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

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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
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Etiology
Prolonged immobilization
Central venous catheters
Surgery
Obesity
Advancing age
Hypercoagulability
History of thromboembolism
Cancer diagnosis
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4. 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.
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5. 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
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Interventions
Evaluate chest pain
Auscultate breath sounds
Encourage good ventilation and relaxation
(Continued)
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7. Interventions (Continued)
Monitor the following:
respiratory pattern
tissue oxygenation
symptoms of respiratory failure
laboratory values
effects of anticoagulant medications
Surgery
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8. Decreased Cardiac Output
Interventions include:
Intravenous fluid therapy
Drug therapy
Positive inotropic agents
Vasodilators
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Anxiety
Interventions include:
Oxygen therapy
Communication
Drug therapy: antianxiety agents
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10. 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.
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11. 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
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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
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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.
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14. 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.
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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
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16. 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
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17. 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.
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18. 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
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Interventions
Endotracheal intubation and mechanical ventilation with positive end-expiratory pressure or continuous positive airway pressure
Drug therapy
Nutrition therapy; fluid therapy
Case management
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20. Endotracheal Intubation
Components of the endotracheal tube
Preparation for intubation
Verifying tube placement
Stabilizing the tube
Nursing care
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21. Mechanical Ventilation
Types of ventilators:
Negative-pressure ventilators
Positive-pressure ventilators
Pressure-cycled ventilators
Time-cycled ventilators
Microprocessor ventilators
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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
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23. 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
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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.
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Complications
Complications can include:
Lung
Cardiac
Gastrointestinal and nutritional
Infection
Muscular complications
Ventilator dependence
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Chest Trauma
About 25% of traumatic deaths result from chest injuries:
Pulmonary contusion
Rib fracture
Flail chest
Pneumothorax
Tension pneumothorax
Hemothorax
Tracheobronchial trauma
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