PE, ARDS, pneumothorax

-Parenteral anticoagulant therapy

Upon diagnosis of a PE, the nurse expects to perform which therapeutic intervention for the patient?

ANS: B, C, E Hemoptysis, sharp chest pain, and hypotension all may be caused by pulmonary embolism and the pulmonary hypertension that results. Rather than wheezes, crackles usually occur along with a dry cough. pg 664

Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus (PE)? (Select all that apply.) a. Wheezes throughout lung fields b. Hemoptysis c. Sharp chest pain d. Flattened neck veins e. Hypotension f. Pitting edema

Monitoring the Patient's Response

-Monitor, evaluate, & document the patient's response to the ventilator. Assess VS, & listen to breath sounds every 30 to 60 minutes at first. Monitor respiratory parameters (capnography, pulse ox) & check ABG values. Assess breathing pattern- assess & record breath sounds- determine the need for suctioning by observing secretions for type, color, & amount. Assess area around the ET tube or trach. site at least every 4 hours for color, tenderness, skin irritation, & drainage & document findings.

amniotic fluid

An _____________ _______________ embolus carries a high mortality rate & occurs as a rare complication of childbirth, abortion, or amniocentesis.

-Use a lift sheet when moving or turning the patient in bed.

An older adult patient on anticoagulation therapy for a PE is somewhat confused & requires assistance with ADLs. Which instruction specific to this therapy does the nurse give to the UAP?

blood clots

Any substance can cause an embolism, but ______________ ___________ are the most common cause.

Diagnostic Assessment- ARDS-

Diagnosis of ARDS is established by a lowered partial pressure of arterial oxygen (Pao2) value, determined by arterial blood gas (ABG) measurements. The patient has a progressive need for higher levels of oxygen. He or she doesn't respond to high concentrations of oxygen (refractory hypoxemia) & often needs intubation & mechanical ventilation. -Sputum cultures obtained by bronchoscopy & by transtracheal aspiration are used to determine if a lung infection also is present. -Chest X-Ray may show diffuse haziness or a "whited-out" (ground-glass) appearance of the lung. An ECG rules out cardiac problems & usually shows no specific changes. -Hemodynamic monitoring with a pulmonary artery catheter helps diagnose ARDS. The pulmonary capillary wedge pressure (PAWP) is low to normal.

DRUG ALERT

Heparin comes in a variety of concentrations. Check the prescribed dose carefully & ensure the correct concentration is being used to prevent overdosing or underdosing. Enoxaparin (Lovenox) can be given only subcutaneously or intravenously, NOT INTRAMUSCULARLY.

Hemothorax

-A common problem occuring after blunt chest trauma or penetrating injuries. Simple- a blood loss of less than 1500 mL into the chest caviity; a massive hemothorax is a blood loss of more than 1500 mL. -If small, patient may have no symptoms;; With large patient may have respiratory distress. -Breath sounds are reduced on auscultation. -Percussion on the involved side produces a dull sound. Blood in the pleural space is visible on a chest x-ray & confirmed by thoracentesis. -Interventions focus on removing the blood in the pleural space to normalize breathing & to prevent infection. Anterior & posterior chest tubes are inserted to empty the pleural space. Closely monitor the chest tube drainage. Serial chest x-rays are used to determine treatment effectiveness. -An open thoracotomy is needed when there is initial blood loss of 1500 to 2000 mL from the chest or persistent bleeding at the rate of 200 mL/hr over 3 hours. Monitor VS, blood loss, & I&O. Assess patients' response to chest tubes & infuse IV fluids & blood as prescribed

Tension Pneumothorax

-A rapidly developing & life-threatening complication of blunt chest trauma, results from an air leak in the lung or chest wall. Air forced into the chest cavity causes complete collapse of the affected lung. Air that enters the pleural space during inspiration does not exit during expiration. As a result, air collects under pressure, compressing blood vessels & limiting blood return. This process leads to decreased filling of the heart & reduced cardiac output. *If not promptly detected & treated, tension pneumothorax is quickly fatal***** Causes include blunt chest trauma, mechanical ventilation with PEEP, closed-chest drainage (chest tubes) & insertion of central venous access catheter. Assessment findings: asymmetry of the thorax; tracheal movement away from the midline toward the unaffected side; respiratory distress; absence of breath sounds on one side; distended neck veins; cyanosis; hypertympanic sound on percussion over the affected side. -Is detectable on a chest x-ray. ABG assays show hypoxia & respiratory alkalosis. -A large bore needle is inserted by the HCP into the second intercostal space in the midclavicular line of the affected side as initial treatment for tension pneumonthorax. Then a chest tube is placed into the 4th intercostal space & the other end is attached to a water seal drainage system until the lung re-inflates.

Pulmonary Embolism

-Collection of particulate matter- solids, liquids, air- that enters venous circulation & lodges in pulmonary vessels. -Usually occurs when blood clot from a VTE in leg or pelvic vein breaks off; travels through vena cava into right side of heart. The clot then lodges in the pulmonary artery or within one or more of its branches. Platelets collect on the embolus, triggering the release of substances that cause blood vessel constriction. Widespread pulmonary vessel constriction & pulmonary hypertension impair gas exchange. Deoxygenated blood is moved into the arterial circulation, causing hypoxemia (low arterial blood oxygen level). -Large emobli obstruct pulmonary blood flow, leading to reduced oxygenation, pulmonary tissue hypoxia, & potential death. -Any substance can cause an embolism, but a blood clot is most common. -Fat, oil, air, tumor cells, amniotic fluid, foreign objections (broken IV catheters), injected particles, & infected clots or pus can enter a vein & cause PE. Fat emboli from fracture of a long bone & oil emboli from diagnostic procedures don't impede blood flow in the lungs; instead, they cause blood vessel injury & acute respiratory distress syndrome.

Interventions: Nonsurgical Management

-Focus on increasing gas exchange, improving lung perfusion, reducing risk for further clot formation, & preventing complications. -Priority nursing interventions include: implementing oxygen therapy, administering anticoagulation or fibrinolytic therapy, monitoring the patient's responses to the interventions & providing psychosocial support. -Oxygen therapy- critical for the patient with PE. Severely hypoxemic patient may need mechanical ventilation & close monitoring of ABG studies. -Monitor pt continually for any changes in status. VS, lung sounds, & cardiac & respiratory status @ least 1 to 2 hours.

Health Promotion & Maintenance

-Lifestyle changes can help reduce the risk for PE. -Stop smoking, esp women who use oral contraceptives. -Reduce weight -Become more physically active -If traveling or sitting for long periods, get up frequently & drink plenty of fluids. -Refrain from massaging/compressing leg muscles -For patients know to be at risk for PE, small doses of heparin, low molecular weight heparin, (or something similar) may be prescribed every 8 to 12 hours.

PREVENTING COMPLICATIONS

-Most problems- caused by the positive pressure from the ventilator. -Cardiac problems from MV include hypotension & fluid retention. Hypotension is caused by positive pressure that increases chest pressure & inhibits blood return to the heart. The decreased blood return reduces cardiac output, causing hypotension. Hypotension is most often seen in patients who are dehydrated or need high PIP for ventilation. Teach pt to avoid a Valsalva Maneuver (bearing down while holding the breath) -Lung problems- barotrauma (damage to the lungs by positive pressure); volutrauma (damage to the lung by excess volume delivered to one lung over the other); & acid-base imbalance. Barotrauma includes pneumothorax, subcutaneous emphysema, & pneumomediastinum. Patients at highest risk for barotrauma have chronic airflow limitation (CAL) have blebs or bullae, are on PEEP, have dynamic hyperinflation, or require high pressures to ventilate the lungs (because of "stiff" lungs as seen in acute respiratory distress syndrome [ARDS]). -GI & nutritional problems result from the stress of mechanical ventilation. Stress ulcers occur in many patients receiving mechanical ventilation. These ulcers complicate the nutritional status & b/c the mucosa is not intact, increase the risk for systemic infection. Changes in chest & abdominal cavity pressure can lead to a paralytic ileus. This problem reduces nutrient absorption through the GI system, requiring short-term parenteral nutritional support. -Monitor potassium, calcium, magnesium, & phosphate levels & replace them as prescribed. -Infections are a threat for the patient using a ventilator, especially ventilator-associated pneumonia (VAP). The ET or trach. tube bypasses the body's filtering process & provides a direct access for bacteria to enter the lower respiratory system. The artificial airway is colonized with bacteria within 48 hours, which promotes pneumonia development & increases morbidity. -Ventilator dependence is the inability to wean off the ventilator. This problem usually has physiologic basis but can be psychological. The longer a patient uses a ventilator, the more difficult is the weaning process because the respiratory muscles fatigue & can't assume breathing.

