T2 Respiratory Problems Ch.32 Flashcards
Gas exchange is the process by which oxygen is transported to cells and carbon dioxide is transported from CELLs
Gas exchange
Adequate arterial blood flow through the peripheral tissues (peripheral perfusion) and organs (central perfusion) Act of blood flowing
Perfusion
Gas exchange and perfusion -
Acute or chronic problems more common?
Which is worse ? Why?
How to prevent ?
Chronic problems are more common
but acute problems can cause issues with gas exchange and perfusion and cause death
Prompt recognition is critical in preventing serious long term complications to patients
an inadequate blood supply to an organ or part of the body
Ischemia
deficiency in the amount of oxygen reaching the tissues
Hypoxia
an absence or deficiency of oxygen reaching the tissues; severe hypoxia
Anoxia
the spreading of something more widely
Diffusion
occurs when the diffusion of gases (oxygen and carbon dioxide) becomes impaired because of
Ineffective ventilation
Reduced capacity for gas transportation (reduced hemoglobin and/or red blood cells)*
Increased need for oxygen
Inadequate perfusion
Prompt recognitions is essential!!
Impairment of gas exchange
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Causes of impaired gas exchange
Pulmonary embolism
Acute respiratory failure
Acute respiratory distress syndrome
Chest trauma
Collection of particulate (blood clot, fat, air, oil etc) that enters the venous circulation and becomes lodged in the pulmonary vessels*
If large enough can Cause: emboli obstruct pulmonary blood flow and leads to impaired gas exchange, hypoxia
Any substance can form an embolism but blood clot is most common*
Common preventable death!- often with decreases mobility after surgery
Pulmonary embolism
Collection of particulate matter—solids, liquids, air—that enters venous circulation and lodges in pulmonary vessels usually occurs when a blood clot from a venous thromboembolism in leg or pelvic vein breaks off and travels through the vena cava into the right side of the heart.
Clot then lodges in pulmonary artery or one if its branches causing impaired gas exchange. Unoxygenated blood travels through body causing hypoxemia.
May be most common preventable death but often misdiagnosed
Pulmonary embolism with infarction.
Risk factors for pulmonary embolism
Prolonged immobilization -Central venous catheters Surgery -Obesity -Advancing age Conditions that increase blood clotting History of thromboembolism
Also smoking, pregnancy, birth control (estrogen), heart failure, cancer and trauma
long bone fracture (femur)**
Risks?
Fat embolism risk
Fat emboli don’t block blood flow but injure blood vessels and cause ARDS risk
Femur is most common
Can happen with humorous break
A nurse is caring for an older adult client who had a femoral head fracture 24 hours ago and is in skin traction. The client has sudden onset of dyspnea, confusion, and tachycardia. The nurse suspects the client developed which of the following complications? A. Pneumothorax B. Pneumonia C. Fat embolism D. Mucoid plug in the airway
C.
Long bone fracture
Pulmonary embolism prevention?
Tx
Smoking cessation
Weight reduction
Increased physical activity
Ambulate soon after surgery
If traveling or sitting for long periods, get up frequently and drink plenty of fluids
Refrain from massaging/compressing leg muscles
Stop smoking especially women on birth control
Patients at risk for VTE: preventative heparin, IVC filter
Chart 32-1 Prevention of PE*
Pulmonary embolism s/s
Respiratory-
Cardiac-
Mental-
Respiratory:
Dyspnea, tachypnea, pleuritic chest pain (deep breaths hurts), dry cough-blood may be present, hemoptysis, crackles
Cardiac-
Tachycardia, distended neck veins, syncope(loc), cyanosis, systemic hypotension, abnormal heart sounds (S3 or S4), abnormal ECG, chest pain
Hypoxemia-can trigger anxiety, restlessness and sense of impending doom
Chart 32-2
PE patients are critically ill
Range from vague, nonspecific discomforts to hemodynamic collapse, cardiac arrest, and death
Symptoms relate to decrease gas exchange
PE dx?
