C488 CRITICAL CARE OF OLDER ADULTS Study
Guide
Vent Alarms and Interventions:
Low pressure (low tidal volume alarm): CHECK LUNG SOUNDS b/c of
-Cuff leak, ET tube displacement or disconnection
High pressure (high peak pressure alarm): SUCTION!!
-caused by a blockage like biting (give sedation), kinks, excessive secretions, coughing,
pulmonary edema and pneumothorax
RESPIRATORY
Pneumonia:
S/S: chest Xray shows consolidation or diffuse patchy infiltrates, WBC can be elevated, ABG show
hypoxemia, + sputum and/or blood cultures
TX: oxygenation, good lung down (laterally laying), bronchoscopy, if necessary, ABX within 4 hours,
hydrate, and nutritional support
Suctioning Interventions: INCREASE HOB to prevent INFECTION or VAP, ensure to suction out and never
in- suction 10 secs or less—pre oxygenate—avoid suctioning before ABG and routinely b/c of acute lung
injury—suction only when needed
Air Embolism:
Occurs when air is inadvertently introduced into the venous system and can travel to the brain, heart,
lungs, and cause complications like MI, stroke, and PE. Can be introduced by catheter if damaged during
insertion/removal of CVCs, IV delivery systems (air bubbles), surgical procedures, lung trauma,
manipulation of CVC, scuba diving, blast injuries, etc.
S/S: depends on site but can include dyspnea, chest pain, muscle or joint pain, confusion, loss of
consciousness, hypotension, cyanosis, etc.…
Interventions: prevention is key... When maintaining IV, ensure intact and secure, no air bubbles when
infusing medications/fluids, priming all lines before use, ensuring lumens are clamped/capped when not
in use. When IV and CVC are removed, hold pressure to ensure air doesn’t enter sites. When inserting
CVC—maintain Trendelenburg position, avoid insertion during respiration, ensure no hypovolemia
before insertion. Pt to hold breath, breath out, perform Valsalva upon removal to prevent air from going
in. Cover site with gauze and apply pressure while removing in a slow continuous motion.
ARDS:
Definition: Capillary membrane that surrounds the alveoli sac starts to leak fluid into the sac which
causes a decreased gas exchange----then the sacs collapse and cause hypoxemia---then organs begin to
suffer
INDIRECT Causes: #1 SEPSIS then burns, pancreatitis, multiple blood transfusion, drug o/d
,DIRECT causes (direct to lungs): pneumonia, aspiration, drowning, inhalation injury (like chemical),
embolism
S/S – Early—barely noticeable: random crackles, dyspnea, increased RR, decreased O2 and CO2 = resp.
alkalosis, if pneumonia—cough and fever
--Late- severe difficulty breathing= retractions, refractory hypoxemia, crackles, LOC change, increased HR
Different stages
Exudate- 24 hours after injury, pulmonary edema, atelectasis, hypoxemia, decreased lung compliance,
HALLMARK SIGN: REFRACTORY hypoxemia (o2 sat that doesn’t improve with O2 admin)
Proliferative- (14 days post injury)- lungs try to help but cause more damage, worsening hypoxemia and
decreased lung compliance, lung tissue is dense and fibrous
Fibrotic stage - ~3 weeks post injury- fibrosis in lungs which results in major lung damage and poor
prognosis
TX: mech vent with PEEP—adding pressure to keep lungs open and increase O2, watch for hyperinflation
(too much pressure), prone position to increase O2 sat. , watch UOP, BP, LOC
Pneumothorax:
Collapsed lung—pressure change causes the lung to collapse
Causes are blunt force trauma, medical procedures like central line placement or thoracentesis, and
mechanical vents.
3 types: open, closed, and tension
Open: penetrating chest would where outside air comes in, TX: sterile occlusive dressing covered on 3
sides to prevent air from entering, but let’s air escape- cover with petroleum gauze dressing and tape
only 3 sides
Closed: air enters pleural space without and outside wound. Causes are MVA’s, spontaneous.