Health Promotion & Maintenance (ARDS)

-Nursing priority in the prevention of ARDS is early recognition of patients at high risk for the syndrome. Because patients who aspirate gastric contents are at great risk, closely asses & monitor those receiving tube feeding & those with problems that impair swallowing & gag reflexes. Follow meticulous infection control guidelines, including handwashing, invasive catheter & wound care, & Contact precautions.

Case Management- ARDS

-Phase 1: this phase includes early changes of dyspnea & tachypnea. Early interventions focus on supporting the patient & providing oxygen. -Phase 2- Patchy infiltrates form from increasing pulmonary edema. Interventions include mechanical ventilation & prevention of complications. -Phase 3- This phase occurs over days 2 through 10, & the patient has increasing hypoxemia that response poorly to high levels of oxygen. Interventions focus on delivering adequate oxygen, preventing complications, & supporting lungs. -Phase 4- Pulmonary fibrosis with progression occurs after 10 days. This phase is irreversible & is often called "late" or "chronic" ARDS. Patients who develop this stage & survive it will have some permanent lung damage. Interventions focus on preventing sepsis, pneumonia, & multiple organ dysfunction syndrome (MODS), as well as weaning the patient from the ventilator. The patient in this phase may be ventilator dependent for weeks to months.

COMMON CAUSES OF ACUTE LUNG INJURY

-Shock-Trauma-Serious nervous system injury- pancreatitis- fat & amniotic fluid emboli- pulmonary infections- sepsis- inhalation of toxic gases (smoke, oxygen)- pulmonary aspiration (esp. of stomach contents)- drug ingestion (heroin, opioids, aspirin)- hemolytic disorders- multiple blood transfusions- cardiopulmonary bypass- submersion in water with water aspiration (esp in fresh water)

Planning & Implementation

-WHEN A PATIENT HAS A SUDDEN ONSET OF DYSPNEA & CHEST PAIN, IMMEDIATELY NOTIFY RAPID RESPONSE TEAM!

INTERVENTIONS: DRUG THERAPY

-With anticoagulants may be prescribed to prevent embolus enlargement & to prevent new clots from forming. -Active bleeding, stroke & recent trauma are reasons to avoid this therapy. -Heparin- usually used unless PE is massive or occurs with hemodynamic instability. A fibrinolytic drug may then be used to break up the existing clot. -Review PT's PTT (aPTT) before therapy is started, every 4 hours when therapy begins, & daily thereafter. Therapeutic PTT values usually range between 1.5 and 2.5 times the control value for this health problem. -Fibrinolytic drugs- alteplase (Activase, tPA) used for PE when specific criteria are met- include massive PE (obstructing blood flow to a lobe or more than one segment) & hemodynamic instability in which BP can't be maintained w/o supportive measures. -Heparin therapy- usually continues for 5-10 days. A low-molecular-weight heparin (dalteparin or enoxaparin) is often used with the warfarin. -MONITOR INR DAILY* -THE ANTIDOTE FOR HEPARIN IS PROTAMINE SULFATE: THE ANTIDOTE FOR WARFARIN IS INJECTABLE PHYTONADIONE, VITAMIN K1. ANTIDOTES FOR FIBRINOLYTIC THERAPY INCLUDE CLOTTING FACTORS, FRESH FROZEN PLASMA, & AMINOCAPROIC ACID (AMICAR)

Weaning

-the process of going from ventilatory dependence to spontaneous breathing. The process is prolonged by complications.

Intervention: Surgical Management

2 surgical procedures: embolectomy & inferior vena cava filtration. Embolectomy is the surgical removal of the embolus from pulmonary blood vessels. May be performed when fibrinolytic therapy can't be used for a patient who has a massive or multiple large PE with shock. -AngioJet- special thrombectomy catheter that mechanically break up clots- allow effective reduction of clots with or without the use of thrombolytic drugs -Inferior vena cava filtration- with placement of a vena cava filter is a lifesaving measure by preventing further embolus formation for some patients. Some filters are removable, allowing filter placement before symptoms develop in patients who are at high risk for clots. These filters can be removed when the risk for clot formation decreases, or they can be left in place permanently.

ANS: A, B, C A client who is developing ARDS presents with a decrease in oxygen despite an increase in the fraction of inspired oxygen. Increased dyspnea goes along with the increased hypoxemia, as does anxiety. Chest pain is not specific to ARDS; although chest pain can occur with ARDS, it occurs with many other conditions as well. Pitting edema would not be an assessment factor that confirms ARDS. Clubbing occurs in chronic, not acute, respiratory conditions. pg 671

A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)? (Select all that apply.) a. Oxygen administered at 100%, PaO2 60 b. Increased dyspnea c. Anxiety d. Chest pain e. Pitting pedal edema f. Clubbing of fingertips

ANS: A Restlessness and confusion are clinical manifestations of hypoxemia. It is important that the nurse stay with the client, ensure that the oxygen is maintained, and attempt to calm the client. Because of the client's restlessness, the nurse cannot delegate care to the spouse. Requesting a sedative might adversely affect the client's respiratory status further. Restraining the client could increase restlessness and increase oxygen demand.

A client admitted with respiratory difficulty and decreased oxygen saturation keeps pulling off the oxygen mask. What action does the nurse take? a. Stays with the client and replaces the oxygen mask b. Asks the client's spouse to hold the oxygen mask in place c. Restrains the client per facility policy d. Contacts the health care provider and requests sedation

ANS: D When clients with respiratory problems are assessed, an arterial blood gas is needed for the most accurate assessment of oxygenation. No indications are known for a breathing treatment or an inhaler, nor does the nurse have enough information to know whether a chest x-ray is warranted.

A client is admitted owing to difficulty breathing. The nurse assesses the client's color, lung sounds, and pulse oximetry reading. The pulse oximetry is 90%. What is the nurse's next action? a. Give an intermittent positive-pressure breathing treatment. b. Administer a rescue inhaler. c. Call for a chest x-ray. d. Assess an arterial blood gas.

ANS: B The nurse should be concerned about possible pulmonary contusion. Interstitial hemorrhage accompanies pulmonary contusion. Bleeding may not be evident at the initial injury, but the client develops hemoptysis and decreased breath sounds up to several hours after injury as bleeding into the alveoli or airways occurs. The pulse oximetry reading is within normal limits and chest pain is expected with movement after chest trauma. Disorientation needs to be investigated, but does not take priority over a breathing problem.

A client is admitted to the emergency department several hours after a motor vehicle crash. The car's driver-side airbag was activated during the accident. Which assessment requires the nurse's immediate intervention? a. Disorientation b. Hemoptysis c. Pulse oximetry reading of 94% d. Chest pain with movement

ANS: C Orthopnea is the sensation of dyspnea or breathlessness in the supine position. Clients feel that they cannot catch their breath in the supine position and must rest or sleep in a semi-sitting position by placing pillows behind their backs or by using a reclining chair. The degree of breathlessness can be measured roughly by the number of pillows needed to make the client less dyspneic (e.g., one-pillow orthopnea, two-pillow orthopnea). With a client who has chronic respiratory problems, a minor increase in dyspnea may indicate a severe respiratory problem. Respiratory failure is a high risk. This client needs to stay in the hospital to be evaluated more completely. The client should not be instructed to try to lie flat, or to take a sleeping pill.

A client states, "At night, I usually need to sleep propped up on two pillows in the chair, but now it seems I need three pillows." What is the nurse's best response? a. "You should try to rest more during the day." b. "You should try to lie flat for short periods of time." c. "You need to stay in the hospital for further evaluation." d. "You can take medication at night so you can sleep."