ABGs
Hyperventilation leads to resp alkalosis
Shunting causes increases PaCo2 leading to resp acidosis with out oxygen gas exchange.
Tissue hypoxia can cause metabolic acidosis
Labs: troponin(to rule out cardiac with chest pain symptoms), d-dimer- determines clotting factors in blood
Imaging assessment
Pulmonary angiography (gold standard)*
CT- (cat scan with contrast) next best
VQ Scan- if allergic to contrast dye
Chest X-ray- rule out other s/s
Doppler ultrasound-find source of blood clot
- Pulmonary embolism
moving blood from right to left side of heart without picking up oxygen (decreased gas exchange)
____doesn’t diagnose PE but if its low, can usually be ruled out. If its high then more testing needs to be done
_______Is gold standard but not always available
_____is next best option
VQ scan is not commonly performed but is useful in some situations (allergy to contrast)
CXR can rule out other causes but not diagnose PE
Doppler: check for VTE
Shunting
D-dimmer
Pulmonary angio- gold standard
CT - next best
Major complications of PE
______decrease exchange
_______inadequate blood circulation to left ventricle
_______from anticoagulation
_______due to hypoxemia
Hypoxemia
Hypotension
Potential for excessive bleeding
Anxiety
Tx of PE?
Oxygen therapy (nasal cannula, mask, possible mechanical ventilation)
Continuous patient monitoring
Obtain adequate venous access
Continuous monitoring of pulse oximetry
Drug therapy*
Anticoagulants
Fibrinolytics- emergency situation - breaks down clots much faster.
PTT - lab to monitor with heparin before starting med. infusion - check frequently until reach goal level. While on patient is transfered to Coumadin or something more long term.
PE nursing interventions
Antidotes for heparin, protamine sulfate, Coumadin
Lab to check before starting heparin
Notify rapid response, reassure patient, elevate head of bed, o2 therapy
Usually nonsurgical but in some cases invasive procedures are needed.
Monitor: assessment, vital signs, lung sounds, dysrhythmias, JVD, edema
Anticoagulants: heparin, lovenox, arixtra: check patients PTT before and during
Heparin 5-10 days then Coumadin or xarelto
Fibrinolytics: alteplase for use when patient in shock or hemodynamic collapse
Know antidotes:
Heparin-protamine sulfate
Warfarin vitamin K
fibrinolytics- clotting factors, FFP, and aminocaproic acid.
PE-
Discuss assigned anticoagulation/ fibrinolytic medication and find answers to the following questions:
Benefits vs risks Monitoring Safety considerations Patient education Antidote
Heparin Warfarin Lovenox Xarelto Alteplase
How to manage hypotension in PE?
IV fluid
Medications to increase cardiac output
Medications to maintain blood pressure
Goals:
Normal pulse and BP
U/O of at least 0.5-1 mL/kg/hr - adequate perfusion
Manage risk for excessive bleeding in PE how?
At risk for bleeding due to anticoagulant or fibrinolytic therapy
Ensure antidotes to anticoagulant or fibrinolytic are available
Assess appropriate lab values
Assess for evidence of bleeding
Watch for Petechiae, bruising, oozing, etc
Great resources for bleeding precautions in book
Minimize anxiety in PE how?
Oxygen therapy
Therapeutic communication
Antianxiety medications
Surgical interventions for PE
Useful when patients are contraindicated for fibrinolytics-
Used in high risk patients and when anticoagulation can’t be used-
Embolectomy-
Useful when patients are contraindicated for fibrinolytics
Placement of IVC filter-
Used in high risk patients and when anticoagulation can’t be used
Either ventilation or perfusion is mismatched, gas exchange reduced
Can be ventilator failure, oxygenation failure, or combination
Classified by ABG values
Patient is always hypoxemic
Acute Respiratory Failure
ABG values* Pao2 <60 mm Hg OR Paco2 >45 mm Hg with pH <7.35 With Sao2 <90%;
Either ventilation or perfusion is mismatch= reduced gas exchange
Acute respiratory failure -resp acidosis