Tension: can be complication of open or closed. Pressure begins to build and cannot escape and starts to
shift onto heart, good lung, and trachea. Body will try to compensate by increasing RR, but the heart has
nothing to pump so the HR will increase, and CO2 will decrease. BP decreases.
S/S: sudden chest pain, cyanosis, unequal chest expansion, dyspnea, decreased O2, decreased BP,
increased HR, absent breath sounds. If OPEN: sucking chest sound. If TENSION: trachea pushed to the
side, subq emphysema.
TX: immediate: open- sterile occlusive dressing tension- needle decompression
For all: chest tube should be inserted, HOB should be in fowlers for breathing, O2, Vitals, and assess
rise/fall of chest
Hemothorax DX S/S
, Like pnemo but blood collects in pleural space and causes the lung to collapse. Caused by puncture
wound from a broken rib, stab wound, GSW, blunt force trauma, or PE
S/S: sudden chest pain, rapid heart rate, cold/pale/clammy skin, low bp, rapid/shallow breathing,
dyspnea, feeling restless/anxious, blood accumulation >1000ml --- shock
TX: CHEST TUBE to drain blood and fluid and reinflate lung. Monitor breath sounds b/c blood
accumulation = hyporesonant. Stop bleeding at any sources and monitor O2
ET Tube Placement- intervention/pt considerations:
Prep: Explain and reason to pt (if conscious) and family. Maintain airway mgmt. using manual
resuscitation bag with facemask connected to 100% oxygen source throughout procedure. HCP, Nurse,
Anesthesia provide, and RT all assist. Nurse ensure all equipment is at bedside and functions properly.
(intubation tray needed) RT brings vent. Restraints may be needed once intubated. Setup suction and
have ready for procedure to ensure patent airway (Yankaur for oral and in-line for once intubated). All
members need PPE and ensure hand hygiene performed.
Intubation: Premedicate with sedation and/or paralytic. Place head in “sniff” position. Hyperoxygenate.
ETT is inserted by anesthesia provider through the vocal cords. ** the cuff of the ETT is inflated and
either RT or the NURSE assesses for bilateral lung sounds and a CO2 detector (if negative.. places wrong)
is used to assist in verifying placement (FIRST STEP TO CONFIRM PLACEMENT) ** Secure with holder.
Attach ventilator and confirm settings to order by HCP. If OGT or NGT ordered, can be placed. Portable
chest xray can be performed. CHART tube placement at the lip or teeth and chart/report at change of
shift.
Mgmt.: Assess frequently for changes in vitals, spo2, resp status, cardiac rhythm and LOC. Monitor vent
settings and alarms. Assess need for suctioning and lungs sounds q2hours. Assess water level for proper
humidification. HOB at 30 degrees and mouth care q 2hours, daily sedation vacations, GI prophylaxis,
and DVT prophylaxis.
Chest Tubes:
Purpose is to reestablish negative pressure in pleural space to reinflate lung. 3 different used.
Pneumothorax- removes air. Hemothorax-removes blood. Pneumohemothorax- removes air and blood.
Chest tubes can be located in 2 places. 1) Apical (high) for air and label “A” at the top of the lung, 2)
Basilar (low) for and labeled “B” for blood at the bottom of the lung.
Unilateral pneumohemothorax= 2 chest tubes; one apical and one basilar, all on same side; Bilateral
pneumothorax= 2 apicals, one on left and one on right. Post op sx: 2 chest tubes, one apical and one
basilar, unilater *exception if sx is a total pneumonectomy then no chest tube b/c there is no pleural
space.
Suction control chamber- gentle steady continuous bubble—you want to see..this means we have a good
amount of suction being applied.
Water seal chamber and air leak monitor- tidaling = rise and fall- good; continous bubbling= bad!! Means
there is an air leak.