ANS: D Alteplase is a fibrinolytic agent that dissolves formed clots. The drug has an impact on clots outside the pulmonary embolism, and the client is at great risk for hemorrhage and shock. The nurse should realize the potential for a severe problem and should call the health care provider immediately for orders. The other actions would not be appropriate first actions in this situation.

A client with a large pulmonary embolism is receiving alteplase (Activase). The nurse notes frank red blood in the Foley catheter drainage bag. What is the nurse's first action? a. Irrigate the Foley. b. Administer an antibiotic. c. Clamp the Foley. d. Notify the health care provider.

ANS: D The nurse should assess the client's oxygenation; however, this client's arterial blood gas documents that the client's hypoxia has resolved. At this time it is not necessary to increase the oxygen or administer a bronchodilator; both of these interventions would be appropriate if the client were hypoxic. The client with respiratory problems should not take an antianxiety medication as a first-line intervention, because this may decrease the respiratory rate and/or alertness. The best intervention at this time is to assist with relaxation techniques.

A client with dyspnea is becoming very anxious. An arterial blood gas (ABG) shows a PaO2 of 93 mm Hg. How does the nurse best intervene? a. Increase the oxygen. b. Administer an antianxiety medication. c. Administer a bronchodilator. d. Assist with relaxation techniques.

NS: B Clients with shortness of breath and decreased oxygen saturation must be monitored closely. Minimal involvement in activities is required if the client is severely short of breath. The nurse should continue to assess the client and can increase involvement in activities if shortness of breath subsides. The Rapid Response Team is not required. Clustering or spacing of activities does nothing to decrease the client's involvement, which is the cause of shortness of breath.

A client with severe respiratory insufficiency becomes short of breath during activities of daily living. Which nursing intervention is best? a. Call the Rapid Response Team. b. Decrease involvement in care until the episode is past. c. Cluster morning activities to provide long rest periods. d. Space out interventions to provide for periods of rest.

Rib Fracture

A common injury to the chest wall, often resulting from direct blunt trauma to the chest. -The force applied to the ribs fractures them & drives the bone ends into the chest. Thus there's a risk for deep chest injury, such as pulmonary contusion, pneumothorax, & hemothorax. -Patient has pain on movement & splints the chest defensively. Splinting reduces breathing depth & clearance of secretions. -Those with injuries to the first or second ribs, flail chest, seven or more fractured ribs, or expired volumes of less than 15 mL/kg often have a deep chest injury & a poor prognosis. -Management of uncomplicated rib fractures is simple b/c the fractured ribs reunite spontaneously. Main focus is to decrease pain so that adequate ventilation is maintained. An intercostal nerve block may be used if pain is severe. Analgesics that cause respiratory depression are avoided.

"It increases the time it takes for blood to clot, therefore preventing further clotting & improving blood flow"

A patient with a PE asks for an explanation of heparin therapy. What's the nurse's best response?

-Examine skin every 2 hours for evidence of bleeding.

A patient with a PE is receiving anticoagulant therapy. Which assessment related to the therapy does the nurse perform?

-Dobutamine (Dobutrex)

A patient with a massive PE has hypotension & shock, & is receiving IV crystalloids. However, the patient's cardiac output is not improving. The nurse anticipates an order for which drug?

Pulmonary Contusion

A potentially lethal injury, is a common chest injury & occurs most often with injuries caused by rapid deceleration during car crashes. -After a contusion, respiratory failure develops over time rather than immediately. Hemorrhage & edema occur in & between the alveoli, reducing both lung movement & the area available for gas exchange. The patient becomes hypoxemic & dyspneic. The bronchial mucosa is irritated & secretions increase. -Patients may be asymptomatic at first- these patients often have bloody sputum, decreased breath sounds, crackles, & wheezes. At first, the chest x-ray may show no abnormalities. A hazy opacity in the lobes or parenchyma may develop over several days. If there is no disruption of the parenchyma, bruise resorption often occurs without treatment. -Management includes maintenance of ventilation & oxygenation. Monitor central venous pressure (CVP) closely, & restrict fluid intake as needed. The patient in obvious respiratory distress may need mechanical ventilation with PEEP to inflate the lungs.

-PTT values for greater than 2.5 times the control &/or the pt for bleeding.

A pt is being treated with heparin therapy for a PE. The patient has the potential for bleeding with the administration of heparin. What does the nurse monitor in relation to the heparin therapy?

-52 mm Hg -<60 mm Hg ->50 mm Hg with a pH value of <7.3

Acute respiratory failure is classified by which critical values of Paco2?

Assessment

Assess for dyspnea (perceived difficulty breathing), the hallmark of respiratory failure. Evaluate dyspnea with a dyspnea assessment guide. Slowly progressive respiratory failure may first be noticed as dyspnea on exertion (DOE), for when laying down. The patient may have orthopnea, finding it easier to breathe in an upright position. With chronic respiratory problems, a minor increase in dyspnea may represent severe gas exchange problems. That's for a change in the patient's respiratory rate or pattern, a change in lung sounds, and manifestations of hypoxemia (pallor, cyanosis, increased heart rate, restlessness, confusion) and hypercarbia (high arterial blood levels of carbon dioxide). Pulse oximetry Michel decreased oxygen saturation, but an arterial blood gas (ABG) analysis is needed for the most accurate assessment of oxygenation.

CRITICAL RESCUE

Assess patients at risk for PE for the symptom cluster of distended neck veins, syncope, cyanosis, & hypotension. If this cluster is present, notify the Rapid Response Team.

Physical Assessment/Clinical Manifestion- ARDS

Assess the breathing of any patient at increased risk for ARDS. Determine whether increased work of breathing is present, as indicated by hyperpnea, noisy respirations, cyanosis, pallor, & retraction intercostally (between the ribs) or substernally (below the ribs). Document sweating, respiratory effort, & any change in mental status. *Abnormal lung sounds are not heard on auscultation because the edema occurs first in the interstitial space & not in the airways* Assess VS at least hourly for hypotension, tachycardia, & dysrhythmias.

Oxygenation failure

Chest pressure changes are normal in air move in and out without difficulty but does not oxygenate the blood sufficiently It occurs in the type of V cue mismatch in which air movement in oxygen intake (ventilation) are normal but lung blood flow (perfusion) is decreased. Many long disorders can cause I accidentally Shin failure problems include impaired diffusion of oxygen at the alveolar level, right to left shunting of blood in the pulmonary vessels, VQ mismatch, breathing air with a low oxygen level, and abnormal hemoglobin that fails to bind oxygen

Combined ventilatory and oxygenation failure

Combined ventilatory an oxygen ation failure involves hypoventilation. (Poor respiratory movements) impaired gas exchange at the alveolar capillary membrane results in poor diffusion of oxygen into arterial blood and carbon dioxide retention. The condition may or may not include poor lung perfusion. When long perfusion is not adequate VQ mismatch occurs in both ventilation and perfusion adequate. This type of respiratory failure leads to a more profound hypoxemia then either ventilatory failure oxygenation failure alone. A combination of ventilatory failure in oxygenation failure occurs in patients who have are abnormal lungs such as those who have any form of chronic bronchitis, have emphysema, or are having an asthma attack. the bronchioles and alveoli are diseased, causing oxygenation failure, and the work of breathing increases until the respiratory muscles cannot function effectively, causing ventilatory failure. Acute respiratory failure results. This process can also occur in patients who have cardiac failure along with respiratory failure.

Drug & Fluid Therapy= ARDS

Corticosteriods are used to manage ARDS b/c they decrease WBC movement, reduce inflammation, & stabilize capillary membranes. -Antibiotics are used to treat infections when organisms are identified.

Common Causes of Ventilatory Failure

Extrapulmonary Causes: Neuromuscular disorders: myasthenia gravis; guillain-barre syndrome; poliomyelitis. Spinal cord injuries affecting nerves to intercostal muscles; central nervous system dysfunction: stroke, increased intracranial pressure, meningitis; chemical depression: opioid analgesics, sedatives, anesthetics. Kyphoscoliosis, massive obesity, sleep apnea, external obstruction/constriction Intrapulmonary Causes: airway disease: COPD; ventilation-perfusion mismatch: pulmonary embolism, pneumothorax, ARDS, amyloidosis, pulmonary edema, iinterstitial fibrosis.

