respiratory 2

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respiratory 2
2010-02-25 17:51:04
respiratory 2

respiratory 2
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  1. mechanical ventilation
    • assists in moving air or oxygen enriched air into and out of the lungs for a pt who cannot sustain adequate ventilation on his/her own
    • e.g. airway obstruction, acute respiratory distress, respiratory failure
    • PaO2 less than 50, PaCO2 greater than 50
  2. before initiating mechanical ventiolation...
    • pt must have an artifical airway
    • ETT nasal or oral-this is quicker and shorter, don't need an order with nasal but check to see if they have a deviated septum or sinus problems

    airway mgmt is a vital part of ventilator mgmt
  3. nursing responsibility with ETT or trach tube
    • maintain correct tube placement
    • to assess if tube is correctly placed, check bilat. lung sounds, tube marking, X-ray, equal sounds and chest expansion
    • if dislodged-bronchial tube will most likely go to the right so you would hear better breath sounds on the right, check to see if chest movement is symmetrical, do they have both lungs?-echoing sound when missing, are they coughing or gagging excessively?
  4. nursing responsibilities with ETT or trach tube
    • maintain proper cuff inflation
    • -minimal occluding volume (MOV)-should have no air exchange around tube, just mininmal amount (3-5)
    • will be able to feel pressure on trachea
    • blow up balloon then deflate till you feel a little air

    • indications for inflating cuff-feeling a lot of air, pt is talking, TEF from tube being inflated too much,too long-when suctioned looks like gastric contents, will have more air exchange if not blown up enough (cuff leak)
    • when cuff needs re-inflated check breath sounds
  5. nursing responsibilities with ETT or trach tube
    • maintaing tube patency
    • -does ot need suctioned?
    • bubbles in tubing, secretions, coughing, color change, dec. pulse ox, increased airway resistance
    • just ask and they will tell you

    • fostering comfort and communication
    • -sedation/pain med, may use sign language, read lips, ect., yes/no questions, keept it short and simple

    safety and monitoring-to determine minimum amt of sedation and pain med to meet tx goals. Important b/c pt cannot verbalize problems
  6. nursing responsibilities with ET/trach tube
    • providing oral care and maintaining skin integrity
    • -oral ETT retaped and repositioned q24 hrs to avoid corner mouth abrasion, could lead to VAP medicare won't cover
    • trach care
    • mouth care q2 hrs-needs to be documented
  7. complication with ET/trach tube
    • accidental extubation/dislodgement
    • can happen when turning and moving pt
    • s/s-tube in hand, talking, low pressure alarm, diminished breath sounds , repsiratory or gastric distress
    • prevention-wrist restraints, don't manipulate trach for 24 hrs-can cuase irritation and bleeding, want to unit 7 days for really good healing

    • what to do if extubation occurs-support airway, bag pt, call resp. staff, call Dr., alarm will sound
    • nursing alert-accidential removal of an ETT, can cause laryngeal swelling, hypoxemia, bradycardia, hypotension or death
  8. complications with an ET/trach tube
    • aspiration
    • -tx: increase HOB 30 degrees Semi-Fowler's (gravity to keepout of stomach, can be on side) can also happen if cuff becomes slightly deflated, coughing can cause tube to come up, swallow, stop tube feeding while moving bed lower to 20 degrees

    • infection
    • -lower airway can become infected within 30 minutes-partly b/c normal way of humidification, filtering, and warming are bypassed) sx appear in 2-3 days
  9. suctioning
    • oral-open suctioning technique/closed suctioning
    • indications:
    • noisy respirations
    • dyspnea
    • restlessness
    • tachycardia
    • tachypnea
    • cyanosis-late sign pt is hypoxic

    • if bradycardia develops while suctioning STOP and ventilate
    • suction only when needed to prevent hypoxia, prevent injury to bronchial and lung tissue, and/or secretions if present
  10. compliance is...
    how easily the lungs can stretch to take in a volume of air
  11. resistance
    opposition to the flow of O2/CO2 through the airways
  12. pressure is...
    force used to aid ventilation
  13. oxygen concentration delivered by the ventilator (40%=0.40)
  14. pt's own inspiratory effort triggers the ventilator
  15. the ventilator is set to automatically deliver a breath
  16. amount of effort needed by the pt to initiate a ventilator breath
  17. (VT) volume of air inhaled and exhaled with each normal (ventilator) breath (volume in ml ordered by Dr.)
    tidal volume
  18. peak airway pressure
    amount of pressure exerted onairways with ventilation
  19. common ventilator modes
    continuous mandatory ventilation (CMV) or assist control (AC)
    • ventilator delivers a preset number of breaths with a preset tidal volume
    • pt may trigger trigger own breaths which are delivered at the preset tidal volume-ventilator does the rest of the work