Guide
Vent Alarms and Interventions:
Low pressure (low tidal volume alarm): CHECK LUNG SOUNDS b/c of
-Cuff leak, ET tube displacement or disconnection
High pressure (high peak pressure alarm): SUCTION!!
-caused by a blockage like biting (give sedation), kinks, excessive secretions, coughing,
pulmonary edema and pneumothorax
RESPIRATORY
Pneumonia:
S/S: chest Xray shows consolidation or diffuse patchy infiltrates, WBC can be elevated, ABG show
hypoxemia, + sputum and/or blood cultures
TX: oxygenation, good lung down (laterally laying), bronchoscopy, if necessary, ABX within 4 hours,
hydrate, and nutritional support
Suctioning Interventions: INCREASE HOB to prevent INFECTION or VAP, ensure to suction out and never
in- suction 10 secs or less—pre oxygenate—avoid suctioning before ABG and routinely b/c of acute lung
injury—suction only when needed
Air Embolism:
Occurs when air is inadvertently introduced into the venous system and can travel to the brain, heart,
lungs, and cause complications like MI, stroke, and PE. Can be introduced by catheter if damaged during
insertion/removal of CVCs, IV delivery systems (air bubbles), surgical procedures, lung trauma,
manipulation of CVC, scuba diving, blast injuries, etc.
S/S: depends on site but can include dyspnea, chest pain, muscle or joint pain, confusion, loss of
consciousness, hypotension, cyanosis, etc.…
Interventions: prevention is key... When maintaining IV, ensure intact and secure, no air bubbles when
infusing medications/fluids, priming all lines before use, ensuring lumens are clamped/capped when not
in use. When IV and CVC are removed, hold pressure to ensure air doesn’t enter sites. When inserting
CVC—maintain Trendelenburg position, avoid insertion during respiration, ensure no hypovolemia
before insertion. Pt to hold breath, breath out, perform Valsalva upon removal to prevent air from going
in. Cover site with gauze and apply pressure while removing in a slow continuous motion.
ARDS:
Definition: Capillary membrane that surrounds the alveoli sac starts to leak fluid into the sac which
causes a decreased gas exchange----then the sacs collapse and cause hypoxemia---then organs begin to
suffer
INDIRECT Causes: #1 SEPSIS then burns, pancreatitis, multiple blood transfusion, drug o/d
,DIRECT causes (direct to lungs): pneumonia, aspiration, drowning, inhalation injury (like chemical),
embolism
S/S – Early—barely noticeable: random crackles, dyspnea, increased RR, decreased O2 and CO2 = resp.
alkalosis, if pneumonia—cough and fever
--Late- severe difficulty breathing= retractions, refractory hypoxemia, crackles, LOC change, increased HR
Different stages
Exudate- 24 hours after injury, pulmonary edema, atelectasis, hypoxemia, decreased lung compliance,
HALLMARK SIGN: REFRACTORY hypoxemia (o2 sat that doesn’t improve with O2 admin)
Proliferative- (14 days post injury)- lungs try to help but cause more damage, worsening hypoxemia and
decreased lung compliance, lung tissue is dense and fibrous
Fibrotic stage - ~3 weeks post injury- fibrosis in lungs which results in major lung damage and poor
prognosis
TX: mech vent with PEEP—adding pressure to keep lungs open and increase O2, watch for hyperinflation
(too much pressure), prone position to increase O2 sat. , watch UOP, BP, LOC
Pneumothorax:
Collapsed lung—pressure change causes the lung to collapse
Causes are blunt force trauma, medical procedures like central line placement or thoracentesis, and
mechanical vents.
3 types: open, closed, and tension
Open: penetrating chest would where outside air comes in, TX: sterile occlusive dressing covered on 3
sides to prevent air from entering, but let’s air escape- cover with petroleum gauze dressing and tape
only 3 sides
Closed: air enters pleural space without and outside wound. Causes are MVA’s, spontaneous.
