILATION
Allows patient to breathe spontaneously through ventilator circuitry. Periodically, at pre selected rate and volume or pressure, cycles to give a mandated ventilator breath. A minimum level of ventilation is provided. Gas provides spontaneous breathes usually flows continuously through the ventilator. Indicated for patients who are breathing spontaneously , but a tidal volume and / or rate less than adequate for their needs. Allows a person to do some work of breathing.
SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV)
Allows the patient to breathe spontaneously through ventilator circuitry. Periodically, at a pre- selected time, a mandatory breath is delivered with own effort and the ventilator breath will be synchronized with the patients efforts or will be assisted. If the patient does not provide inspiratory effort, the breath will still be delivered or controlled. Gas provide for spontaneous breathing is usally delivered through a demand regulator, which is activated by the patient. Indicated for patients who are breathing spontaneously, but a tidal volume and /or less than adequate for their needs. But allows the patient to do some breathing.
Spontaneous breathing mode bec ventilator does not deliver a tidal volume or rate. During spontaneous inspiration, ventilator circuitry is rapidly pressurized to the pre determined pressure and held at this pressure. Decreases work of breathing by overcoming resistance of airway and ventilatory circuitry.
****** PEEP-(POSITIVE END EXPIRATORY PRESSURE)
A positive airway pressure maintained at the end of exhalation. This allows more time for gas exchange and opens small airways and closed alveolar units., thus improving oxygenation and a reduction in the severity of the ventilation perfusion imbalance. A lower F1O2 is required.
******* CPAP-( CONTINOUS POSITIVE AIRWAY VENTILATION)
Maintenance of a positive airway pressure above atmospheric pressure during inspiration and expiration in the spontaneously breathing client. It improves oxygenation in the same manner as PEEP
*******PEEP AND CPAP SETTINGS
Tidal volume- amount of air per breath, usually set at 10-15 ml/kg body weight Respiratory rate-usually at 10-15 breaths per minute PEEP and /or pressure support level if applicable ²usually 5 to 15 cm H2O FIO2-50% or less maintains an arterial oxygen pressure PaO2 of greater than or equal to 60mmhg which is the goal of oxygenation. Sensitivity a 2cm H2O inspiratory force should trigger the ventilator Inspiratory pressure limit- normal is 15- 20 cm H2O, this increases where there is increased airway resistance or decreased compliance. INSPIRATORY AND EXPIRATORY RATIO: usually 1:3 (1 Second of inspiration to 3 seconds of expiration) or 1:2 Minute volume (tidal volume x respiratory rate) usually 6 to 8 LPM
ALARMS WITH NURSING INTERVENTIONS:
a. LOW PRESSURE ALARM
*sounds when the ventilator has no resistance to inflating the lung
1. Tube maybe disconnected 2. E.T displaced above vocal cords 3. Leaking tidal volume from cuff pressure(underinflated ruptured cuff or a leak in the cuff) 4. Ventilator malfunction 5. Leak in the circuitry (loose connection, hole in the tube, loss of temporary sensitive device, cracked humidification jar)
1. 2. Reconnect the tube to M.V Check tube placement reposition if needed. If extubation/ displacement has occurred, manually ventilate the patient and call the doctor ASAP Listen for a whoosing sound around the tube, indicating an air leak. If you hear ,check the cuff pressure. If you cannot maintain pressure,call doctor he may need to insert a new tube. Disconnect the patient from the ventilator and ventilate him manually. If necessary get another M.V. Make sure all connections are intact. Check for holes, leaks in the tubing and replace if necessary.