    • indications
    • commonly used ventilator support mode for pts with normal respiratory drive, but respiraotry muscles are too weak to breath (post anesthesia), normal respiratory drive but muscles are unable to perform the work of breathing due to lung abnormalities (apnea)

    disadvantage-hyperventilate r/t anxiety, pain, or neurologic factors>>>respiratory alkalosis
  20. intermittent mandatory ventilation (IMV) or synchronized intermittent mandatory ventilation (SIMV)
    • most common mode
    • -ventilator delivers a preset number of breaths at a preset tidal volume (mandatory)
    • in btwn mandatory breaths, pt may initiate spontaneous breaths with variable tidal volumes
    • with SIMV the mandatory breaths are synchronized to the pts spontaneous respiratory efforts
  21. indications for IMV and SIMV is commonly used in pts with...
    • normal respiratory drive, but respiratory muscles connot perform all the work of breathing
    • waening from the ventilator
    • advantages:
    • synchronizing the mandatory breaths, reduces competition btwn the pt and ventilator, and improves pt comfort
    • hyperventilation is less of a problem b/c the pt can control rate and volume of spontaneous breaths
    • doesn't dec. CO as much as AC or CMV
    • disadvantage:
    • work of breathing may increase due to the effort needed to trigger the ventilator and the lag time in delivering the gas
    • can decrease BP from increasing pressure on the heart b/c the heart sits behind the lungs
  22. pressure support ventilation (PSV) inspiratory assist ventilation
    • provides positive pressure during inspiration with a pt's spontaneous respirator
    • provides an "inspiratory boost" so pt can get a good breath with less effort
    • ordered 5-20 cm H2O
    • may be used with SIMV
    • indications:
    • weaning
    • long-term mechanical ventilation to reduce the work of breathing
  23. PSV continued
    • advantages:
    • dec. the work of breathing so there's a dec. O2 consumption
    • overcomes airway resistance
    • gives pt more control of ventilation
    • disadvantage:
    • tidal volumes varies-alveolar ventilation not guaranteed
  24. positive end expiratory pressure (PEEP)
    • positive pressure is maintained within the airways during expiration maximizing the number of alveoli available for ventilation so they don't stick together and reduce 02/CO2 exchange
    • ordered 5-15 ccm H20 and pressure on the heart
    • safety alert-may take 20-30 min. to restore PEEP if vent circut is opened with suctioning. Not a problem with closed suctioning
  25. PEEP
    • indications:
    • prevent and reduce atelectasis (alveolar collapse)
    • pts with ARDS, neuromuscular diseases causing respiratory failure
    • advantages:
    • allows oxygenation with a lower FiO2, reducing risk of oxygen toxicity
    • improves oxygenation in pts with PO2 of CO2 or less FiO2 of less than 0.5 or more
    • disadvantages:
    • decreased CO, increased intrathoracic pressure, decreased preload and increased right ventricular afterlioad
    • safety alert-the higher the amount of PEEP, the greater the risk of braotrauma, "blow off lung"/pneumothorax
  26. pressure control (PC)
    • newer mode being used in some hospitals
    • preset respiratory rate with each breath
    • augmented by a preset inspiratory pressure used with pts with noncompliant lungs, poor oxygenation>>ARDS
    • preset (20-30 cm H2O)
  27. proportional assist ventilation (PAV)
    • previous partial ventilator support
    • ventilator generates pressure in proportion to pts inspiratory efforts
  28. continuous positive airway pressure (CPAP)
    • non-invasice mode of ventilation
    • continuous positive pressure maintained throughout the respiratory cycle while the pt breaths spontaneously
    • this results in increased oxygenation
    • it helps avoid premature airway closure and air trapping in the chest which interferes with normal breathing and air exchange
    • air tight face mask or ET tube is used
  29. asepsis
    principles of mechanical ventilation
  30. asepsis
    • tracheobronchial tree is considered sterile
    • all handling of equiptment should be done using sterile technique including suctioning and trach care
    • aspiration is always possible with an ETT or trach
    • oral suctioning should follow ETT suctioning in order to clear mouth of secretions and prevent introduction of bacteria into the tracheobronchial tree
  31. oxygenation
    it is important to allows be aware of the FiO2 setting and the pts PO2 using the lowest amount of O2 to achieve an acceptable PO2, which would help prevent oxygen toxicity
  32. communication
    • verbalization is impossible with an ETT or trach in place
    • therefore, it is imperitive to establish a method of communication with the pt-lip reading, paper/pencil, pictures, ect
  33. resp. status assessments
    • LOC
    • respiratory rate/pulse ox
    • breath sounds
  34. LOC
    • earliest sign of inadequate oxygenation is usually a change in LOC
    • ask yes/no questions
    • pt may be able to follow simple commands e.g. squeeze hand but still be disoriented
    • pt's level of anxiety may affet his response
  35. resp. rate/pulse ox
    • note rate and O2% q1-2hrs
    • compare pts actual rate with ventilator rate
    • ventilator may not pick up on weak respirations
  36. breath sounds
    • assess q2hrs or more frequently if indicated
    • assess if suspect change in tube position
    • document and report diminished breath sounds-could indicate inadequate ventilation from fluid accumulation or atelectasis
  37. ventilator
    • settings-mode, O2, tidal volume, rate, PEEP, ect
    • is O2%set according to orders?
    • are pts tidal volumes close to set tidal volumes?
    • if pt's TV is decreasing from what's set, could mean that pt is fatigued or condiditon is worsening
    • check alarms-coughing, kinked, need suctioned
    • low pressure alarms:
    • disconnected tubing
    • biting on ET
    • deflated cuff
    • extubated tube
    • Nursing Alert-if problems with ventilator, manually ventilate with Ambu bag, call for assistance
  38. PaO2 is less than 50
    PaCO2 id greater than 50
    pH is less than 7.35 when breathing room air
    respiratory failure
  39. types of respiratory failure
    • chronic-renal compensation for hypercapnia occurs (inc. CO2)
    • pH is close to normal b/c of inc. HCO3