CHEST TRAUMA

First emergency approach to all chest injuries is ABC (airway, breathing, circulation) followed by rapid assessment & treatment of life-threatening conditions.

MANAGING HYPOTENSION

IV fluid therapy involves giving crystalloid solutions to restore plasma volume & prevent shock. Continuously monitor the ECG & pulmonary artery & central venous/right atrial pressures of the pt receiving IV fluids b/c increased fluids can worsen pulmonary hypertension & lead to right-sided HF. -Drug therapy with agents that increase myocardial contractility (positive inotropic agents) may be prescribed when IV therapy alone doesn't improve cardiac output. Common drugs: milrinone (Primacor) & dobutamine (Dobutrex). Assess cardiac status hourly during therapy. Vasodilators such as nitroprusside (Nipride, Nitropress) may be used to decrease pulmonary artery pressure if it's impeding cardiac contractility.

Acute respiratory distress syndrome

Is acute respiratory failure with these features: hypoxemia that even with 100% oxygen, decreased pulmonary compliance, non- cardiac - associated bilateral pulmonary edema, dyspnea, dense pulmonary infiltrates on x-ray. Often occurs after an acute lung injury as a traumatic event in people who had no pulmonary disease. The mortality rate is high even when intensive are used. The trigger is a systemic inflammatory response. The main site of injury in the long is the alveolar capillary membrane, which normally is permeable only to small molecules. It can be injured during sepsis, pulmonary embolism, shock, aspiration, or inhalation injury. When injured, this membrane becomes more permeable 2 large molecules, which allows debris, proteins, & Fluid into the alveoli. Lung tissue normally remains relatively dry, but in patients with ARDS, lung fluid increases & contains more proteins. Etiology & genetic risk-- has many causes! Nervous system injury, such as head or spinal trauma, strokes, tumors,& sudden increases in intracranial pressure, may cause massive sympathetic discharge. Systemic blood vessel constriction results& moves large volumes of blood into lung circulation. TRALI is mediated by inflammation. During transfusion, patients are exposed to plasma that contains foreign proteins & antibodies. This exposure activates WBCs & causes them to clump with these proteins, which then go to the lungs. The clumped material injures lung capillaries, causing capillary leak & inflammation. *Other factors produce ARDS by direct injury to the lung. For EXAMPLE: aspiration of acidic gastric contents may obstruct or burn the airway. This type of direct injury destroys type I pneumocytes. Injured capillaries allow protein & cells to escape from the blood vessels into lung tissues. -Trauma, sepsis, drowning, & burns also cause the release of proteins (thromboplastins) that form fibrin clots in the blood. These clots, together with platelets & leukocytes, are filtered out in the lung. In many causes of ARDS, esp. after trauma, clot production is increased & fibrinolysis (clot breakdown) is reduced. As a result, small emboli remain in the lung.

ACUTE RESPIRATORY FAILURE

Is classified by blood gas abnormalties. Critical values are partial pressure of arterial oxygen (Pao2) less then 60 mm Hg, arterial oxygen saturation (Sao2) less than 90%, or partial pressure of arterial carbon dioxide (Paco2) more than 50 mm Hg occurring with acidemia (pH <7.30) Whatever the underlying problem, the patient in acute respiratory failure is always hypoxemic (has low arterial blood oxygen levels).

ANS: A Airway and breathing are the top priority. The nurse would also need to monitor for bleeding when administering fibrinolytic therapy, and would monitor the IV site as well. Teaching the client is also a need, however. Oxygenation is the highest priority.

It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic therapy is initiated. What is the nurse's priority action? a. Monitor the client's oxygenation. b. Teach the client about potential side effects. c. Monitor the IV insertion site. d. Monitor for bleeding.

Common causes of oxygenation failure

Low atmospheric oxygen concentration: high altitudes, closed spaces, smoke inhalation, carbon monoxide poisoning Pneumonia, CHF with pulmonary edema, pulmonary embolism, acute respiratory distress syndrome, interstitial pneumonitis- fibrosis, abnormal hemoglobin, hypovolemic shock, hypoventilation, complications of nitroprusside therapy: thiocyanate toxicity, methemoglobinemia

Tracheobronchial Trauma

Most tears of the tracheobronchial tree result from severe blunt trauma or rapid deceleration & often involve the mainstem bronchi. Injuries to the trachea usually occur at the junction of the trachea & cricoid cartilage, often by striking the neck against the dashboard or steering wheel during a car crash. -Patients with tracheal lacerations develop massive air leaks, which cause air to enter the mediastinum & leads to extensive subcutaneous emphysema. Upper airway obstruction may occur, causing severe respiratory distress & stridor. Large tracheal tears require cricothyroidotomy or tracheotomy below the level of injury. A patient with a torn mainstem bronchus may develop a tension pneumothorax rapidly when intubated & ventilated with positive pressure. -Assess for hypoxemia by AB assays. Apply oxygen as needed. Depending on degree of injury, patient may need mechanical ventilation or surgical repair. Assess VS every 15 minutes because hypotension & shock are likely Assess for subcutaneous emphysema & listen to the lungs every 1 to 2 hours. Decreased breath sounds or wheezing may indicate further obstruction, atelectasis, or pneumonthorax.

Pneumothorax

Often caused by blunt chest trauma & may occur with some degree of hemothorax. Can also occur as a complication of medical procedures. Can be open (pleural cavity is exposed to outside air, as through an open wound in the chest wall) or closed (such as when a patient with COPD has a spontaneous pneumothorax). Assessment findings commonly include: -Reduced breath sounds on auscultation; hyperresonance on percussion; prominence of the involved side of the chest, which moves poorly with respirations; deviation of the trachea away from (closed) or toward (open) the affected side. Patient may have pleuritic pain, tachypnea, & subcutaneous emphysema (air under the skin in the subcutaneous tissues). -An ultrasound exam or a chest x-ray is used for diagnosis. Chest tubes may be needed to allow the air to escape & the lung to re-inflate.

INTERVENTIONS- ARDS

Often needs intubation & conventional mechanical ventilation with positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP). Airway pressure-release ventilation (APRV) & high-frequency oscillatory ventilation are alternative modes of mechanical ventilation that improve oxygenation & ventilation in patients with moderate to severe ARDS. -Sedation & paralysis may be needed for adequate ventilation & to reduce tissue oxygen needs. -Side effects of PEEP is tension pneumothorax, assess lung sounds hourly & suction as often as needed to maintain a patent airway.

Interventions

Oxygen therapy is appropriate for any patient with acute hypoxemia. It is use in acute respiratory failure to keep the arterial oxygen (Pao2) level above 60 mm Hg while treating the cause of the respiratory failure. Drugs given systemically or by metered dose inhaler to widen the bronchioles and decrease inflammation to promote gas exchange. Encourage deep breathing and other breathing exercises.

Minimizing Bleeding

Priority nursing actions are ensuring that appropriate antidotes are present on the nursing unit, protecting the patient from situations that could lead to bleeding, & monitoring closely the amount of bleeding that's occurring. -Assess at least every 2 hours for evidence of bleeding. Stools, urine, drainage, & vomitus for gross blood, & test for occult blood.

Major Risk Factors for VTE leading to PE:

Prolonged immobility; central venous catheter; surgery; obesity; advancing age; conditions that increase blood clotting; history of thromboembolism. -In addition, smoking, pregnancy, estrogen therapy, HF, stroke, cancer (lung or prostate), Trouseau's syndrome, & trauma increase the risk for VTE & PE.

