1. Presented By: Diana Gedamke, BSN, RN, CCRN Marion College - Fond du Lac Masters of Nursing Student

2. Assessing the Ventilated Patient

3.  Arterial blood sampling (known as arterial blood gases or ABG) is an invasive procedure requiring the puncture of an artery or placement of an arterial catheter.  Blood gas values reflect an isolated moment in time rather than a trend of how the patient is doing. They should be used to correlate and document trends established by noninvasive monitoring devices, such as pulse oximetry or CO2 detection monitoring.  Inaccurate results can occur with introduction of air bubbles, dilution with excessive heparin, or with faulty handling of the sample itself.

4.  It is important for the nurse to understand what the ABG results mean for the patient, as this may determine what ventilator adjustments need to be made, or it the patient’s nutritional status is adequate.  The purpose of the next few slides is to review how to determine the results of the arterial blood gases.

5. First, let’s look at what is considered “Normal”  pH: Normal = 7.35 – 7.45  Acidotic = pH < 7.35  Alkalotic = pH > 7.45  CO2: Normal = 35 – 45  pO2: Normal = 80 – 100  O2 Saturation: Normal = 93 – 100%  HCO3: Normal = 22-26  Base Excess: Normal = +2 to -2

6. There are 3 names to an arterial blood gas result.  The first name will either be: Compensated or Uncompensated  The second name will either be: Respiratory or Metabolic  The third name will be either: Acidosis or Alkalosis

7. There are three critical questions to ask yourself when attempting to interpret and name the arterial blood gases (ABGs) results.  First Question: Does the patient exhibit acidosis or alkalosis? This will be the “last name” of the result.  Second Question: What is the primary problem? Metabolic or Respiratory? That’s the “middle name”.  Third Question: Is the patient exhibiting a compensatory state? This is the “first name”. These essential questions will guide you while you analyze the ABGs.

8.  First Question: Does the patient exhibit acidosis or alkalosis? Look at the pH.  Normal is 7.35 – 7.45, so look at anything from 7.40 as to what side it is on.  7.30 = acidotic  7.48 = alkalotic  7.38 = acidotic  7.42 = alkalotic Record the “last name” = alkalosis or acidosis

9.  Second Question: What is the primary problem? Metabolic or Respiratory? Is it the Teeter Totter Vs. The Elevator?  Teeter Totter: pH and CO2 go in opposite directions = Respiratory  Elevator: pH and CO2 go in the same direction = Metabolic e.g. pH 7.29 (low) and pCO2 48 (high) = Resp.  pH 7.47 (Hi) and pCO2 32 (low) = Metabolic What is the results “Middle Name”?

10. Third Question: Is the patient exhibiting a compensatory state? Look at the HCO3.  When there’s an imbalance in the pH, the opposing system of the problem will attempt to compensate by adjusting the HCO3. If the HCO3 is out of its normal range, it is attempting to compensate.  E.g: pH 7.27; pCO2 58; HCO3 30.  Both pCO2 and HCO3 are elevated, therefor this is Partially Compentated Respiratory Acidosis with pH still outside normal range.

11.  To get a much more thorough review and some practice scenarios, please go the the ABG link and complete the tutorial there.  ABG Tutorial ABG Tutorial

12.  For a review of lung sounds and a brief “treasure hunt” of the abnormal lung sounds- please click on the following link:  Lung Sound Assessment Lung Sound Assessment  Abnormal Breath Sounds: http://it.spcollege.edu/edtech/instr uctorResources/RLO/RLO_Objects/staticRLO/ general/breathAbnormal/http://it.spcollege.edu/edtech/instr uctorResources/RLO/RLO_Objects/staticRLO/ general/breathAbnormal/

13.  Endotracheal tube  Position  Stability  Cuff inflation  Patency  Oral cavity  Trauma to lip and palate  Secretions

14.  Patient Position  Patient-Ventilator Synchrony  Physical Assessment ◦ VS, General assessment, breath sounds  Ventilator Mode  Alarms  Reason for intubation ◦ MV in disease states  Does patient still need to be intubated and mechanically ventilated?

15.  Nasal or oral  Size (6 – 8.5 cm)  Position ◦ 21 cm from the teeth in women & 23 cm in men ◦ Confirm position by CXR (even when breath sounds are bilateral) ◦ 3 - 5 cm above carina  Affects of head position

16.  Position ◦ End Tidal CO 2 to confirm ETT placement

19.  Sinusitis - occurs in > 25% of patients ventilated > 5days; nasal > oral; subtle findings (unexplained fever & leukocytosis), polymicrobial  Laryngeal damage - ulceration, granulomas, vocal cord paresis, laryngeal edema  Aspiration/Ventilator-associated pneumonia - occurs despite cuffed tube  Tracheal necrosis - tracheal stenosis, tracheomalacia  Death – ventilator malfunction/inadvertent disconnection/endotracheal tube dysfunction/VAP

20.  Sterile suctioning ◦ assess as routine part of assessment; only suction when patient needs it  Elevate HOB to 45 degrees