    acute-renal compensation doesn't have time to develop and pH falls
  40. causes or respiratory failure
    • combination of failure to oxygenate and ventilate
    • -impaired oxygenation/failure to oxygenate (hypoxemia)
    • lumga can move air but can't oxygenate blood properly (ARDS,PE, pneumonia, acute asthma, atelectasis)
    • -impaired ventilation/failure to ventilate (hypercapnia)
    • perfusion is normal but ventilation isn't>>insufficient O2 reaching the alveoli and CO2 is retained
    • happens in neuromuscular d/os, MD, ALS, Guillain Barre, drugs, obesity, brain, trauma, stroke, tumor, COPD, infection and heart failure, which are all precipitators
  41. most common causes of respiratoory failure in kids
    • foreign body obstruction
    • laryngotrachobronchitis "croup"
    • epiglottitis-total obstruction in 2-5 hrs
    • asthma
  42. hypoxemia
    • oxygen failure
    • CNS-anxiety, restlessness, agitation, irritability, confusion, dec. LOC (lethargy)
    • cardiovascular-tryiing to improve blood flow to increase oxygenation-tachycardia, bounding pulse, HTN, arrthymias
    • pulmonary (response to hypoxemia)-tachypnea, SOB, dyspnea, orthopnea, use of accessory muscles/retractions, dec. pulse ox/low PO2
    • skin (vasoconstriction)-pallor, cyanosis, cool
  43. hypercapnia
    • failure to ventilate
    • CNS-headache, drowsiness, dec. LOC
    • cardiovascualr-same as hypoxemia-tachycardia, bounding pulse, HTN, arrthymias
    • pulmonary-dyspnea, shallow respirations, inc. or dec. resp. rate
    • skin-flushed, warm
  44. acidosis
    • depressant effect on cells
    • CNS-drowsiness, confusion, dec. LOC
    • cardiovascular-weak pulse, hypotension, bradycardia
    • pulmonary-same as hypoxemia @ first-tachypnea, SOB, dyspnea, orthopnea, use of accessory muscles/retractions, dec. pulse oc/low PO2
    • skin-pale, cool
  45. mgmt of respiratory failure
    • treat underlying process
    • focus is to restore adequate gas exchange including oxygenation, intubation, mechanical ventilation
    • is it a COPD pt, ect?
    • know nursing care for endotrachial tube/tracheostomy and indications for mechanical and modes of ventilation
  46. complications of mechanical ventilation
    • drops BP esp. with PEEP
    • pulmonary system
    • -barotrauma from positive pressure>>tension pneumothorax, common with PEEP
    • -VAP-2nd most common nosocomial infection r/t colonization of orophryngeal secretions, causes nosocomial pneumonia, infection w/i 30 min., sx in 2-3 days
    • s/s-low grade fever, SOB, dyspnea, crackles, sputum (prurulent, change in color), x-ray shows white infiltrate
    • interventions-aimed at prevention:mouth care, sterile technique with suction, elevate HOB, hand washing
    • TX-ATB
  47. a major cause of VAP is colonization and aspiration of oropharnheal secretions
    cause of VAP
  48. preventative measures for VAP
    • handwashing b/r and after touching any respiratory equipment gloves when suctioning, even with closed suction
    • sterile technique with suctioning
    • oral and nasal hygeine-brushing teeth, suctioning to keep pooled secretions off
    • tube cuff (q2hrs)
    • elevate HOB 30-45 degress to prevent gastric aspiration
  49. cardiovascular system
    • dec. CO>>hypotension secondary to inc. intrathoracic pressure and dec. venous return
    • fluid retention b/c of decreased CO and retention of humidified air in the closed ventilatorsystem with dec, blood flow to kidneys
    • ADH is stimulated>>retains fluid can absorb moisture>>fluid retention (pts have edema and may be on Lasix) conserves Na, excretes K+-may need to replace K+
  50. inadequate nutrition
    • stress ulcer: stress response by body, stress excretes more-ventilators are stressful *give pepcid, protonix, if NG not to suction give Crafate, Zantac, Protonix prophylactically
    • s/s-dark stools, with suction pink
    • gastric distention/paralytic ileus-portion of bowel stops working, change in thoracic pressure, pt not eating, not moving, put in NG tube to keep stomach empty to dec. stress ulcer and paralytic ileus
    • inadequate nutrition-as PRO depletion occurs, cells can't maintain normal function
    • diaphram an dresp. muscles are catabolized first as PRO source to meet metabolic needs (ep. COPD pts)
  51. inadequate nutrition cont.
    • put on vent, not eating, first source of energy is carbs, then PRO, then fat
    • vent pts need increased PRO especially, fat and CHO
    • PRO strengthens immune system
