Resp: 1. NIV nursing care Mx 2.

COPD medicines ,in side effect,contraindication education, BiPAP Smoking seccation

Nursing care in NIV 1. Assess patients conscious level and vital signs 2. Reassure and Explain 3. Apply infection control measures 4. Prop up patient if no contraindication 5. Select appropriate size and type of interface and accessories 6. Verify correct connections and set up for the NIV unit with appropriate mode according to prescription 7. Ensure a correct flow of oxygen supply 8. Provide Adequate humidification 9. Apply interface appropriately to minimize air leak and discomfort to patient 10. Teach patient to close the mouth or apply chin strap to avoid leakage --------------------------------------------------------------------------------------------------------------11. Assess and monitor patients vital signs, respiratory status and conscious level 12. Set up appropriate alarm limits 13. Take safety precaution for oxygen and electric hazards (OSH) 14. Observe and document the NIV settings and patients respiratory parameters periodically 15. Ensure necessary equipment are ready for emergency intubation 16. Detect any mechanical malfunction 17.Identify complications and abnormalities and take appropriate actions accordingly 18.Document nursing observations and interventions

1. Assess patients conscious level and vital signs Oxygen saturation (SpO2) Respiratory rate Blood pressure Heart rate ABG Glasgow Coma Score (GCS)

2. Reassure and Explain Explain the purpose, procedure and potential complications to patient and relatives Building a trusting relationship Relieve feeling of fear Gain cooperation and compliance Reassure the equipments are safe and effective Reassure to satisfy patient s needs e.g. drink water Develop communication means e.g. call bell 3. Apply infection control measures Masks, exhalation ports & tubing sent for higher level disinfection(CSSD) Ventilator surface should be cleaned between patients A high flow & low resistant bacterialviral filter should be attached at the ventilator outlet and change daily - PPE Minimizing the risk of infection Good hand washing before and after attending the patient Change ventilator circuit according to hospital policy Early detection of S/S of infection 4. Prop up patient if no contraindication Prop up patient 30 45 Allows a lower drift of abdomen towards the diaphragm with better lung expansion Sit out if condition stable 5. Select appropriate size and type of interface and accessories A fullface mask should be used for the first 24 hours in acute setting (BTS, 2008) Enhance patient comfort and reduce air leak Good mask fitting ( S, M or L ) ? Head gear or soft cap ? Try different size, materials and brands of mask 6. Verify correct connections and set up for the NIV unit with appropriate mode according to prescription - Proper connections of viral filter, circuit , humidifier, exhalation port and mask Functional self test before use

7. Ensure a correct flow of oxygen supply Oxygen titration to keep SPO2 > 88- 92% for COPD patient 8. Provide Adequate humidification A heated humidifier can help to moisten airway and provide patients comfort Empty and clean the humidifier daily Renew sterile / distilled water daily Refill up to the fill line Note for any excessive water trapped in the circuit Do not use HME. A moistened HME has high resistance 9. Apply interface appropriately to minimize air leak and discomfort to patient Pressure sores on the nasal bridge and skin rashes with masks are reported as high as 10 20% (Bambi, 2009) Reduce pressure over the nasal bridge and facial Good mask fitting and avoid excessively tight Minimize strap tension Place a skin patch or dressing e.g. Duoderm CGF over the pressure area Rotating interfaces Reduce air leaking which can cause eye irritation 10. Teach patient to close the mouth or apply chin strap to avoid leakage 11. Assess and monitor patients vital signs, respiratory status and conscious level BP, Pulse, SPO2, RR ABG monitoring and interpretation Within 12 hour after NIV therapy and 1 hour after changing setting Daily ABG as prescribed Conscious level Chest wall movement Patient comfort Skin integrity Patientdevice synchrony Air leak: 25L/min is acceptable 12. Set up appropriate alarm limits Including NIV alarm and cardiac monitor alarm