Clinical Manifestations

Respiratory manifestations- dyspnea, sudden onset; sharp stabbing chest pain (pleuritc chest pain) Breath sounds may be normal, but crackles usually occur. Dry cough is present. Hemoptysis (bloody sputum) may result from pulmonary infarction. Cardiac Manifestations: tachycardiac, distended neck veins, syncope (fainting or loss of consciousness), cyanosis, & hypotension. Systemic hypotension results from acute pulmonary hypertension & reduced forward blood flow. Abnormal heart sounds, such as an S3 or S4 may occur. ECG findings are abnormal, nonspecific, & transient. T-wave & ST-segment changes occur. Miscellaneous manifestations: low grade fever & petechiae on the skin over the chest & in the axillae. IT'S IMPORTANT TO REMEMBER THAT MANY PATIENTS WITH PE DON'T HAVE THE "CLASSIC" MANIFESTATIONS BUT INSTEAD HAVE VAGUE SYMPTOMS RESEMBLING THE FLU, SUCH AS NAUSEA, VOMITING, & GENERAL MALAISE.

Mechanical Ventilation

Support & maintain gas exchange -Purpose- to improve gas exchange & to decrease the work needed for effective breathing. IT's used to support the patient until lung function is adequate or until the acute episode has passed. -A VENTILATOR DOES NOT CURE DISEASED LUNGS; IT PROVIDES VENTILATION UNTIL THE PATIENT CAN RESUME THE PROCESS OF BREATHING. *TYPES OF VENTILATORS* Most- positive pressure ventilators. During inspiration, pressure is generated that pushes air into the lungs & expands the chest. Usually an ET tube or tracheostomy is needed. Positive-pressure ventilators are classified by the mechanism that ends inspiration & starts expiration. Inspiration is cycled in 3 major ways: pressure-cycled, time-cycled; or volume cycled. -Pressure cycled ventilators push air into the lungs until a preset airway pressure is reached. Used for short-periods such as just after surgery & for respiratory therapy. Bi-level positive airway pressure (Bi-PAP) ventilators are a modern form of pressure-cycled ventilator in which the ventilator provides a preset inspiratory pressure & an expiratory pressure similar to positive end-expiratory pressure (PEEP). -Time-cycled ventilators push air into the lungs until a preset time has elapsed. TV & pressure vary. -Volume-cycled ventilators- push air into the lungs until a preset volume is delivered. A constant tidal volume is delivered regardless of the pressure needed to deliver the tidal volume. a set pressure limit, however, prevents excessive pressure from being exerted on the lungs. -Microprocessor ventilators- computed managed positive pressure ventilators- a computer is built into the ventilator to allow ongoing monitoring of ventilatory functions, alarms, & patient conditions. These are more responsive to patient who have severe lung disease & those who need prolonged weaning trials. *MODES OF VENTILATION* Assist-control (AC) ventilation- used often as a resting mode. Ventilator takes over the work of breathing for the patient. Tidal volume & ventilatory rate are preset. If patient doesn't have spontaneous breaths, a ventilatory pattern is established by the ventilator. Disadvantage- the ventilator continues to deliver a preset tidal volume even when the patient's spontaneous breathing rate increases. This can cause hyperventilation & respiratory alkalosis. -Synchronized intermittent mandatory ventilation (SIMV)- similar to AC in that tidal volume & ventilatory rate are preset. If patient doesn't breathe, a ventilatory pattern is established by the ventilator. SIMV allows spontaneous breathing at the patient's own rate & tidal volume between the ventilator breaths. Can be used as a main ventilatory mode or as a weaning mode. Bi-Level positive airway pressure (BiPAP)- provides noninvasive pressure suppose ventilation by nasal mask or face-mask. Most often used for patients with sleep apnea, but may also be used for patients with respiratory muscle fatigue to avoid more invasive ventilation methods. -VENTILATOR CONTROLS & SETTINGS- Tidal Volume (Vt)- the volume of air the patient receives with each breath, as measured on either inspiration or expiration. average between 7 & 10 mL/kg of body weight. Fraction of inspired oxygen (Fio2)- the oxygen level delivered to the patient. Prescribed Fio2 is based on the ABG values & patient's condition. Peak airway (inspiratory) pressure (PIP) the pressure used by the ventilator to deliver a set tidal volume at a given lung compliance. Appears on the display of the ventilator. It's the highest pressure reached during inspiration. An increased PIP reading means increased airway resistance in the patient or in the ventilator tubing (bronchospasm or pinched tubing), increased secretions, pulmonary edema, or decreased pulmonary compliance (the lungs or chest wall is "stiffer" or harder to inflate). An upper pressure limit is set to prevent barotrauma. When limit is reached, the high-pressure alarm sounds & the remaining volume is not given. CPAP- applies positive airway pressure throughout the entire respiratory cycle for spontaneously breathing patients. CPAP keeps the alveoli open during inspiration & prevents alveolar collapse during expiration. This process increases functional residual capacity (FRC) & improves oxygenation. Commonly used to help in the weaning process. PEEP- positive pressure exerted during expiration. PEEP improves oxygenation by enhancing gas exchange & preventing atelectasis. It's used to treat persistent hypoxemia that doesn't improve with an acceptable oxygen delivery level. It may be added when the arterial oxygen pressure (Pao2) remains low with an Fio2 of 50% to 70% or greater. Need for PEEP indicates a severe gas-exchange problem. IT'S IMPORTANT TO LOWER THE FIO2 DELIVERED WHENEVER POSSIBLE B/C PROLONGED USE OF A HIGH FIO2 CAN DAMAGE LUNGS FROM THE TOXIC EFFECTS OF OXYGEN. -PEEP prevents alveoli from collapsing because the lungs are kept partially inflated so that alveolar-capillary gas exchange is promoted throughout the ventilatory cycle. -PEEP- "dialed in" on the control panel. Amount is usually 5 to 15 cm H20 & is monitored on the peak airway pressure dial. -Flow Rate is how fast each breath is delivered & is usually set at 40 L/min. If patient is agitated or restless, has a widely fluctuating inspiratory pressure reading, or has other signs of air hunger, the flow may be set too low. Increasing the flow should be tried before using chemical restraints. *NURSING MANAGEMENT* When caring for a ventilated pt, be concerned with the patient first & the ventilator second. Vital to understand why mechanical ventilation is needed- causes such as excessive amounts of secretions, sepsis, & trauma require different interventions for ventilator independence.

ANS: D Increasing restlessness in a client being mechanically ventilated may mean that the client is not receiving sufficient oxygen. It can also be a manifestation of pain. When in doubt, determining the adequacy of ventilation has the highest priority. The nurse would not sedate the client until the cause of the restlessness has been addressed. The nurse would call the provider if the cause could not be determined and addressed, or if the client's status deteriorated.

The client receiving mechanical ventilation has become more restless over the course of the shift. Which is the nurse's first action? a. Sedate the client. b. Call the health care provider. c. Assess the client for pain. d. Assess the client's oxygenation.

Laboratory Assessment & Imaging

The hyperventilation triggered by hypoxia & pain first leads to respiratory alkalosis, indicated by low partial pressure of arterial carbon dioxide (Paco2) values on arterial blood gas (ABG) analysis. The Pao2-Fio2 (fraction of inspired oxygen) ratio falls as a result of "shunting" of blood from the right side of the heart to the left without picking up oxygen from the lungs. Shunting causes the Paco2 level to rise, resulting in respiratory acidosis. Later, metabolic acidosis, results from buildup of lactic acid due to tissue hypoxia. -A chest x-ray- may show a PE if it's large. Some lung infiltration may be present around the embolism site. -CT scans are most often used to diagnose PE. -A newer diagnostic method is high-resolution multidetector computer tomographic angiography (MDCTA)- very specific -Transedophageal echocardiography (TEE)- help detect PE. -Doppler ultrasound or impedance plethysmography (IPG) may be used to document the presence of VTE & to support a diagnosis of PE.