    • fat produces the most energy and less CO2 as a by product, don't overdo because it can cause ketone buildup with diabetes
    • CHO is used up for metabolism w/i 24-48 hrs
    • *Kreb's cycle-CHO breaks down into CO2, increasing sugar, inc. CO2 production..may not be able to wean from vent if too much sugar b/c of carbs when breakdown occurs in Kreb's cycle
    • most commonly used is Jevity and Glucerna
  52. nursing alert
    if problems with a ventilator, assess pt and if inadequately ventilated, take pt off and ventiliate manually with Ambu bag, call for assistance and page RT
  53. Aminophylline (Theophylline)
    • bronchodilator
    • relaxes smooth muscle in bronchiole tree-inc. CNS stimulation, inc. CO, drug of choice, therapeutic range *10-20 mcg/ml
    • s/e: jitteriness, nervousness, tachycardia (anxiety)
    • serious s/e:seizures, circulatory failure-hypotension, tachycardia, resp. arrest
    • dizziness is common in elderly early in therapy
    • too rapid infusion>>chest pain, dizziness, tachypnea, hypotension
    • 1st sign of toxicity may include seizures, tachcardia, ventricular arrhythmias
    • tx-treat seizures, Dilantin, Valium
  54. Lorazepam/Ativan and Morphine Sulfate
    • ventilator control/sedation
    • alternated with each other q2hrs
    • Ativan/Lorazepam-dosage .5-1mg, 1mg may be toomuch for elderly
    • s/e: dec. LOC, relaxant, dizziness, drowsiness, lethargy, dec. BP, can wire pts giving them anxiety
    • Morphine Sulfate-2-4 mg, monitor pt for s/e: dec. LOC, dizziness, drowsiness, lethargy, dec. BP
  55. propofol (diprivan)
    • verntilator control/sedation
    • looks white/milk colored
    • great for surgery-intubating, ventilator action-short acting hypnotic, produced amnesia, does not provide analgesia
    • onset-40 sec. duration-3-5 min
    • s/e: apnea, bradycardia, hypotension, pain, burning, stinging at IV site
    • dosage range-5-50 mcg/kg/min titrated to pts response
    • nursing assessment-turn off med b/f assing, monitor VS continuously, wake up and assess LOC/CNS @ least daily b/c they could have a stroke w/o knowing
  56. Solu-Medrol
    • streoid of choice for vent pts
    • can inc. sugar, mask infection
    • Decadron can be used as a substitute if allergic
    • Solu-Cortef used in MS
  57. weaning rfom ventilator
    • affected by:
    • how long pt has been on a vent.
    • pt's physical condition
    • disease process is managable
    • resp. btwn 12-24
    • ABGs are stable
    • reduction in anterior and viscosity of secretions
    • emotionally and mentally ready to wean
    • How to determine if ot's respiratory status is deteriorating and pt isn't tolerating weaning process:
    • dec. pulse ox, inc. anxiety, dec. resp. rate, ABGs, color, diaphoretic, working hard at breathing, tachy>brady>PVCs, BP changes
  58. when pt isn't tolerating weaning
    • place back on ventilator and/or inc. oxygen
    • call Dr. and rep.
    • on vent and still low-tell resp. therapist to put back on vent b/c pts not tolerating
    • hints:
    • weaning should be initiated in AM or when ptis rested
    • whenever there's a change in vent. settings, monitor and observe pt closely
    • be cautious with the use of medications that sedate the pt or depress respirations
  59. extubation
    • monitor closely for s/s of airway obstruction following extubation>>may need to re-intubate (dyspnea, coughing, inability to expectorate secretions, stridor, VS, LOC changes)
    • kids-sometimes steriods are given b/f extubation to control laryngeal edema
    • place child on cardiac and apnea monitor and cool mist
  60. nursing mgmt for acute resp. failure
    • care plan of pt with ARF:
    • assess respiratory status (LOC, VS, pulse ox, breath sounds, ABGs)
    • monitor client's response to ventilation and medical mgmt
    • intervene to maintain oxygenation and ventilation (positioning, suctioning, trach care)
    • implement strategies to prevent complications (turning, mouth care-dec. VAP, back rubs, ROM, nutrition
    • establish communication
  61. ARDS
    • hallmark sign is pulse ox, ABGs, dec. O2 sat with inc. O2, not retaining CO2
    • progressive pulmonary insufficiency, develops w/i 224-48 hrs after an injury/illness
    • usually happens to someone with "normal lungs"
    • causes:
    • massive trauma/surgery
    • aspiration of gastric contents
    • infections>e.g. pancreatitis, diffuse pneumonia
  62. pathophysiology of ARDS
    • pathophysiology
    • non-cardiac form of pulmonary edema
    • process may take up to 3 weeks after initial injury