13. Take safety precaution for oxygen and electric hazards (OSH) Place the oxygen container in a secure position with portable NIV Connect the oxygen adapter correctly and carefully NIV plug in the emergency socket 14. Observe and document the NIV settings and patients respiratory parameters periodically Mode, IPAP, EPAP, RR, Ti, Rise time, O2 as prescribed Patient TV, MV ,total RR, patient trigger breath, air leak 15. Ensure necessary equipment are ready or emergency intubation Emergency trolley Defibrillator Ventilator 16. Detect any mechanical malfunction Signs of mechanical malfunction Regular preventive maintenance Regularly change dust filter 17.Identify complications and abnormalities and take appropriate actions accordingly 1. Nasal or oral dryness and nasal congestion Add humidifier Take a break and drinking regularly if stable Oral or nasal hygiene Steroid or antihistamine may be helpful for nasal congestion 2. Conjunctivitis Good mask fitting to reduce air leaks Prevent the hole of exhalation port towards patient 3. Gastric distention and gastric aerophagia Control IPAP < 25cmH2O opening pressure of stomach sphincter is 2025cmH2O Wear dentures to help to close mouth to avoid gastric distention Insertion of nasogastric tube for air aspiration is controversial 4. Aspiration

 Prop up Stop NIV during feeding Educate patient to pull out facemask if vomiting Avoid eat or drink 23 hours prior to bed time if using NIV 5. Decrease cardiac output Close monitoring of blood pressure because increased intrathoracic pressure may decrease venous return Titrate IPAP/EPAP IV Fluid resuscitation 6. Barotrauma Observe signs of sudden dypsnea and chest discomfort Increased intrathoracic pressure may induce pneumothorax Auscultation and percussion CXR +/ Chest drain 18.Document nursing observations and interventions clear & accurate Contraindications of NIV 1. Cardiac or respiratory arrest 2. Hemodynamic unstable 3. 4. 5. 6. 7. 8. 9. 10. Unable to protect airway Fixed obstruction of upper airway High aspiration risk Severe upper GI bleeding Unable to clear secretions Facial or upper airway trauma/surgery/burns Undrained pneumothorax Uncooperative and agitated

COPD Medicines Stepwise increase in treatment depending on the severity of the COPD Stress the importance of adherence on order to reduce frequency and severity of exacerbation, improve health status and exercise tolerance and daily activities Bronchodilators

Commonly use: Salbutamol ( ventolin ) - onset of action : a few minutes - duration of action : 4-6 hrs - for rapid symptom relief ( rescue inhaler) - usual MDI dosage: 2 puff QID or as needed Nursing advice: bring along medication for emergency symptom relief For acute exacerbation: increase Ventolin 4 puffs with using spacer if indicated Side-effect: Tachycardia and fine tremor

Inhaled corticosteroids For anti-inflammation The addition of regular treatment with inhaled steroid to bronchodilator treatment is appropriate for symptomatic COPD patient with : FEV1<50% predicted ( stage III: severe COPD and stage 4: very severe COPD)

Repeated exacerbations Benefits: reduce frequency of exacerbation, reduce rate of decline of health-related quality of life Inhaled corticosteroids Adverse effect: - Hoarseness of the voice - Dryness of mouth - Oral fungal infection ( high incidence of candidiasis) Nursing advice: - rinsing the mouth and brushing teeth after inhalation - Use spacer device to reduce the aerosol impaction in the back of mouth Inhaled cortisteroids are much safer than oral therapy: system absorption is minimal and side effect is fewBronchodilator

Bronchodilator Make breathing easier. Open the small airways Reduce the uncomfortable over-inflation of the lungs. last between 4 and 24 hours Short-acting bronchodilators are used whenever symptoms are troublesome. Glucocorticosteroids Reduce inflammation in the small airways Prevent about a quarter of exacerbations Recommended for people with more severe COPD who have more than two

exacerbations per year Can be given in a combined inhaler with long-acting bronchodilators

____________________________________________________________ Strategies to quit smoking 5A Strategies Ask Systematically identify all tobacco users at every visit Advise Strongly urge all tobacco users to quit Assess Determine willingness to make a quit attempt Assist Aid the patient in quitting Arrange Schedule follow-up contact

Strategies to Coping 5D Strategies DECLARE Discuss your thoughts and feelings with someone DELAY the urge to smoke then it will pass DISTRACT Do something else to distract your selfKtake a walk, call a friend, keep your hands busy by doing chores or squeezing a rubber ball DRINK WATER Drink water, chew gum or have a healthy snack to fight cravings DEEP BREATHE Deep breaths will relax you. Close your eyes and take 10 slow deep breaths or meditate