Respiratory
NURS Advanced 202 Winter, 2011
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Acute Respiratory Failure
Classified by ABG abnormalities PaO2 < SaO2 < PaCO2 > with pH < Caused by failure of: Ventilation Oxygenation Both
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Acute Respiratory Failure
Pulmonary system is unable to maintain Common causes pulmonary embolism (PE) flail chest pneumothorax hemothorax pulmonary edema
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Pulmonary Embolism (PE)
Clot dislodges & floats down stream
DVT
Other causes
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DVT/VTE
Etiology: At greatest risk: Stasis of Endothelial Other Risk Factors hx thromboembolism immobility surgery trauma advanced hormone therapy
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DVT/VTE
2 million cases/yr
The most common complication of LE surgery or trauma Sx Unilateral distal Localized
Note: Homans sign is unreliable and 2010 W is therefore no longer recommended 6
Dx lab test
D-Dimer - Normal: ~ Low value High value may indicate
is value a lo w
______ _ ______ not _ ______ value is ___ gh ut a hi b
e erefor Th
D-Dimer: global marker of coagulation activation; measures fibrin degradation products produced from W 2010 fibrinolysis
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Management of DVT
SCDs Elevation of extremity Warm, moist compresses Anticoagulants Heparin (unfractionated heparin [UFH]) IV or SQ for Pts w/ confirmed clots SQ to prevent clots in high risk Pts
Low-molecular weight heparins (LMWHs) / dalteparin / enoxaparin Selective factor Xa inhibitors / fondaparinux Oral anticoagulant / warfarin Thrombolytics W 2010 - Streptokinase
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Prevention of DVT
Promote circulation Early Leg Avoid Prolonged Constricting clothing Leg elevation Hose TED Pneumatic (SCDs) Foot pump Good Rx prophylaxis antianti-
Ts DV s ng PE nti ts ve en r e ev P r p
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Sx of PE
Resp Pleuritic Crackles See Chart 34-2 Pg. 679 Other Low fever Petechiae
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Note: Sx & Tx of PE & fat embolism are virtually the same
Cardiac JVD
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Prevention of PE Same as prevention of DVT Management O2 PRN: Rx: Frequent assessment Monitor closely changes Labs Promote good Treat anxiety
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Initially Pt may develop brief but ABGs won't reveal this unless they are done right away Then
Dx may be challenging Gold standard:
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Flail Chest
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Sx Dx H&P PE Restlessness Asymmetric
Mgt Intubation
Rarely:
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Pneumothorax
Open Pneumothorax Hole in chest wall allows atmospheric air into pleural space
Trauma: Gunshot Stabbing etc.
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Closed Pneumothorax spontaneous
Air enters pleural space
Internal Injury
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Sx of Pneumothorax
(if open) chest movement SOB CP Tachypnea Cyanosis
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Tension pneumothorax
1st lung collapses Pressure against 2nd lung collapses
Medical emergency!
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Sx same as others + engorgement progressive severe paradoxical chest movement deviated cyanosis
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Hemothorax
Cause: e.g. e.g.
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Hemothorax
Sx: same as for pneumothorax + Tx: Chest tube Releases Reestablishes
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Dx PE
Chest tube Drainage System
Purpose:
Tx
pneumothorax hemothorax pleural effusion empyema
Decision to Use:
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Chest Tube Tube Placement
Air: tube placed
12-40 French sterile flexible vinyl or silicone catheter ~ 20 in long
Liquid: tube placed
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Three-chamber system 1. Collects fl 2. Water seal prevents back-low of air/liquid allows air to escape from 3. Suction control enhances pressure difference between pleural space & drainage system determined by should be
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Nurse's Role in Chest Tube placement
Prepare Pt HOB Insure Medicate PRN O2 per order
Assist MD PRN Help attach Dress CT site Adjust
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Other f/u Equipment / supplies chest tube insertion tray CDU (set up)
Assess & monitor Resp status Sx of Cardiac Liquid Presence of
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Ongoing Assessment
Resp/cardiac status Insertion site Sx of Promote drainage & lung expansion *TCDB / IS *Splint w/ Monitor drainage system * Liquid Air leak Tube position tubing Milk PRN (don't strip)
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Heimlich Valve
for little or no no small & "portable" for
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Trouble-Shooting
CDU fills up tips over or cracks Set up new Temporarily Switch
Continuous Air Leak Use Momentarily clamp tubing starting
Dislodgement of CT Apply If air present cover w/ Accidental Disconnect Place end of tube in container of sterile water or saline
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When can CT be removed? CXR confirms Resp status is normal Drainage over previous 24 h
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CT Removal Wear Medicate PRN Instruct Pt
Apply
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Pulmonary edema/CHF
Begins w/ increased filtration through loose junctions of pulmonary capillaries.