    injury to alveolar capillary membrane occurs>>protein/water leaks into interstitial/alveolar spaces>>pulmonary edema

    PRO destrpys surfactant>>alveolar collapse>>impaired gas exchange occurs>>massive atelectasis>>severe hypoxemia

    fluid in lungs causes decreased lung compliance>>pulmonary fibrosis>>lungs become stiff (worsens with hypoxemia) hyaline membrane develops
  63. sx of ARDS
    • sx:chracterized by shallow, rapid breathing>dyspnea>use of accessory muscles, sluggishness, disorientation, tachycardia, restlessness, agitation
    • breath sounds are normal at first (fluid not in airways)>>crackles, diminished breath sounds
    • bilateral pulmonary infiltrates on CXR "white out"
    • 1st ABGs: dec. PO2 (hypoxia) in spite of giving O2, dec. PCO2 (with hyperventilation) hypocapnia then PO2 continues to dec. (hypoxia worsens)-getting tired, inc. PCO2 (hypercapnia and resp. acidosis)
    • as ARDS progresses, sx of multiorgan involvement occur:cardiac, renal, peripheral vascular
  64. medical mgmt of ARDS
    • goals
    • respiratory and ventilator support:
    • oxygen for hypoxia-atelectasis with dec. surfactant, ventilation with PEEP, nitric oxide being used some places (causes bronchial dilation w/o dec. BP)
    • maintainence of hemodaynamic stability:
    • Dobutamine/Dopamine inc. CO and BP
    • fluid restriction to prevent overload, diuretics
    • treat underlying cause:
    • trauma
    • pancreatitis
    • may give steroids
  65. goals of ARDS
    • prevent complications
    • dysrhythmias from hypxemia (PVCs)
    • pneumonia
    • pneumothorax from PPEP
    • MOD-major cause of death
    • if pt survives may have permanent loss of kunf tissue and dec. vital capacity (impaired gas exchange)
  66. nursing mgmt of ARDS
    • assess resp. status, breath sounds
    • monitor pts response to ventilation and mgmt
    • ABGs
    • interveneto maintain oxygenation/ventilation
    • suction, trach care
    • proning, put pt in prone position-promote O2 and drainage of secretions, dec. lung pressure from heart, if no O2 reaching the brain, the rest of the injuries don't matter b/c death will occur, however, the client must be removed from immenent danger e.g. fire
    • nursing care: turn, ROM, meds, establish communication, suction, trach care
  67. ARDS
    • Assult to respiratory system
    • Respiratory distress
    • Decreased lung complicance
    • Severe resp. failure
  68. s/s ARDS
    • "white lung"
    • tacypnea
    • dyspnea
    • retractions
    • hypoxia
    • tachycardia
    • crackles