Flail Chest

The inward movement of the thorax during inspiration, with outward movement during expiration. It often involves one side of the chest & results from multiple rib fractures caused by blunt chest trauma leaving a segment of the chest wall loose, often as a result of high-speed car crashes. -More common in older patients & has a high mortality rate. -Movement of this loose segment becomes opposite of the expansion & contraction movement of the rest of the chest wall. Flail chest can also occur from bilateral separations of the ribs from their cartilage connections to each other anteriorly, without an actual rib fracture. This condition can occur during cardiopulmonary resuscitation on an older adult. Other injuries to the lung tissue under the flail segment may be present. Gas exchange, coughing, & clearance of secretions are impaired. -Assess the patient with a flail chest for paradoxic chest movement, dyspnea, cyanosis, tachycardia, & hypotension. -Paradoxic chest movement is the "sucking inward" of the loose chest area during inspiration & a "puffing out" of the same area during expiration. -Interventions include humidified oxygen, pain management, promotion of lung expansion through deep breathing & positioning, & secretion clearance by coughing & tracheal aspiration. Patient with a flail chest may be managed with vigilant respiratory care. Mechanical ventilation is needed if respiratory failure or shock occurs. Monitor ABG values & vital capacity closely. With severe hypoxemia & hypercarbia, the patient is intubated & mechanically ventilated with PEEP. -With lung contusion or an underlying pulmonary disease, the risk for respiratory failure increases. Usually flail chest is stabilized by positive-pressure ventilation. -Monitor patient's VS & fluid & electrolyte balance closely so the hypovolemia or shock can be managed immediately. If he or she has a lung contusion, monitor central venous pressure (CVP) & give IV fluids as prescribed. Assess for & relieve pain with prescribed analgesic drugs by IV, epidural or nerve block route.

ANS: C Blunt chest trauma can cause an air leak into the thoracic cavity, collapsing the lung on the side with the air leak (pneumothorax). More air enters the pleural space with each breath, increasing intrathoracic pressure on the affected side, moving the trachea to the unaffected side, and leading to decreased cardiac output. This condition (tension pneumothorax) is life threatening without intervention. The client will need oxygen administration right away and a chest tube inserted

The nurse assesses a client admitted for chest trauma who reports dyspnea. The nurse finds tracheal deviation and a pulse oximetry reading of 86%. What is the nurse's priority intervention? a. Notify the health care provider and document the symptoms. b. Intubate the client and prepare for mechanical ventilation. c. Administer oxygen and prepare for chest tube insertion. d. Administer an intermittent positive-pressure breathing treatment.

ANS: C Puffiness of the skin around the chest tube and a crackling feeling indicate subcutaneous emphysema, or air leaking into the tissue around the insertion site. This must be addressed immediately. A hemothorax involves bleeding into the thoracic cavity and decreased lung inflation on the affected side, resulting in duller and less resonant percussion notes. Pain at the insertion site, fluctuation in the water seal, and dullness to percussion are all expected.

The nurse assesses a client who has a hemothorax and a chest tube inserted on the right side. What finding requires immediate attention? a. Pain at the chest tube insertion site b. Fluctuation in the water seal chamber with breathing c. Puffiness of the skin around the chest tube insertion site and a crackling feeling d. Dullness to percussion on the affected side

ANS: C This client has a flail chest characterized by paradoxical chest wall motion. With the oxygen saturation dropping, the client is at high risk for respiratory failure and needs to be intubated. Deep-breathing exercises are not enough at this point. Rib binders are not used anymore because they limit chest wall expansion and were used only for simple rib fractures.

The nurse assesses a client who suffered chest trauma and finds that the left chest sucks in during inhalation and out during exhalation. The client's oxygen saturation has dropped from 94% to 86%. What is the priority action by the nurse? a. Encourage the client to take deep, controlled breaths. b. Document findings and continue to monitor the client. c. Notify the health care provider and prepare for intubation. d. Stabilize the chest wall with rib binders.

ANS: C The endotracheal tube is more likely to slip into the right mainstem bronchus, leading to the breath sounds described. The nurse should assess placement of the ET tube by assessing where the markings are, making sure it is taped, and confirming equal breath sounds bilaterally. If it is believed that the tube has slipped into the right mainstem bronchus, the health care provider should order a chest x-ray and reposition the tube.

The nurse auscultates the lungs of a client on mechanical ventilation and hears vesicular breath sounds throughout the right side but decreased sounds on the left side of the chest. What is the nurse's best action? a. Turn the client to the right side. b. Elevate the head of the bed. c. Assess placement of the endotracheal (ET) tube. d. Suction the client.

ANS: D This client has the most severe hypoxia and respiratory alkalosis, indicated by low partial pressure of arterial carbon dioxide (PaCO2) values on ABG analysis.

The nurse is assessing arterial blood gases (ABGs). The client with which ABG reading requires the nurse's immediate attention? a. pH, 7.32; PaCO2, 55 mm Hg; PaO2, 70 mm Hg b. pH, 7.45; PaCO2, 42 mm Hg; PaO2, 70 mm Hg c. pH, 7.48; PaCO2, 38 mm Hg; PaO2, 60 mm Hg d. pH, 7.55; PaCO2, 32 mm Hg; PaO2, 50 mm Hg

ANS: A, C, F Reasons for a high-pressure alarm include water or a kink impeding airflow or mucus in the airway. The nurse first should assess the client and determine whether he or she needs to be suctioned; then the nurse should auscultate the lungs. The nurse also should assess the tubing for kinks. The high-pressure alarm sounding would not be a reason to call the health care provider or the Rapid Response Team. If the tubing became disconnected, the low-pressure alarm would sound.

The nurse is caring for a client on a ventilator when the high-pressure alarm sounds. What actions are most appropriate? (Select all that apply.) a. Assess the tubing for kinks. b. Assess whether the tubing has become disconnected. c. Determine the need for suctioning. d. Call the health care provider. e. Call the Rapid Response Team. f. Auscultate the client's lungs.

ANS: D The client who is being treated for pulmonary embolism usually continues on heparin and warfarin until the INR reaches a therapeutic level between 2 and 3. Heparin can then be discontinued because warfarin is therapeutic.

The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary embolus. The client's international normalized ratio (INR) is 2.0. What is the nurse's best action? a. Increase the heparin dose. b. Increase the warfarin dose. c. Continue the current therapy. d. Discontinue the heparin.

ANS: D The client who is intubated needs nutrition delivered via enteral tube feeding. If nutrition is ignored, the client's respiratory status can deteriorate, because respiratory muscle function can deteriorate.

The nurse is caring for a client who has been intubated and placed on a ventilator for treatment of acute respiratory distress syndrome (ARDS). Aside from assessing oxygenation, what is the nurse's priority action? a. Assess hemoglobin. b. Administer ferrous sulfate. c. Assess muscle strength. d. Consult with the registered dietitian.

ANS: A If the client has the cuff on the endotracheal tube inflated, the cuff should prevent air from going around the cuff and through the vocal cords. If the client can talk with the cuff inflated, the cuff probably has a leak, causing it to become deflated and allowing air to pass through. The risk is that the client will not receive the prescribed tidal volume.

The nurse is caring for a client who is intubated with an endotracheal tube and on a mechanical ventilator. The client is able to make sounds. What is the nurse's first action? a. Check cuff inflation on the endotracheal tube. b. Listen carefully to the client. c. Call the health care provider. d. Auscultate the lungs.

ANS: A Increased intrathoracic pressure can inhibit blood return to the heart and cause decreased cardiac output. This manifests with a drop in blood pressure. The pulse oximetry reading, ABGs, and urinary output are all normal.

The nurse is caring for a client who is receiving mechanical ventilation accompanied by positive end-expiratory pressure (PEEP). What assessment findings require immediate intervention? a. Blood pressure drop from 110/90 mm Hg to 80/50 mm/Hg b. Pulse oximetry value of 96% c. Arterial blood gas (ABG): pH, 7.40; PaO2, 80 mm Hg; PaCO2, 45 mm Hg; HCO3-, 26 mEq/L d. Urinary output of 30 mL/hr

ANS: D A requirement for using CPAP is that the client will be able to breathe spontaneously. Antianxiety and sleep medications should not be administered to the client during weaning. Telling the client to relax may be helpful in some cases but does not take priority over ensuring the client's ability to breathe spontaneously.