a. HIGH PRESSURE 1. Increased airway ALARM pressure or decreased ** ventilator has met lung compliance caused by worsening resistance to deliver condition the tidal volume and requires more 1. Pt. biting the oral E.T pressure to inflate 2. Secretions in airway the lungs 3. Condensate in the tubings 4. Intubation of the right bronchi 5. Pt coughing, gagging attempting to talk 6. Chest wall resistance 7. bronchospasm
1. Auscultate the lungs for evidence of increased lung consolidation, barotrauma, wheezing, call the doctor if indicated. 2. Insert a bite block 3. Look for secretions, remove them by suctioning. 4. Check the tubing for condensate, remove fluid. 5. Check tube positions,if it has slipped, call the doctor, he may order Reposition 1. If patients fights the ventilator, call the doctor he may order sedative. 2. Reposition the patient, to see if repositioning can improve the chest expansion. 3. Assess for cause and refer
WEANING PATIENT FROM MECHANICAL VENTILATOR
RESPIRATORY WEANING=WEANING THE
PATIENT FROM DEPENDENCE ON VENTILATOR, USUALLY PERFORM EARLIEST POSSIBLE TIME, USUALLY DONE IF PATIENT IS RECOVERING FROM ACUTE STAGE OF MEDICAL SURGICAL PROBLEM AND WHEN RESPIRATORY FAILURE IS SUFFICIENTLY REDUCED.
3 STAGES: 1. GRADUALLY FROM THE
2. FROM THE TUBE 3. FROM THE OXYGEN
CRITERIA FOR WEANING
An ability to generate minimal vital capacity of 10-15 ml/ kg ( minimal required volume is in range of 1000ml in a normal adult) Spontaneous inspiratory force of atleast -20 cm H2O PaO2 of greater than 60 mmhg with an FIO2 less than .4o % Stable vital signs ****note the following baseline measurements: Vital capacity, Inspiratory force, respiratory rate, resting tidal volume, minute ventilation (frequency times volume) arterial blood gase levels, FiO2.
psychological preparation is necessary before and after weaning. Proper preparation reduces time of weaning.
METHODS OF WEANING
METHOD SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV) METHOD
switching from assist control or SIMV mode to one or more T-Piece trials. Usually used when there is short term ventilator assistance ( less than 2 days) Done when pt is alert and awake,(during daytime not at night) breathing without difficulty, has good gag ,cough reflex and hemo dynamically stable.
The patient breathes spontaneously with aid of humidified oxygen DURING WEANING: patient is maintained on same or higher O2 concentration than when on ventilator WHILE ON T-PIECE: observe pt for s/sx of hypoxia, increasing fatigue
SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV) METHOD ²INDICATED IF
PATIENT SATISFIES ALL CRITERIA FOR WEANING BUT CANNOT SUSTAIN ADEQUATE SPONTANEOUS VENTILATION FOR LONG PERIODS.
pressure support ² frequently used as an adjunct to SIMV weaning mode. **pressure support provides- a set of inspiratory pressure boost with spontaneous breaths. *pressure support gradually reduced as patients strength increases
WEANING FROM A TUBE CRITERIA
Spontaneous ventilation is adequate gag reflexes are active Can maintain adequate airway can swallow, move jaw, clench the teeth or voluntary cough is effective in bringing up secretions. ***if ineffective: Tube is needed for suctioning secretions *** before a pt is weaned from T.Tube ²a trial period of mouth breathing/nose breathing is conducted
WEANING FROM OXYGEN- THE FIO2 IS GRADUALLY REDUCED UNTIL THE PO2 IS IN RANGE OF 70- 100 MMHG WHILE PATIENT IS BREATHING ROOM AIR. IF THE PO2 IS LESS THAN 70 MMHG ON ROOM AIR, SUPPLEMENTAL O2 IS NECESSARY.
CENTRAL VENOUS PRESSURE MONITORING
measurement of right atrial pressure or pressure of the great veins within the thorax requires the threading of a catheter into a large central subclavian, internal or external jugular, median or basilica or femoral vein. Catheter tip is then positioned in the right atrium, upper portion of superior vena cava, or inferior vena cava.
PURPOSE OF CVP:
To serve as a guide for fluid replacement To monitor pressures of the right atrium and central veins To administer blood products, TPN and drug therapy contraindicated for peripheral infusion To obtain venous access when peripheral vein sites are inadequate. To insert a temporary pacemaker To obtain central venous sample.