    • ABGs:
    • dec. PO2, inc. dyspnea
  69. causes of ARDS
    • massive trauma
    • severe resp. d/o
    • prolinged mechanical ventilation
    • hemmorrhagic shock
    • fat emboli
    • septic condition
  70. PE
    • obstruction of the pulmonary artery or one of its brances by a thrombus that originates somewhere in the venous system or in the right side of the heart
    • often associated with trauma, surgery (orthopedic, major abd, pelvic, gynecologic), pregnancy, HF, age over 50, hypercoaguable states, and prolonged immobility
  71. risk factors for PE
    • venous stasis (slowing of blood flow in veins):
    • prolonged immobilization (esp. post-op)
    • prolonged periods of sitting/traveling
    • varicose veins
    • spinal cord injury
    • hypercoaguability:
    • injury
    • trauma (pancreatic, gastrointestinal, genitourinary, breast, lung)
    • increased platelet count (polycythemia, spenectomy)
    • certain disease states:
    • heart disease (esp HF)
    • trauma esp. fracture of hip, pelvis, vertebrae, lower extremities
    • post-op state, postpartum period
    • DM
    • COPD
  72. other predisposing conditions for PE
    • advanced age
    • obesity
    • pregnancy
    • oral contraceptives
    • hx of thrombophlebitis, PE
    • constrictive clothing
  73. risk factors for PE
    • DVT-most common cause
    • immobility
    • obesity
    • oral contraceptives
  74. s/s of PE
    depends on size of embolus and the vessel occluded

