Pulmonary Embolism/Obstructive Sleep Apnea - EXAM 3

Question 1

Where do PE originate?

Answer 1

1. Deep veins of the legs (DVTs)
2. Right side of the heart (with atrial fibrillation)
3. Upper extremities (rare)
4. Pelvic veins ( esp. after child birth or surgery because of increased pressure on vessels

Question 2

Risk factors of PE

Answer 2

• Obesity
• Sedentary lifestyle
• BC pills
• Pregnancy
• Recent travel
• Recent leg, calf, knee pain
• Hx of heart dysrhythmias
• Family hx of clotting disorder
• Smoker
• Recent surgery

Question 3

Virchow’s Triad

Answer 3

A patient at risk for the development of a PE often has a predisposition to:

1. Venous Stasis
2. Damage of the endothelium (inner lining of vein)
3. Hypercoaguability

Question 4

CPAP

Answer 4

Continuous Positive Airway Pressure

• A ventilator mode in which a constant positive pressure is delivered to the airway during inspiration and expiration
• Administered VIA a tight-fitting face or nasal mask or endotracheal/tracheal tube

Question 5

BiPAP

Answer 5

• A ventilator mode that provides two levels of positive pressure support: higher during inspiration and lower during expiration
• Administered VIA a tight-fitting face or nasal mask
• Better option for patients with COPD

Question 6

Indications for use of a non-invasive positive pressure ventilation system (NIPPV)

Answer 6

1. OSA
2. COPD (BiPAP)
3. Acute/chronic respiratory failure (hypoventilation)
4. Heart Failure
5. After extubation to avoid reintubation
6. Patient who refuses intubation but desires ventilatory support
7. Chest wall or neuromuscular disease (restrictive causes)

Question 7

Who is a NIPPV not appropriate for?

Answer 7

• Absent ventilation
• Excessive secretions
• Confusion/Decreased LOC
• Facial Trauma
• High O2 requirements
• Hemodynamic instability (shock)

Question 8

Nursing Considerations of NIPPV

Answer 8

1. Patient must be able to breathe spontaneously
2. Patient must be able to cooperate with treatment
3. Assist with proper fit, care, selection of mask/device
4. When used in acute respiratory failure: patient should be NPO to protect from aspiration

Question 9

Possible Complications of NIPPV

Answer 9

1. Poor compliance r/t discomfort of tight fitting mask
2. Difficulty communicating when using
3. Skin breakdown over face/nose
4. Risk of aspiration (when used for resp. distress)
5. Nasal congestion/stuffiness
6. Excessive dryness (consider humidification)
7. Eye irritation
8. Gastric distention

Question 10

What assessments should be made when considering a PE?

Answer 10

1. Respiratory Assessment
   
   1. O2 Sat
   2. Rate
   3. LS
   4. Assess for cough
   5. Assess WOB
   6. Hemoptysis
2. Cardiac Assessment
   
   1. JVD d/t fluid backup
   2. cardiac rhythm
      
      1. muscle needs O2 to function
3. PAIN assessment
4. Mental status changes
5. Fever

** Anxiety, sudden onset of dyspnea, or tachycardia are common signs of a PE, early recognition of these vague signs can prevent further respiratory complications**

Question 11

What is a PE?

Answer 11

Blood clot has blocked off blood supply to massive number of alveoli. These alveoli contain O2 that cannot get into blood stream b/c blood flow distal to the embolus is blocked. Depending on amount of lung affected by a PE, patient may experience resp. failure, acute corpulmonale, or sudden circulatory and/or respiratory collapse

Question 12

What are nursing interventions for PE?

Answer 12

1. O2
2. Raise HOB
3. Bedrest
4. Mental Status Assessment (freq. LOC monitoring)
5. Freq. SpO2 and VS
6. Freq. monitoring of cardiopulmonary status

Question 13

What respiratory state is a patient in with PE?

Answer 13

Respiratory alkalosis. High pH and PaCO2 are due to hyperventilation, worsened if hyperventilation is prolonged. Low PaO2 is due to occluded pulmonary vessels. Low O2 sat indicates hypoxemia. Mild-moderate hypoxemia with a low PaCO2 is common in a patient with a PE.

Question 14

V/Q Scan

Answer 14

Intravenous injection of a radioactive isotope in preparation for a scanning device to determine the adequacy of her pulmonary perfusion. VIA face mask patient inhales a radioactive gas as her lungs are again scanned, to determine the distribution of the inhaled gas.

Question 15

V/Q Mismatch

Answer 15

The V/Q ratio represents the balance between alveolar ventilation and capillary blood flow and determine the adequacy of gas exchange in the lung (normal is 1:1). A mismatch b/w ventilation and oxygenation is the most common cause of hypoxemia. Results of a V/Q scan are expressed as high, med, low probability of a PE.