Tension: can be complication of open or closed. Pressure begins to build and cannot escape and starts to
shift onto heart, good lung, and trachea. Body will try to compensate by increasing RR, but the heart has
nothing to pump so the HR will increase, and CO2 will decrease. BP decreases.
S/S: sudden chest pain, cyanosis, unequal chest expansion, dyspnea, decreased O2, decreased BP,
increased HR, absent breath sounds. If OPEN: sucking chest sound. If TENSION: trachea pushed to the
side, subq emphysema.
TX: immediate: open- sterile occlusive dressing tension- needle decompression
For all: chest tube should be inserted, HOB should be in fowlers for breathing, O2, Vitals, and assess
rise/fall of chest
Hemothorax DX S/S
, Like pnemo but blood collects in pleural space and causes the lung to collapse. Caused by puncture
wound from a broken rib, stab wound, GSW, blunt force trauma, or PE
S/S: sudden chest pain, rapid heart rate, cold/pale/clammy skin, low bp, rapid/shallow breathing,
dyspnea, feeling restless/anxious, blood accumulation >1000ml --- shock
TX: CHEST TUBE to drain blood and fluid and reinflate lung. Monitor breath sounds b/c blood
accumulation = hyporesonant. Stop bleeding at any sources and monitor O2
ET Tube Placement- intervention/pt considerations:
Prep: Explain and reason to pt (if conscious) and family. Maintain airway mgmt. using manual
resuscitation bag with facemask connected to 100% oxygen source throughout procedure. HCP, Nurse,
Anesthesia provide, and RT all assist. Nurse ensure all equipment is at bedside and functions properly.
(intubation tray needed) RT brings vent. Restraints may be needed once intubated. Setup suction and
have ready for procedure to ensure patent airway (Yankaur for oral and in-line for once intubated). All
members need PPE and ensure hand hygiene performed.
Intubation: Premedicate with sedation and/or paralytic. Place head in “sniff” position. Hyperoxygenate.
ETT is inserted by anesthesia provider through the vocal cords. ** the cuff of the ETT is inflated and
either RT or the NURSE assesses for bilateral lung sounds and a CO2 detector (if negative.. places wrong)
is used to assist in verifying placement (FIRST STEP TO CONFIRM PLACEMENT) ** Secure with holder.
Attach ventilator and confirm settings to order by HCP. If OGT or NGT ordered, can be placed. Portable
chest xray can be performed. CHART tube placement at the lip or teeth and chart/report at change of
shift.
Mgmt.: Assess frequently for changes in vitals, spo2, resp status, cardiac rhythm and LOC. Monitor vent
settings and alarms. Assess need for suctioning and lungs sounds q2hours. Assess water level for proper
humidification. HOB at 30 degrees and mouth care q 2hours, daily sedation vacations, GI prophylaxis,
and DVT prophylaxis.
Chest Tubes:
Purpose is to reestablish negative pressure in pleural space to reinflate lung. 3 different used.
Pneumothorax- removes air. Hemothorax-removes blood. Pneumohemothorax- removes air and blood.
Chest tubes can be located in 2 places. 1) Apical (high) for air and label “A” at the top of the lung, 2)
Basilar (low) for and labeled “B” for blood at the bottom of the lung.
Unilateral pneumohemothorax= 2 chest tubes; one apical and one basilar, all on same side; Bilateral
pneumothorax= 2 apicals, one on left and one on right. Post op sx: 2 chest tubes, one apical and one
basilar, unilater *exception if sx is a total pneumonectomy then no chest tube b/c there is no pleural
space.
Suction control chamber- gentle steady continuous bubble—you want to see..this means we have a good
amount of suction being applied.
Water seal chamber and air leak monitor- tidaling = rise and fall- good; continous bubbling= bad!! Means
there is an air leak.