    • s/s:
    • dyspnea
    • tacypnea
    • tachycardia
    • pleuritic chest pain
  75. how to diagnose PE
    • D-DIMER
    • VQ scan
  76. how PE can be prevented
    • early ambulation
    • don't cross legs
    • avoid sitting for prolonged times
    • stay hydrated (inc. fluids)
    • SCDs
  77. tx for PE
    • oxygen
    • anticoagulation:
    • -heparin usually 5-10 days
    • protocol is to check HCT and PTT prior, IV bolus followed by continuous infusion-fast acting
    • Coumadin-therapeutic level for 3-5 days
    • monitor PTT-therapeutic range is 60-70 OR 1 1/2 TO 2 1/2 x's the control
    • follow anticoagulation protocols, once achived watch for excessive anticoagulation (bleed)
    • antidote-protamine sulfate
  78. tx for PE cont.
    • for long term therapy
    • usually started on 3rd day while still on heparin
    • may take 3-5 days to reach therapeutic levels
    • monitor effect of Coumadin by PT-10-13 or 1 1/2-2 1/2 x's normal to get therapeutic level
    • INR-2-3
    • antidote-Vit K
    • other tx-thrombolytic therapy, surgical mgmt
  79. nursing diagnosis for PE
    • ineffective breathing pattern
    • impaired gas exchange
    • pain
    • altered tissue perfusion
    • anxiety
  80. nursing mgmt for PE
    • goal:
    • prevent or minimize resp. distress
    • promote home care
    • health teaching r/t prevention, need to continue anticoagulation therapy, follow up care
  81. PE
    • Sudden sense of doom
    • Untreated>death
    • Dyspnea
    • Density on xray
    • Emergency condiditon
    • New sx
  82. predisposing conditons of ARDS
    • aspiration (gastric secretions, drowning, hydrocarbons)
    • drug ingestion and overdose
    • hematologic d/os-DIC, massive transfusions, cardiopulmonary bypass
    • prolonged inhalation of high concentrations of oxygen, smoke, or corsive substances
    • localized infection-bacterial, fungal, viral pneumonia
    • metabolic d/os-pancreatitis, uremia
    • shock of any cause
    • trauma-pulmonary contusion, multiple fractures, head injuries
    • major surgery
    • fat or air embolism
    • systemic sepsis
  83. clinical manifestations for ARDS
    • rapid onset of severe dyspnea that occurs 12-48 hrs after the initial even
    • arterial hypoxemia that doesn't respond to supplemental oxygen
    • cardiogenic pulmonary edema is what it resembles on a CXR and appears as bilateral infiltrates and quickly worsen
    • severe hypoxemia can progress to alveolar dead space (ventilation to alveoli, but poor perfusion and dec. pulmonary compliance-stiff lungs)
    • if hypoxemia gradually resolves, the CXR improves and lungs become more compliant
  84. s/s of resp. distress
    • anxiety, irritability
    • position-want them to sit up
    • energy/effort to breathe:
    • nasal flaring
    • open mouth breathing
    • chin lag (air hunger look)
    • chest movement:
    • accessory muscles
    • are shoulder going up and down?
    • skin color:
    • cyanosis
    • resp. rate/pattern
    • breath sounds-diminished, absent, expiratory grunting, inspiratory stridor (crowing)
  85. s/s or resp. distress cont.
    • speech:
    • hard to speak?
    • ask direct simple yes/no questions
    • cough/sputum:
    • is it productive?
    • color?
    • productive or non-productive?
  86. early signs of hypoxia
    • restless
    • anxiety
    • tachycardia
    • tachypnea
    • disorientation
    • confusion
    • headaches
  87. late signs of hypoxia
    • bradycardia
    • extreme restlessness
    • dyspnea
    • cyanotic
    • cold
    • in PEDS:
    • feeding difficulty
    • inspiratory stridor
    • flaring nares
    • expiratory grunting
    • sternal retactions
  88. nursing interventions for hypoxia
    • high-fowler's-minimal 30-45 degrees depending on pt
    • encourage CDD
    • suction PRN
    • o2 if dyspnea is present (standard w/o order is 2 L NC)
    • never withhold O2 from a client with severe hypoxia for fear of inc. PO2 level and dec. stimulus to breathe
  89. to decrease hypoxia...
    • assess airway:
    • can pt speak, if not check airway, could be obstructed
    • yes/no if speaking is difficult, stay with pt, call Dr.
    • if pt speaks w/o difficulty continue to monitor, check secretions, cough
    • assess use of accessory muscles:
    • stay calm
    • semi-fowler's
    • vs, breath sounds
    • O2
    • remain with client experiencing acute dyspnea or hypoxic episodes
  90. safety alert
    • administer fluids cautiously if having trouble breathing
    • begin with small sips of water to determine
    • don't begin with fluids that contain milk or caolories b/c could aspirate
  91. early signs of hypoxia
    • Restless
    • Anxiety
    • Tachycardia/tachypnea
  92. late signs of hypoxia
    • Bradypnea
    • Extreme restlessness
    • Dyspnea
  93. s/s of hypoxia in PEDS
    • Feeding difficulty
    • Inspiratory stridor
    • Nares flare
    • Expiratory grunting
    • Sternal retractions
  94. nursing interventions for mechanically ventilated pt
    • pulmonary auscultation
    • interpretation of ABGs

    the nurse is usually the first to note changes in physical assessment or significant trends in ABGs that signal the development of a serious problem (e.g. pneumothoraz, tube displacement, PE)
  95. purpose of mechanical ventilation
    • to optimize gas exchange by maintaining alveolar ventilation and oxygen delivery
    • the cause may ne an underlying illness or mechanical factors r/tnadjustment of machine to the pt
  96. nursing interventions to promote optimal has exchange
    administration of analgesics to relieve pain w/o supressing respiratory drive and frequent repositioning to diminish the pulmonary effcts of immobility

    monitors fluid balance by assessing for peripheral edema, I/O, daily weights

    administer meds to control primary disease and monitor s/e
  97. promoting effective airway clearance with mechanically ventilated pt
    • continuous positive pressure increases secretions so the nurse assess by lung auscultation q2-4 hrs
    • may have to suction, CPT, frequent position changes, increase in mobility ASAP
    • not that suctioning can damage airway mucosa and impair cilia action so routine suctioning may be unnecessary

    • bronchodilators-andrenergic/anticholinergic for muscle relaxation (e.g. Albuterol, terbutaline)
    • watch for tacycardia, palpitations, tremors, dizziness, nausea, dec. O2, hypokalemia, inc. HR, urine retention

    Mucomyst-monitor sputum, cough reflex, N/V, bronchospasm, rhinorrhea, stomatitis, uticaria
  98. preventing trauma and infection with mechanically ventilated pt
    • position tube so there's minimal pulling/distortion of the tube in the trachea
    • monitor cuff pressure q6-8 hrs (want <25 mmHg, optimal 15-20) monitor for cuff leak