The nurse is caring for a client who is taken off a ventilator and placed on continuous positive airway pressure (CPAP). What intervention is most appropriate for this client? a. Administering antianxiety medications PRN b. Administering a medication to help the client sleep c. Telling the client to relax and let the ventilator do the work d. Making sure the client is breathing spontaneously

ANS: A, D Both antiembolism stockings (or sequential pressure devices) and a turning schedule can help prevent venous thromboembolism, which can lead to PE. Massaging the calves is discouraged because this can cause a clot to break loose and travel to the lungs. Legs should be elevated when in bed, and the client should perform active range of motion (ROM) if able. If the client is unable to perform active ROM, the nurse should provide passive ROM. pg 663

The nurse is caring for a client with a high risk for pulmonary embolism (PE). Which prevention measures does the nurse add to the client's care plan? (Select all that apply.) a. Use antiembolism stockings. b. Massage calf muscles per client request. c. Maintain supine position with the legs flat. d. Turn every 2 hours if client is in bed. e. Refrain from active range-of-motion exercises.

ANS: B Urinary output is very low; this could indicate that the client has decreased cardiac output. The nurse will need to intervene and notify the health care provider. A respiratory rate that is slightly elevated is expected in this condition. Likewise, a heart rate that is a little higher is expected in this situation. A dry cough is also commonly found with pulmonary embolus.

The nurse is caring for a client with a pulmonary embolus who also has right-sided heart failure. Which symptom will the nurse need to intervene for immediately? a. Respiratory rate of 28 breaths/min b. Urinary output of 10 mL/hr c. Heart rate of 100 beats/min d. Dry cough

ANS: B Clients who are being mechanically ventilated are experiencing a problem in that their normal ventilation is not adequate. The recommended position for clients who have one lung more affected by a problem than the other lung is to place the "good lung down," keeping the healthier lung dependent to the less healthy lung. Such positioning allows gravity to keep more blood in the lower lung (healthier lung) and better ventilation in the upper lung, thus helping a ventilation/perfusion mismatch. Antibiotics are not prescribed for this disorder. The pilot balloon line should be inflated to ensure that the cuff is inflated, keeping the endotracheal tube in place and directing ventilated air into the lungs. The client with an endotracheal tube that is nonfenestrated, with the cuff inflated, will not be able to speak. Communication is addressed in other ways.

The nurse is caring for a client with a ventilation/perfusion mismatch who is receiving mechanical ventilation. Which intervention is a priority for this client? a. Administering antibiotics every 6 hours b. Positioning the client with the "good lung dependent" c. Making sure that the pilot balloon line on the endotracheal tube is deflated d. Ensuring that the client is able to speak clearly

ANS: C One of the biggest risks in the client with ARDS on mechanical ventilation with PEEP is tension pneumothorax. The nurse needs to assess lung sounds hourly. The alarms on a ventilator should never be turned off. If the client needed to be suctioned, the high-pressure alarm would sound. Changing the client's position would not change the pressure needed to administer a breath.

The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation and positive end-expiratory pressure (PEEP). The alarm sounds, indicating decreased pressure in the system. What is the nurse's best action? a. Change the client's position. b. Suction the client. c. Assess lung sounds. d. Turn off the pressure alarm.

-Pulse ox of 95% -Absence of pallor or cyanosis -Mental status at pt's baseline

The nurse is caring for a patient with a post-op complication of PE. The pt has been receiving treatment for several days. Which factors are indications of adequate perfusion in the patient?

ANS: A The client's immediate need is to have oxygen applied. The nurse should then assess the client's pulse oximetry.

The nurse is caring for a postoperative client who suddenly reports difficulty breathing and sharp chest pain. After notifying the Rapid Response Team, what is the nurse's priority action? a. Elevate the head of the bed and apply oxygen. b. Listen to the client's lung sounds. c. Pull the call bell out of the wall socket. d. Assess the client's pulse oximetry.

ANS: C The older adult who has aspirated a tube feeding is at high risk and should be assessed closely for the possibility of ARDS. A client with COPD and a middle-aged client with no other risk factors are not at as high a risk for ARDS. The client who has a broken leg from an accident is not at high risk.

The nurse is caring for several clients on the respiratory floor. Which client does the nurse assess most carefully for the development of acute respiratory distress syndrome (ARDS)? a. Older adult with COPD b. Middle-aged client receiving a blood transfusion c. Older adult who has aspirated his tube feeding d. Young adult with a broken leg from a motorcycle accident

-Recurrent bleeding while receiving anticoagulants

The nurse is caring for several patients at risk for DVT & PE. Which condition causes the patient to be the most likely candidate for placement of a vena cava filter?

-Start passive & active range-of-motion exercises for the extremities. -Ambulate postop. patients soon after surgery. -Use anti-embolism devices post op. -Administer drugs to prevent episodes of Valsalva maneuver.

The nurse is caring for several post op patients at risk for developing PE. Which interventions does the nurse use to help prevent the development of PE in these patients?

-Sudden dry cough

The nurse is caring for several post op patients with high risk for a PE. All of these patients have pre-existing chronic respiratory problems. What's a unique assessment finding for a clot in the lung?

ANS: C, D, E The nurse should assess the client when an alarm sounds and should intervene accordingly. The nurse should also check the settings to make sure they are correct and should evaluate the water level to make sure the humidifier does not go dry. The nurse would not be responsible for changing ventilator settings, weaning the client, or changing the ventilator tubing.

The nurse is prioritizing care for a client on a ventilator. What are essential nursing interventions for this client? (Select all that apply.) a. Change the settings in accordance with provider orders. b. Modify the settings for weaning the client. c. Assess the reasons for alarms. d. Compare the ventilator settings with ordered settings. e. Assess the water level in the humidifier. f. Change the ventilator tubing according to hospital policy.

ANS: D An increase in peak inspiratory pressure (PIP) in the ARDS client is indicative of decreased lung compliance, making it more difficult to ventilate diseased lungs. The nurse first should assess the airway to make sure no sputum is present in the airway and that no kinks are noted in the tubing. The nurse is not able to make changes in the ventilator settings, so an order is needed to increase inspiratory pressure to oxygenate the client. Suctioning or performing chest physical therapy (PT) will not help the client's lung compliance; however, if mucus is impeding the airway, these interventions would be necessary and would be noticed when the airway is assessed. Administering a bronchodilator may help the client; however, an inhaler could not be used by a client on a ventilator.

The nurse notes that each time the mechanical ventilator delivers a breath to a client with acute respiratory distress syndrome (ARDS), the peak inspiratory pressure alarm sounds. What is the nurse's best intervention? a. Suction the client. b. Perform chest physiotherapy. c. Administer an inhaler. d. Assess the airway.

-Spiral CT scan

The nurse suspects a pt has a PE & notifies the physician who orders an arterial blood gas. The physician is en route to the facility. The nurse anticipates & prepares the patient for which additional diagnostic test?

-Drink water; get up every hour for @ least 5 minutes during the flight.

The nurse's young neighbor who smokes is going on an overseas flight. The neighbor knows he's at risk for DVT & PE, & asks the nurse for advice. What does the nurse suggest?

-Ventilatory failure -Oxygenation failure -Combination of ventilatory & oxygenation failure

Which conditions define respiratory failure?