Question 16

Spiral (or helical) CT

Answer 16

Noninvasive procedure where patient lies on table while special imaging machine rotates rapidly around the body, taking over 100 pictures in sequence. Provides 3 dimensional information regarding size/location of thrombus.

Question 17

D-Dimer Test

Answer 17

Blood test. A substance (FDP) produced by the breakdown of thrombus (fibrin degradiaiton). Not specific for PE, recognizes any clot breakdown in the body. A positive D-dimer will increase suspicion of a PE and other tests will be ordered.

Question 18

Pulmonary Angiography

Answer 18

Invasive procedure involving insertion of a catheter through the antecubital or femoral vein, advanced to the pulmonary artery and injection of contrast medium; allows for visualization/location of emboli.

Question 19

Nursing Interventions for a PE

Answer 19

1. TCDB
2. Analgesia
3. Prepare for intubation, mechanical ventilation
4. Psychosocial support

Question 20

Treatments of PE

Answer 20

1. Anticoagulants/Thrombolytics
2. Embolectomy/IVC filter placement

Question 21

Anticoagulation

Answer 21

Prevention:

Heparin,m lovenox/fragmin, and/or coumadin

Use of PT/INR and APTT in titrating these medications

Question 22

Teaching on prevention of PE

Answer 22

1. How to prevent further dislodgement/jarring of the thrombi by mechanical forces such as:
   
   1. Sudden standing
   2. Sudden position changes
   3. Changes in rate of blood flow (valsalva manuever)
2. Signs/Symptoms of bleeding

Question 23

What is OSA?

Answer 23

Obstructive sleep apnea.

Partial or complete airway obstruction during sleep. Occurs when tongue/soft palate fall backward and partially/completely obstruct pharynx, causing a period of apnea that can last 15-90 seconds as many as 200-400 times during 6-8 hours of sleep. During apneic episodes, hypoexmia and hypercapnia can result, causing the patient to partially awaken, startle, snort, and gasp, casuing the tongue and soft palate to move forward and airway to open

Question 24

OSA Risk Factors

Answer 24

1. Smoking
2. Obesity
3. HTN
4. COPD

Question 25

S/Sx of OSA

Answer 25

1. Morning headaches
   
   1. Hypercapnia causes vasodilation of cerebral blood vessels)
   2. Freq. arousal during sleep
   3. Difficulty concentrating
   4. Witnessed apneic episodes
   5. Irritability
   6. Daytime sleepiness
   7. Loud snoring

Question 26

Complications from untreated OSA

Answer 26

1. HTN
2. Right sided heart failure from pulmonary HTN caused by chronic nocturnal hypoxemia
3. Cardiac dysrhythmias
4. Children: poor learning, behavioral problems
5. Interpersonal difficulties r/t sleep deprivation

Question 27

OSA Diagnosis

Answer 27

1. Sleep history and medical history
2. Polysomnography (PSG)

Question 28

Polysomnography (PSG)

Answer 28

Measures patient’s chest and abdominal movement, oral airflow, nasal airflow, SpO2, occular movement, HR, and rhythm during various sleep stages (in acute setting, patient may have continuous nocturnal O2 saturation monitoring before a formal sleep study can be done)

Question 29

Two types of NIPPV

Answer 29

1. CPAP
   
   1. Delivers a constant pressure in the airway during inspiration and expiration to prevent airway and alveolar collapse, thus preventing the apneic epidsodes and providing more surface area for gas exchange. Can be administered VIA tight fitting face or nasal mask or an endotracheal/tracheal tube.
2. BiPAP
   
   1. Delivers a higher inspiratory pressure and lower pressure during expiration. Apnea can be relieved with a lower mean pressure and may be better tolerated.

Question 30

Rationale for NIPPV in treatement of OSA?

Answer 30

CPAP or BiPAP will lessen the patient’s WOB without the need for intubation (Lewis states CPAP increases WOB but other sources contraindicate this)

Question 31

Complications with CPAP/BiPAP

Answer 31

1. Poor compliance due to discomfort of tight fitting mask
2. Difficulty communicating while wearing
3. Skin breakdown over face/nose
4. Nasal congestion/stuffiness
5. Aspiration
6. Eye irritation
7. Gastric Distention
8. Excessive dryness (consider humidification)

Question 32

Patient teaching for a patient with OSA using CPAP or BiPAP therapy

Answer 32

1. Risk factor reduction may reduce/eliminate need for NIPPV
   
   1. Exercise and diet management for weight loss
   2. Don’t smoke
   3. HTN control
2. Use, fit, care of CPAP/BiPAP equipment
3. Avoid use of petrolatum productions (increases flammability and erodes plastic)
4. Avoid sedatives/ETOH 3-4 hours before sleep
5. Avoid supine position for sleep
   
   1. Side lying is best