    • trach care @ least q8 hrs
    • oral hygiene
    • NG tube can inc. risk for aspiration>>nosocomial pneumonia
    • position pt with head elevated as much as possible
    • antiulcer meds to dec. incidence of aspiration pneumonia
  99. promoting optimal level of mobility with a mechanically ventilated pt
    • ROM q6-8 hrs if bed bound
    • if pt can't do ROM, provide passive ROM q 8hrs to prevent contractures and venous stasis
    • with stable pt who can get OOB, move to chair as much as possible

    movement stimulates respirations and improves morale
  100. promoting optimal communication with mechanically ventilated pt
    • assess communication abilities
    • find most suitable way to communicate
    • speech therapist
  101. promoting coping ability with mechanically ventilated pt
    • verbalize feelings
    • explain procedures
    • inform about progress
    • provide diversions
  102. maintaining and managing potential complications with a mechanically ventilated pt
    • positive pressire ventilation can dec. CO, inc. thoracic pressure during inspiration compressing the heart and great vessels, reducing venous return and CO-corrected dung exhalation when positive pressure is off
    • pt may have dec. CO, dec. tissure perfusion, dec. oxygenation
    • obeserve for hypoxia (restlessness, apprehension, confusion, tachycardia, tachypnea, labored breathing, pallor>>cyanosis, diaphoresis, transient HTN, dec. CO
    • excessive positive pressure can cause barotrauma causing spontaneous pneumothorax, dec. venous return, dec. CO, dec. BP
    • pulmonary infection-assess color and color of sputum
  103. criteria for weaning
    • takes place in 3 stages
    • vital capacity-assess pts ability to take deep breaths, should be 10-15 ml/kg to meet criteria
    • maximum inspiration-assess pts resp. muscle strength AKA negative inspiratory pressure, should be 20 cm H2O
    • tidal volume- air inhaled/exhaled during an effortless breath, should be >3.5 ml/kg
    • minute ventilation-equal to resp. rate x tidal volume, normal is 6 L/min
    • rapid shallow breathing index- divide resp. rate by tidal volume, assess breathing pattern and pts with < 105 breaths/min/L are more successful at weaning
    • PO2> 60 with FiO2 < 50%
  104. guidelines for being weaned
    • assess pt for weaning criteria
    • vital capacity 10-15 ml/kg
    • MIP at least 20 cm H2O
    • tidal volume 7-9 ml/kg
    • min. ventilation-6 L/min
    • rapid shallow breathing <100 breaths/min/L
    • PaO2 >60 mmHg with Fio2 <40%
    • monitor activity level, dietary intake, lab tests for nutritional status
    • explain process and address concerns (may feel SOB initially)
    • explain weaning method prescribed-A/C, IMV, PSV, PAV.SIMV, CPAP, or T-piece
    • monitor VS, pulse ox, ECG, and resp. pattern for the first 20-30 min and q 5 min after until weaning is complete
  105. guidelines for being weaned
    • maintain patent airway, ABGs and pulmonary function tests should be monitored, suction airway as needed
    • terminate with collaboration with Dr.,inc. HR of 20 bpm, systolic BP > 20 mmHg, dec. O2 sat < 90%, <8 breaths per min, ventricular dysrhythmias, fatigue, panic, cyanosis, erratic or labored breating, paradoxical chest movement
    • if continuing to wean, measure tidal volume q 20-30 min., compare with pt's desired values
    • assess psychological dependance if physiologic parameters indicate weaning is feasible and pt still resists
  106. methods used for successful weaning
    • oxygen therapy
    • ABG evaluation
    • pulse ox
    • bronchodilator therapy
    • CPT
    • adequate nutrition, hydration, and humidification
    • incentive spirometry
  107. weaning pt from mechanical ventilation
    • once pt can clear secretions adequately, trial periiod of mouth breathing or nose brathing is conducted
    • can change to smaller sized tube, change to a fenestrated tube (tube with an opening in its bend), switch to a smaller tracheostomy button tube (helps keep windpipe open after larger trach tube is removed)
    • occlusive dressing over stoma-heals in days-wks
    • FiO2 gradually reduced intil PaO2 is 70-100, if < 70 give supplemental O2, financial reimbursement if <55 while awake and at rest
    • adequate PRO 25% of total daily intake or 1.2-1.5 g/kg/day
    • don't overfeed