Interventions for Critically Ill Clients with Respiratory Problems Chapter 35 Interventions for Critically Ill Clients with Respiratory Problems

Elsevier items and derived items © 2006 by Elsevier Inc. Pulmonary Embolism A collection of particulate matter—solids, liquids, or gases—enters venous circulation and lodges in the pulmonary vessels. In most people with pulmonary embolism, a blood clot from a deep vein thrombosis breaks loose from one of the veins in the legs or the pelvis. Sentence and phrase Elsevier items and derived items © 2006 by Elsevier Inc.

Elsevier items and derived items © 2006 by Elsevier Inc. Etiology Prolonged immobilization Central venous catheters Surgery Obesity Advancing age Hypercoagulability History of thromboembolism Cancer diagnosis Elsevier items and derived items © 2006 by Elsevier Inc.

Health Promotion and Illness Prevention Stop smoking. Reduce weight. Increase physical activity. If traveling or sitting for long periods, get up frequently and drink plenty of fluids. Refrain from massaging or compressing leg muscles. Elsevier items and derived items © 2006 by Elsevier Inc.

Clinical Manifestations Assess the client for: Respiratory manifestations: dyspnea, tachypnea, tachycardia, pleuritic chest pain, dry cough, hemoptysis Cardiac manifestations: distended neck veins, syncope, cyanosis, hypotension, abnormal heart sounds, abnormal electrocardiogram findings Low-grade fever, petechiae, symptoms of flu Elsevier items and derived items © 2006 by Elsevier Inc.

Elsevier items and derived items © 2006 by Elsevier Inc. Interventions Evaluate chest pain Auscultate breath sounds Encourage good ventilation and relaxation (Continued) Elsevier items and derived items © 2006 by Elsevier Inc.

Interventions (Continued) Monitor the following: respiratory pattern tissue oxygenation symptoms of respiratory failure laboratory values effects of anticoagulant medications Surgery Elsevier items and derived items © 2006 by Elsevier Inc.

Decreased Cardiac Output Interventions include: Intravenous fluid therapy Drug therapy Positive inotropic agents Vasodilators Elsevier items and derived items © 2006 by Elsevier Inc.

Elsevier items and derived items © 2006 by Elsevier Inc. Anxiety Interventions include: Oxygen therapy Communication Drug therapy: antianxiety agents Elsevier items and derived items © 2006 by Elsevier Inc.

Risk for Injury (Bleeding) Interventions include: Protect client from situations that could lead to bleeding. Closely monitor amount of bleeding. Assess often for bleeding, ecchymoses, petechiae, or purpura. Examine all stool, urine, nasogastric drainage, and vomitus and test for occult blood. Elsevier items and derived items © 2006 by Elsevier Inc.

Acute Respiratory Failure Pressure of arterial oxygen < 60 mm Hg Pressure of arterial carbon dioxide > 50 mm Hg pH < 7.3 Ventilatory failure, oxygenation failure, or a combination of both ventilatory and oxygenation failure Elsevier items and derived items © 2006 by Elsevier Inc.

Elsevier items and derived items © 2006 by Elsevier Inc. Ventilatory Failure Type of mismatch in which perfusion is normal but ventilation is inadequate Thoracic pressure insufficiently changed to permit air movement into and out of the lungs Mechanical abnormality of the lungs or chest wall Defect in the brain’s respiratory control center Impaired ventilatory muscle function S&P Elsevier items and derived items © 2006 by Elsevier Inc.

Elsevier items and derived items © 2006 by Elsevier Inc. Oxygenation Failure Thoracic pressure changes are normal, and air moves in and out without difficulty, but does not oxygenate the pulmonary blood sufficiently. Ventilation is normal but lung perfusion is decreased. Elsevier items and derived items © 2006 by Elsevier Inc.

Combined Ventilatory and Oxygenation Failure Hypoventilation involves poor respiratory movements. Gas exchange at the alveolar-capillary membrane is inadequate—too little oxygen reaches the blood and carbon dioxide is retained. Elsevier items and derived items © 2006 by Elsevier Inc.

Elsevier items and derived items © 2006 by Elsevier Inc. Dyspnea Encourage deep breathing exercises. Assess for: Perceived difficulty breathing Orthopnea: client finds it easier to breathe when in upright position Oxygen Position of comfort Energy-conserving measures Pulmonary drugs Elsevier items and derived items © 2006 by Elsevier Inc.

Acute Respiratory Distress Syndrome Hypoxia that persists even when oxygen is administered at 100% Decreased pulmonary compliance Dyspnea Noncardiac-associated bilateral pulmonary edema Dense pulmonary infiltrates seen on x-ray Elsevier items and derived items © 2006 by Elsevier Inc.

Causes of Lung Injury in Acute Respiratory Distress Syndrome Systemic inflammatory response is the common pathway. Intrinsically the alveolar-capillary membrane is injured from conditions such as sepsis and shock. Extrinsically the alveolar-capillary membrane is injured from conditions such as aspiration or inhalation injury. Elsevier items and derived items © 2006 by Elsevier Inc.

Diagnostic Assessment Lower PaO2 value on arterial blood gas Poor response to refractory hypoxemia Ground-glass appearance to chest x-ray No cardiac involvement on ECG Low to normal PCWP Sentences and phrases Elsevier items and derived items © 2006 by Elsevier Inc.

Elsevier items and derived items © 2006 by Elsevier Inc. Interventions Endotracheal intubation and mechanical ventilation with positive end-expiratory pressure or continuous positive airway pressure Drug therapy Nutrition therapy; fluid therapy Case management Elsevier items and derived items © 2006 by Elsevier Inc.

Endotracheal Intubation Components of the endotracheal tube Preparation for intubation Verifying tube placement Stabilizing the tube Nursing care Elsevier items and derived items © 2006 by Elsevier Inc.

Mechanical Ventilation Types of ventilators: Negative-pressure ventilators Positive-pressure ventilators Pressure-cycled ventilators Time-cycled ventilators Microprocessor ventilators Elsevier items and derived items © 2006 by Elsevier Inc.

Elsevier items and derived items © 2006 by Elsevier Inc. Modes of Ventilation The ways in which the client receives breath from the ventilator include: Assist-control ventilation (AC) Synchronized intermittent mandatory ventilation (SIMV) Bi-level positive airway pressure (BiPAP) and others Elsevier items and derived items © 2006 by Elsevier Inc.

Ventilator Controls and Settings Tidal volume Rate: breaths per minute Fraction of inspired oxygen Sighs Peak airway (inspiratory) pressure Continuous positive airway pressure Positive end-expiratory pressure Elsevier items and derived items © 2006 by Elsevier Inc.

Elsevier items and derived items © 2006 by Elsevier Inc. Nursing Management First concern is for the client; second for the ventilator. Monitor and evaluate response to the ventilator. Manage the ventilator system safely. Prevent complications. Elsevier items and derived items © 2006 by Elsevier Inc.

Elsevier items and derived items © 2006 by Elsevier Inc. Complications Complications can include: Lung Cardiac Gastrointestinal and nutritional Infection Muscular complications Ventilator dependence Elsevier items and derived items © 2006 by Elsevier Inc.

Elsevier items and derived items © 2006 by Elsevier Inc. Chest Trauma About 25% of traumatic deaths result from chest injuries: Pulmonary contusion Rib fracture Flail chest Pneumothorax Tension pneumothorax Hemothorax Tracheobronchial trauma Elsevier items and derived items © 2006 by Elsevier Inc.