Interventions for Critically Ill Clients with Respiratory Problems

Pulmonary Embolism A collection of particulate matter (solids, liquids, or gases) that enters venous circulation and lodges in the pulmonary vessels. A collection of particulate matter (solids, liquids, or gases) that enters venous circulation and lodges in the pulmonary vessels. Large emboli obstruct pulmonary circulation, leading to decreased systemic oxygenation, pulmonary tissue hypoxia, and potential death. Any substance can cause an embolism, but a blood clot is the most common. Large emboli obstruct pulmonary circulation, leading to decreased systemic oxygenation, pulmonary tissue hypoxia, and potential death. Any substance can cause an embolism, but a blood clot is the most common. 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. 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.

Etiology Prolonged immobilization Prolonged immobilization Central venous catheters Central venous catheters Surgery Surgery Obesity Obesity Advancing age Advancing age Hypercoagulability Hypercoagulability History of thromboembolism History of thromboembolism Cancer diagnosis Cancer diagnosis

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

Clinical Manifestations Assess the client for: 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

Etiology COMMON CAUSES OF VENTILATORY FAILURECOMMON CAUSES OF OXYGENATION FAILURE

Dyspnea Encourage deep breathing exercises. Encourage deep breathing exercises. Oxygen administration Oxygen administration Help the client find a position of comfort Help the client find a position of comfort Energy-conserving measures Energy-conserving measures Pulmonary drugs (e.g. bronchodilators) Pulmonary drugs (e.g. bronchodilators)

Acute Respiratory Distress Syndrome Hypoxia that persists even when oxygen is administered at 100% Hypoxia that persists even when oxygen is administered at 100% Decreased pulmonary compliance Decreased pulmonary compliance Dyspnea Dyspnea Noncardiac-associated bilateral pulmonary edema Noncardiac-associated bilateral pulmonary edema Dense pulmonary infiltrates seen on x-ray Dense pulmonary infiltrates seen on x-ray

Acute Respiratory Distress Syndrome ARDS usually occurs after an acute catastrophic event in people with no previous pulmonary disease. ARDS usually occurs after an acute catastrophic event in people with no previous pulmonary disease. The mortality rate remains at 50% to 60% despite continuing research. The mortality rate remains at 50% to 60% despite continuing research. Terminology for ARDS includes the current term noncardiogenic pulmonary edema and the former term shock lung Terminology for ARDS includes the current term noncardiogenic pulmonary edema and the former term shock lung

Etiology

Interventions Endotracheal intubation and mechanical ventilation with positive end-expiratory pressure or continuous positive airway pressure Endotracheal intubation and mechanical ventilation with positive end-expiratory pressure or continuous positive airway pressure Drug therapy Drug therapy Nutrition therapy; fluid therapy Nutrition therapy; fluid therapy

Interventions Case management Case management Phase 1. This phase includes early changes with the client exhibiting dyspnea and tachypnea. Early interventions focus on supporting the client and providing oxygen Phase 1. This phase includes early changes with the client exhibiting dyspnea and tachypnea. Early interventions focus on supporting the client and providing oxygen Phase 2. Patchy infiltrates form from increasing pulmonary edema. Interventions include mechanical ventilation and prevention of complications. Phase 2. Patchy infiltrates form from increasing pulmonary edema. Interventions include mechanical ventilation and prevention of complications. Phase 3. This phase occurs over days 2 to 10, and the client exhibits progressive refractory hypoxemia. Interventions focus on maintaining adequate oxygen transport, preventing complications, and supporting the failing lung until it has had time to heal Phase 3. This phase occurs over days 2 to 10, and the client exhibits progressive refractory hypoxemia. Interventions focus on maintaining adequate oxygen transport, preventing complications, and supporting the failing lung until it has had time to heal

Interventions Phase 4. Pulmonary fibrosis pneumonia with progression occurs after 10 days. This phase is irreversible and is frequently referred to as "late" or "chronic" ARDS. Interventions focus on preventing sepsis, pneumonia, and multiple organ dysfunction syndrome (MODS), as well as weaning the client from the ventilator. The client in this phase may be ventilator dependent for weeks to months. He or she may be cared for in specialized units or facilities that focus on rehabilitation and long-term weaning. Some clients may not be weanable and go home ventilator dependent Phase 4. Pulmonary fibrosis pneumonia with progression occurs after 10 days. This phase is irreversible and is frequently referred to as "late" or "chronic" ARDS. Interventions focus on preventing sepsis, pneumonia, and multiple organ dysfunction syndrome (MODS), as well as weaning the client from the ventilator. The client in this phase may be ventilator dependent for weeks to months. He or she may be cared for in specialized units or facilities that focus on rehabilitation and long-term weaning. Some clients may not be weanable and go home ventilator dependent

MAJOR INDICATIONS FOR INTUBATION

Endotracheal Intubation Preparation for intubation Preparation for intubation Verifying tube placement Verifying tube placement –The nurse assesses for bilateral equal breath sounds, bilateral equal chest excursion, and air emerging from the ET tube. If breath sounds and chest wall movement are absent on the left side, the tube may be in the right mainstem bronchus. The person intubating the client should be able to reposition the tube without repeating the entire intubation procedure. –The nurse auscultates over the stomach to rule out esophageal intubation. If the tube is in the stomach, louder breath sounds are heard over the stomach than over the chest and abdominal distention may be present. –Chest wall movement and breath sounds are continuously monitored until tube placement is verified by chest x-ray examination

Endotracheal Intubation Stabilizing the tube Stabilizing the tube –The nurse, respiratory therapist, or anesthesia personnel stabilize the ET tube at the mouth or nose. The tube is marked at the level at which it touches the incisor tooth or naris. –An oral airway may also need to be inserted to keep the client from biting an oral tube. One person stabilizes the tube at the correct position and prevents head movement while a second person applies the tape. After the procedure is completed, the nurse verifies the presence of bilateral and equal breath sounds and the level of the tube Nursing care Nursing care

Mechanical Ventilation Types of ventilators: Types of ventilators: –Negative-pressure ventilators –Positive-pressure ventilators  Pressure-cycled ventilators  Time-cycled ventilators  Microprocessor ventilators

Modes of Ventilation The ways in which the client receives breath from the ventilator include: 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

Nursing Management First concern is for the client; second for the ventilator. First concern is for the client; second for the ventilator. Monitor and evaluate response to the ventilator. Monitor and evaluate response to the ventilator. Manage the ventilator system safely. Manage the ventilator system safely. Prevent complications. Prevent complications.

Complications Complications can include: Complications can include: –Lung –Cardiac –Gastrointestinal and nutritional Infection Infection Muscular complications Muscular complications Ventilator dependence Ventilator dependence

Chest Trauma About 25% of traumatic deaths result from chest injuries: About 25% of traumatic deaths result from chest injuries: –Pulmonary contusion –Rib fracture –Flail chest –Pneumothorax –Tension pneumothorax –Hemothorax –Tracheobronchial trauma