As intracapillary pressure increases, normally impermeable (tight) junctions between alveolar cells open, permitting alveolar flooding to occur
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Pulmonary edema/CHF
Begins w/ increased filtration through loose junctions of pulmonary capillaries.
As intracapillary pressure increases, normally impermeable (tight) junctions between alveolar cells open, permitting alveolar flooding to occur
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Pulmonary Edema
failure
Lungs become
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Sx
Pulmonary Edema
Begins w/ L-sided failure Cough Paroxysmal nocturnal dyspnea (PND)
BP may be or depending on volume status and (DOE) CO status
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Pulmonary Edema Sx
Progression to R-sided failure Hepatomegaly/splenomegaly Dependent Edema:
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Dx Lab B-type natriuretic peptide (BNP) Produced and released by
Imaging ECG
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See ch 37 to review heart failure
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Tx Reduce fluid Rx: Tx pain & anxiety /
CO
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Pleural Effusion
+
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Sx Unilateral Dyspnea Pleural Decreased
Pleural Effusion
Tx Possible chest tube Pulmonary hygiene
Dx H&P CXR Sputum for C&S
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Adult Respiratory Distress Syndrome (ARDS)
AKA non-cardiogenic pulmonary edema shock-lung
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Etiology of ARDS
Lung injury
Inflammatory response
Injured alveolar-capillary membrane Complicated by
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ARDS is characterized by severe progressive
mortality is rate:
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Sx of ARDS
Early Neuro Sx Resp Progressive Use of Severe VS Changes
o titial; s s is inter r a ly edem ound clea Ear s s may lung
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Dx
ABGs Reveal Early: resp Later: mixed Serial CXR bilateral changes
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Tx
Ventilatory support Moderate Permissive CO2
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Tx
Ventilatory support Moderate Permissive CO2 50-70 acceptable
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Drug Tx
Antimicrobials PRN Steroids (controversial can mask infection) Surfactant replacement Analgesics Possible:
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Nutritional support Promotes healing Fluid Replacement PRN Hemodynamic Monitoring
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Tx: mechanical ventillation
High % PEEP: positive end-expiratory pressure (10-15) Maintains alveolar surface area for inverse-ratio ventilation
exhalation time traps air in alveoli
May cause
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extracorporeal membrane oxygenation (ECMO)
Technique of providing both cardiac and respiratory support to patients whose heart and lungs are so severely diseased or damaged that they can no longer serve their function (something like the heart/lung bypass machines used during open heart surgery) Initially used in neonatal units. Currently also used in some adult ICUs
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Intubation & Mechanical Ventilation Most common indications
Hypoxemia w/ progressive alveolar hypoventilation & respiratory acidosis during surgery Procedures requiring heavy sedation
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Airways
Endotracheal tube (ET tube) up to may be adult tube size
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Nurse's role during Intubation
Monitor - sx hypoxia, dysrhythmias, aspiration Assist w/ Time attempts
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Verification of Tube Placement
Assessment Bilateral = Air emerging from Auscultation over Check for abdominal
Nursing Care
Prevent Soft Pain mgt Oral care Suction PRN
Stabilizing the Tube
Mark at Secure w/ Oral airway PRN Prevents
Goals of Ventilation
Improve Allow Pt
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Airways
Tracheostomy > 14 days
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