MANUAL CENTRAL VENOUS PRESSURE MONITORING
PREPARATORY PHASE: (NURSE) Assemble equipment Explain procedure Position patient appropriately-Place in supine for arm vein, Neck veins for trendelenburg·s position Flush IV infusion set and manometer or prepare heparin flush for use with transducer . Secure all connections to prevent air emboli and bleeding.
Attach manometer to an IV pole. The zero point of manometer should be on a level with the patients right atrium ( level of atrium is at the fourth ICS midaxillary line.) Calibrate/zero transducer and level port with the patients atrium.(mark mid axillary line with indelible ink for subsequent readings to ensure consistency of the zero level.) Institute ECG
TO MEASURE CVP:
pt in position of comfort Position the zero point of the manometer at the level of the right atrium Turn the stopcock so IV solution flows into manometer, filling to about 20-25 cm level. Then turn stopcock so solution in the manometer flows to the patient.
Observe the fall in the height of the column of fluid in the manometer. Record the level at which the solution stabilizes or stops moving downward. This is CVP. Record CVP and position the patient. CVP may be connected to a transducer and an electrical monitor with either digital or calibrated CVP wave readout. CVP may range from 5-12 cm H2O or 2 to 6 mmhg.
THANK YOU AND
GYNECOLOGIC TEST AND PROCEDURES
PAPANICOLAOU TEST (ALSO CALLED PAP SMEAR, PAP TEST, CERVICAL SMEAR, OR SMEAR TEST)
screening test used in gynecology to detect premalignant and malignant (cancerous) processes in the ectocervix. Significant changes can be treated, thus preventing cervical cancer. The test was invented by and named after the prominent Greek doctor Georgios Papanikolaou..
a tool is used to gather cells from the outer opening of the cervix of uterus and the endocervix. cells are examined under a microscope to look for abnormalities. aims to detect potentially pre-cancerous changes : cervical intraepithelial neoplasia (CIN) or cervical dysplasia, which are usually caused by sexually transmitted human papillomaviruses (HPVs). test remains an effective, widely used method for early detection of pre-cancer and cervical cancer may also detect infections and abnormalities in the endocervix and endometrium.
is recommended that females who have had sex seek regular Pap smear testing. from annually to every five years. If results are abnormal, and depending on the nature of the abnormality, the test may need to be repeated in three to twelve months
best results, a Pap test should not occur when a woman is menstruating. Pap smears can be performed during a woman's menstrual period, especially if the physician is using a liquid-based test; if bleeding is extremely heavy, endometrial cells can obscure cervical cells,
best time:10 ² 20 days after first day of menstrual cycle. 2 days before the test: avoid intercourse,douching, spermicidal foams, creams, jellies, vaginal meds ²hide away abnormal cells
a speculum into the patient's vagina, to allow access to the cervix. Samples are collected from the outer opening or os of the cervix using an Aylesbury spatula and an endocervical brush, or (more frequently with the advent of liquid-based cytology) a plasticfronded broom. ] The cells are placed on a glass slide and checked for abnormalities in the laboratory.
The sample is stained using the Papanicolaou technique, in which tinctorial dyes and acids are selectively retained by cells. Unstained cells cannot be visualized with light microscopy. The stains chosen by Papanicolaou were selected to highlight cytoplasmic keratinization,
MAJOR CATEGORIES FOR ABNORMAL PAP SMEAR TEST:
ASC-US- atypical squamous cells of undetermined significance- mild abnormality, the squamous cells do not appear completely normal
ASC-H ( atypical squamous cells cannot exclude a high grade squamous epithelial lesion) Cells do not appear normal At higher risk of being pre cancerous
3. AGC- atypical glandular cells-
mucus producing cells found in the endo cervical canal or in the lining of the uterus appear abnormal
AIS-endocervical adenocarcinomain situ-- precancerous cells found in the glandular tissue
grade squamous intraepithelial lesion- early changes in the size or shape of cells. (lesion) an area of abnormal tissue. Considered mild abnormalities caused by HPV infection
HSIL- High grade squamous intra epithelial lesion: there is marked changes in the size and shape of the abnormal precancerous cells. Are more severe abnormalities and likely to progress to cancer.
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