chapter 29: care of pt. with respiratory emergencies Flashcards
pulmonary embolism (PE)
- collection of particulate matter that enetrs venous circulation and lodges in pulmonary vessels
- embolism is a blood clot (thrombus) or other object
what causes an embolism?
- any substance but blood clot is most common
infarction
tissue death or necorsis
risk factor for pe
- prolonged immoblization
- central venous catheters
- surgery
- obesity
- advancing age
- GENETIC conditions that increase blood clotting
- history of thromboembolism
- SMOKING
- ESTROGEN THERAPY
- heart failure
- stroke
- cancer
lifestyle changes with pe
- smoking cessation
- reducing weight
- physically active
- herarin or indirect thrombin inhibitor
- IVC filter
if traveling with a pe
- drink plently of water
- change positions often
- avoid crossing legs
- get up from sitting for 5 mins each hour
s/s of pe
- onset of dyspnea
- sharp stabbing chest pain
- restlessness
- impending doom
- cough
- hemoptysis- coughing up blood
- diaphoresis
- increased rr
- crackles
s/s of pe (heart&lungs)
- pleural friction rub
- tachycardia
- s3 or s4 heart sound
- petechiae over chest
- arterial oxygen stat
lab assessment for pe
- low PaCO2 on ABG
- general metabolic panel, TROPONIN, brain natriuretic peptide, D-DIMER
imaging assessment
- CT-PA or helical CT
PE analysis & prioritze
- hypoxemia due to mismatch of lung perfusion and alveolar gas exchange with oxygenation
- hypotension due to inadequate circulation to the left ventricle
- potential for excessive bleeding due to anticoagulation or fibrinolytic therapy causing inadequate clotting
- anxiety due to hypoxemia and life-threatening illness
managing hypoxemia in pe
- sudden onset of dyspnea: activate rapid response team
- apply oxygen, elevate the HOB and reassure the pt
- oxygen therapy
- monitor pt
- admin anticoagulation or fibronolytic therapy
ptt time
1.3-2.5
warfarin diet
no green leafy vegies
cranberries juice
alc
tpa
breaks down existing clots
managing hypotension in pe
- iv therapy (crystalloid substance) to restore plasma volume and prevent shock
- drug therapy with vasopressors (norepinephrine, epinephrine, dopamine) used if iv therapy doesn’t work
controlling bleeding in pe
- assess for s/s of bleeding
- ensure correct dosage and timing of medication
- monitor, lab values (INR)
minimizing anxiety in pe
- proper communication
- antianxiety meds
- pain meds
home care management with pe
- need assistance with adls
- home care services
- may have diminished lung sounds
self management education w pe
- may need continues anticoagulation therapy
- teach family and pt. about bleeding precaustions
- activities to reduce risk of VTE and PE
- follow up care
health care resources in pe
- seen in clinic
- home oxygen
- respiratory treatment
- services coordinated by nurse or case manager
pe outcomes
- attains and maintains adequate gas exchnage and oxygenation
- does not experience hypovolemia and shock
- remains free from bleeding ep
- states that the level of anxiety is reduced
- uses effective coping strategies
acute respiratory failure
pa02 <60 hg or paco2 >45 mm hg with ph <7.35 with sa02 <90%
- ventilatory failure
- oxygenation (gas exchange failure)
- combination ventilatory/ oxygenation failure
acute respiratory failure assessment clues
- dyspnea: perceived diffculty breathing
- orthopnea: shortness of breath or difficulty breathing when laying down
- ABGs= hypoxia and hypercarbia
- hypoxic respiratory failure includes restlessness, irritability or agitation, confusion and tachycardia
- hypercapnia failure: includes decreased loc, headache, drowsiness, lethargy, seizures
- effects of acidosis lead to decreased LOC, drowsiness, confusion, hypotension, bradycardia, and weak peripheral pulses
acute respiratory failure oxygen therapy
- should be considered if hypoexmia
- mechanical vent may be needed
acute respiratory failure drug therapy
- nebs or by meter dose inhaler to dilate the bronchioles and decrease inflammation to increase gas exchange
- corticosteroids may be prescribed, benefits still inconclusive -NOT FIRST LINE OF DEFENSE
- analgesics used for pain management
acute respiratory failure position of comfort
- pt. in upright position
- consider relaxation techniques, diversion, and guided imagery
acute respiratory distress syndrome (ards) patho
