Keeping the A & B in ABC

Question: What's the RN's Responsibility with BiPAP/CPAP?

Import: The emphasis of our unit brings us into frequent contact with “noninvasive positive-pressure” ventilation. Recent nights and codes remind me of this. There was an article in Nursing2006, vol. 36, #5 p. 46-7, on this topic, from which much of the rest of this post is gleaned.

Fxn: improve gas exchange w/o intubation

Bilevel Positive Airway Pressure=df. 2 settings, higher on inspiration, than expiration. Can do full ventilation.

Continuous Positive Airway Pressure=df. 1 setting, same on insp. as on exp. (exhaling against pressure helps reexpand and stabilize the alveoli). Pt must be able to spontaneously breathe; cannot do full ventilation.

Whose Responsibility: RT initiates; RN educates, evaluates for, and monitors while on

And now for my newest mnemonic:

1^st and always assess mentition, vitals, ABCs, skin color (aura)

Then, what should also be noted on assessment and documented: “BiPAP”

• B breath sounds
• I inspired oxygen (FiO2)
• P pulse oximetry level
• A accessory muscle use
• P production of sputum (think ability to cough/clear secretions)

Commentary: If a recent and serious negative change has warranted placement of a patient on BiPAP for maintenance of oxygen saturation, then one wants to be particularly thorough AND PERSISTENT in assessments. This is a particularly precarious situation with potentially rapidly changing circumstances. If one has red flags going off, that things are not all well, then simply monitoring “as usual,” or less, not monitoring at all, is insufficient and negligent. This is time for Rapid Response; or you will be coding your patient.

Yours truly,
Christopher

P.S. The following link will take you to the AHRQ National Guideline Clearing House site for CPAP and BiPAP where you will find the practice parameters for the use of these devices to treat adult patients with sleep-related breathing disorders:
http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=9076&nbr=&string=#s21

  ¶ 1:57 PM 1 comments

  Alittle Salt, Alittle Sage, Alittle Novel Direction

There is something new coming to our blog, an enhancement of our on-line endeavours. The next couple of weeks will find me setting up a personal FTP server in order that we may easily traffic documents amongst one another. It remains my intention, since the founding of this blog, to anchor the bulk of discussion around various readings of scientific and educational supplementation germane to the ken of telemetry and all nurses. Once I switch to DSL and establish a simple method for us all to retrieve files, we will have a convenient method of distributing reading materials. I had been reading "From Novice to Expert" by P. Benner, and unless anyone has a more apt offering, I will post her writings there for us to peruse. Once there, I'll update everyone; and we can fix on how to proceed.

In the meantime, have fun with this site; post often, post freely, post period.

Your colleague,
Christopher

  ¶ 12:14 AM 0 comments

  Bi-lateral Blood Pressures?? Just thought I would remind everyone that we are supposed to be documenting bilateral blood pressure comparisons on the admission assessment. "Two BPs!?!," you say. Well, yes; there are a few cardiovascular disease states that enter into the differential by a marked discrepancy in BP symmetry, say 20mmHg or more. I have a short mnemonic: "BP CUFF"

B - Birth defects (Congenital Heart Disease)
P - Periveral Vascular Disease
C - Coarctation of the Aorta
U - Unilateral Neuro/Muscular abnormalities
ff - Aortic Dissection (think of the "ff" as a pictogram for the aortic arch with a line through it; the line representing the dissection. Yes, I know, its a stretch.)

If anyone can improve on this, please do. This and the following bullets are from AACNs newsletter this month.

• Can't get a brachial BP, try a supine calf BP (just slightly higher reading), or a prone thigh.
• If you do a forearm BP, it should be at heart level (lower=higherBP; higher=lowerBP).
• If the cuff's too small (Higher BP) if too big (Lower BP)
• Avoid BP's over picc line sites; and only distal to a PIV

Farewell,
Christopher  ¶ 4:05 PM 0 comments