Endotracheal Intubation

The patient who needs mechanical ventilation must have an artificial airway. -Most common type of airway for a short-term basis ET tube. -A tracheostomy is considered if an artificial airway is needed for longer than 10 to 14 days to reduce tracheal & vocal cord damage. The purposes of intubation are to maintain a patent airway, provide a means to remove secretions, & provide ventilation & oxygen. ET tube- passed through the mouth or nose & into the trachea. The cuff at the distal end of the tube is inflated after placement & can create a seal between the trachea & the cuff. The seal ensures delivery of a set tidal volume when mechanical ventilation is used. When the cuff is inflated to an adequate sealing volume, a minimal amount of air can pass around the cuff to the vocal cords, nose, or mouth. The patient can't talk when the cuff is inflated. The cuff should be inflated using a minimal-leak technique. -The pilot balloon with a one-way valve permits air to be inserted into the cuff & prevents air from escaping. This balloon is a guide for determining when air is present in the cuff but not how much or how little air is present. *PREPARING FOR INTUBATION* Basic life support measures, such as obtaining a patent airway & delivering 100% oxygen by a manual resuscitation bag with a facemask, are crucial to survival until help arrives. During intubation, the nurse coordinates the response & continuously monitors for changes in VS, signs of hypoxia or hypoxemia, dysrhythmias, & aspiration. *VERIFYING TUBE PLACEMENT* Immediately after an ET tube is inserted, placement should be verified. The most accurate ways to verify placement are by checking end-tidal carbon dioxide levels & by chest x-ray. Assess for breath sounds bilaterally, symmetric chest movement, & air emerging from the ET tube. If breath sounds & chest wall movement are absent on the left side, the tube may be in the right main-stem bronchi. *STABILIZING THE TUBE* Stabilizes the ET tube at the mouth or nose. The tube is marked at the level where it touches the incisor tooth or naris. -An oral airway also may be inserted or a commercial bite block placed to keep the patient from biting an oral ET. -After the procedure is completed, verify & document the presence of bilateral & equal breath sounds & the level of the tube. *NURSING CARE* Complications of an ET or nasotracheal tube can occur during placement, while in place, during extubation, or after. Trauma & other problems can occur to the face; eye; nasal & paranasal areas; oral, pharyngeal, bronchial, tracheal, & pulmonary areas; esophageal & gastric areas; & cardiovascular, musculoskeletal & neurologic systems.

-Recent cerebral hemorrhage

The physician orders heparin therapy for a patient with a relatively small PE. The patient states, "I didn't tell the doctor my complete medical history." Which condition may affect the physician's decision to immediately start heparin therapy?

ANS: B The pilot balloon indicates whether the endotracheal tube cuff is inflated or deflated. A deflated balloon means that the cuff is also deflated and a seal is no longer present around the tube to prevent air from escaping. Thus, some of the air being moved into the client's airway by the ventilator is escaping through the client's trachea before it reaches the lower airways and alveoli. The nurse should inflate the cuff. Calling the Rapid Response Team is not necessary, and increasing tidal volume will not improve oxygenation if the cuff is leaking.

The pilot balloon on the endotracheal tube of a client being mechanically ventilated is deflated. What is the nurse's priority action? a. Nothing; this is required during ventilation. b. Inflate the cuff using minimal leak technique. c. Call the Rapid Response Team. d. Increase the tidal volume.

ANS: C A widely fluctuating pressure reading is one indication of inadequate airflow and oxygenation. The nurse's priority is to check the client's oxygenation status. If oxygenation is inadequate, the nurse would assess for a cause while manually ventilating the client and calling for assistance.

The pressure reading during inspiration on the ventilator of a client receiving mechanical ventilation is fluctuating widely. What is the nurse's first action? a. Determine whether an air leak is present in the client's endotracheal tube cuff. b. Have the respiratory therapist check the pressure settings. c. Assess the client's oxygenation. d. Manually ventilate the client with a resuscitation bag.

Managing the Ventilator System

Ventilator settings are prescribed by the physician in conjunction with the respiratory therapist. Settings include: tidal volume, respiratory rate, fraction of inspired oxygen (Fio2), & mode of ventilation (assist-control, synchronized, etc). -Remove any condensation in the ventilator tubing by draining water into drainage collection receptacles & empty them every shift. **TO PREVENT BACTERIAL CONTAMINATION, DON'T ALLOW MOISTURE & WATER IN THE VENTILATOR TUBING TO ENTER THE HUMIDIFIER. *ALARMS* - IF CAUSE OF THE ALARM CAN'T BE DETERMINED, VENTILATE THE PATIENT MANUALLY WITH A RESUSCITATION BAG UNTIL THE PROBLEM IS CORRECTED BY ANOTHER HEALTH CARE PROFESSIONAL. Maintain a patent airway by suctioning when these are present: secretions; increased peak airway (inspiratory) pressure (PIP); rhonchi (wheezes); decreased breath sounds.

-Trauma -HF -Cancer (particularly lung or prostate)

What are the risk factors for pulmonary embolism (PE) & DVT?

ANS: A The nurse should have the client point to words on a board to communicate needs. The endotracheal tube is positioned and placement is maintained with tape or some other type of appliance. Asking the client to move his or her mouth and lips could result in possible extubation. Communication is limited and could be misunderstood with blinking. Teaching the client sign language, even simple, would be an involved and unrealistic goal.

What is the best way for the nurse to communicate with a client who is intubated and is receiving mechanical ventilation? a. Ask the client to point to words on a board. b. Ask the client to blink for "yes" and "no." c. Have the client mouth words slowly. d. Teach the client some simple sign language.

Deep veins of the legs & pelvis

What's the most common site of origin for a clot to occur, causing a PE?

-Stroke -Use of opioid analgesics -Morbid obesity

Which are extrapulmonary causes of ventilatory failure?

ANS: D The endotracheal tube can be taped to the upper lip but should never be taped to the lower jaw because the lower jaw moves too much. The other clients need to be assessed by the nurse, but the one with the ET tube taped to the jaw requires immediate action.

Which assessment finding of a client requires the nurse's immediate action? a. Being intubated for 4 days b. Uneven breath sounds c. Wheezing on auscultation d. Having the endotracheal (ET) tube taped to the lower jaw

ANS: B, C, D, F Older adults, especially those with chronic lung problems, are at higher risk for pulmonary embolism. Prolonged bedrest is also a risk factor, as are abdominal surgery and smoking. Because platelets are involved in the clotting process, elevated platelets may contribute to increased clotting. Diabetes and waiting for surgery are not known risk factors. pg 663

Which clients are at highest risk for pulmonary embolism (PE)? (Select all that apply) a. Middle-aged client awaiting surgery b. Older adult with a 20-pack-year history of smoking c. Client who has been on bedrest for 3 weeks d. Obese client who has elevated platelets e. Middle-aged client with diabetes mellitus type 1 f. Older adult who has just had abdominal surgery

Patient Requiring Intubation & Ventilation

With mechanical ventilation, the patient who has severe problems of gas exchange may be supported until the underlying problem improves or resolves. Usually mechanical ventilation is a temporary life-support technique. MV- most often used for patients with hypoxemia & progressive alveolar hypoventilation with respiratory acidosis. The hypoxemia is usually due to pulmonary shunting of blood when other methods of oxygen delivery do not provide a sufficiently high fraction of inspired oxygen (Fio2). MV- may be used for patients who need ventilatory support after surgery, those who expend too much energy with breathing & barely maintain adequate gas exchange, or those who have general anesthesia or heavy sedation.

VENTILATORY FAILURE

a problem in oxygen intake (ventilation) & blood delivery (perfusion) that causes a ventilation-perfusion (V/Q) mismatch in which perfusion is normal but ventilation is inadequate. -Occurs when the chest pressure doesn't change enough to permit air movement into & out of the lungs. As a result, too litte oxygen reaches the alveoli & carbon dioxide is retained. Either inadequate oxygen intake or carbon dioxide retention leads to hypoxemia. -Usually results from any of these problems: a physical problem of the lungs or chest wall; a defect in the respiratory control center in the brain; or poor function of the respiratory muscles, especially the diaphragm. Causes of ventilatory failure are either extrapulmonary (involving nonpulmonary tissues but affecting respiratory function) or intrapulmonary (disorders of the respiratory tract)

Extubation

the removal of the ET tube. The tube is removed when the need for intubation has been resolved. -Hyperoxygenate the patient, & thoroughly suction both the ET tube & the oral cavity. Then rapidly deflate the cuff of the ET tube & remove the tube at peak inspiration. Immediately instruct the patient to cough. -Monitor vital signs after extubation every 5 minutes at first, & assess the ventilatory pattern for manifestations of respiratory distress. It's common for patients to be hoarse & have a sore throat for a few days after extubation. Teach patient to sit in semi-Fowler's, take deep breaths every half hour- use an incentive spirometer every 2 hours, & limit speaking. Early manifestations of obstruction are mild dyspnea, coughing, & the inability to clear secretions. Stridor is a high-pitched, crowing noise during inspiration caused by laryngospasm or edema above or below the glottis. This sound is a late manifestation of a narrowed airway & requires prompt attention. Racemic epinephrine, a topical aerosol vasoconstrictor, is given, & reintubation may be needed.