- hypoxemia that persists even when 100% oxygen is given
- decreased pulmonary compliance
- dyspnea
- noncardiac- associated bilateral pulmonary edema
- dense pulmonary infiltrates on xray
priority prevention for acute respiratory distress syndrome (ards)
early recognition of pt. at high risk for syndrome
acute respiratory distress syndrome (ards) health promotion
- monitor those receving tube feedings to prevent aspiration
- infection control guidelines such as handwashing, invasive catheter and wound care, and contact precautions
- use a suction toothbrush for oral care for pt. with swallowing problems or poor gag reflex
acute respiratory distress syndrome (ards) s/s
- HYPERPNEA- increase rr
- noisy respiration
- CYANOSIS
- PALOR
- RETRACTION INTERCOSTALLY OR SUBSTERNALLY
- check vitals at least every hour for hypotension, tachycardia, and dysrhthmias
acute respiratory distress syndrome (ards) diagnoistic assessment
- lowered partial pressure of arterial oxygen
- p/f ratio <200
- sputum cultures
- CHEST XRAYS
- ECG
acute respiratory distress syndrome (ards) interventions and phases
- exudative phase
- fibrosing alveolitis phase
- resolution phase
- et intubation and mechanical ventilation with PEEP or CPAP
- drug and fluid therapy
- nutrition therapy
acute respiratory distress syndrome (ards) exudative phase
- early changes of dyspna and tachypnea. interventions focus on supporting the pt. and providing oxygen
acute respiratory distress syndrome (ards) fibrosing alveolitis phase
- increased lung injury leads to pulmonary hypertension and fibrosis. interventions focus on delivering adequate oxygen, preventing complications, and supporting the lungs
acute respiratory distress syndrome (ards) resolution phase
usually, after 14 days, resolution of the injury is possible, if not, the pt. dies or has chronic disease
acute respiratory distress syndrome (ards) drug and fluid therapy
- antibiotics
- vitamin c, e,n
- acetylcysteine
- nitric oxide
- conservative fluid therapy improves lung function
endotracheal tube placement
- end tidal carbon dioxide levels
- chest x ray
- assess for breath sounds bilaterally, symmetrical chest movement, air emerging from et tube
et intubation
- know to contact intubation personell in an emergency
- tube placement and verification and tube stabilization
maintaining pt. airway in et tubuation
- assess tube placement
- cuff leak
- breath sounds
- indications of adequate gas exchange and oxygenation
- chest wall movement
et intubation monitor for complications
- monitor for tube obstruction
- tube dislodgement
- pneumothorax
- tracheal tear
- bleeding
- infection
- trauma
nursing management for mechanical ventilation: monitoring patient response
- assess PATIENT first
- assess vitals and listen to lung sounds every 30-60 mins
- monitor respiratory staus and abg values
- determine need for functioning
- assess area around the et tube or tracheostomy
- consider communication needs
nursing management for mechanical ventilation: managing ventilator system
- perform and document ventilator checks
- check the level of the humidifier and temperature of the humifdying system
- pay attention to alarms
- assess and care for et tube or tracheostomy
- provide oral care at least every 12 hours
complications of mechanical ventilation: cardiac problems
hypotension and fluid retention
complications of mechanical ventilation: lung problems
- barotrauma
- volutrauma
- atelectrauma
- biotrauma
- ventilator-associated injury
complications of mechanical ventilation: gi and nutrition problems
- stress ulcers
- malnutrition
complications of mechanical ventilation: infection
- bacteria can enter low respiratory system through the ET or tracheostomy tube
complications of mechanical ventilation: muscle deconditioning
occurs due to immobility
complications of mechanical ventilation: ventilator dependence
inability to wean off of ventilation
barotrauma
damage to the lung by POSITIVE pressure
volutrauma
damage to the lung by excess volume delivered to one lung over the other
extubation
- hyperoxygenate pt
- thoroughly suction ET tube and oral cavity
- rapidly deflate ET cuff
- remove tube during exhalation
- instruct pt. to immediately cough
- continue oxygen by facemask or nasal cannula
- monitor client every 5 mins
- assess ventilatory pattern for respiratory distress
- incentive spirometer every 20 mins
