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Exam II Altered Respiratory Function

Acute Respiratory Failure results in what? Inadequate gas exchange, with Hypoxemia or without hypercapnia.
Etiology: Acute Respiratory Failure in extrapulmonary? CNS involvement: Drug OD, Brain trauma or lesion, Spinal cord trauma or lesion, Neuromuscular system. Thorax: Pneumothorax, hemothorax, Massive obesity. Other Thorax and Upper Airway Disease.
Extrapulmonary includes what? Anything outside alveoli or pulmonary circulation
Intrapulmonary includes what? Anything Within the lower airways, alveoli, & pulmonary circulation
Acute respiratory failure in intrapulmonary COPD, Pulmonary Embolus, Pneumonia, Pulmonary Edema, ARDS.
NDx: Acute repiratory failure Impaired Gas Exchange related to Alveolar Hypoventilation. Impaired Gas Exchange related to Ventilation/Perfusion Mismatch. Impaired Gas Exchange related to Intrapulmonary Shunting
What happens during alveolar hypoventilation 02 return to Aveoli insufficient. Can Result from Hypercapnia and extrapulmonary etiologies.
V/Q Mismatch Result from Ventilation/Breathing and Bloodflow Mismatch Usually from Intrapulmonary. Blood passes through Aveoli but perfusion is inadequate because aveoli are incompetent (collapsed or fluid filled).
Intrapulmonary Shunting? Unoxygenated blood mixes with oxygenated blood decreases O2 level Thus returns to Arterial system Without adequate O2 exchange.
PaO2 <50 and PCO2 34-45 is indicative of what? Respiratory Failure type I.
Etiology of typr I ARF? Breakdown of O2 transport from the alveolus to the arterial flow
Nursing Dx: for typr I ARF Impaired Gas Exchange, Pneumonia, ARDS, aspiration, atelectasis, pulmonary edema
PaO2 <50 Hypoxemia and PCO2 >50 Hypercapnea is indicative of what? Acute Respiratory Failure type II.
Etiology of typr II ARF Musculoskeletal or anatomical lung dysfunction or suppression
Nursing DX: for typr II ARF Ineffective Breathing Pattern. COPD, head injuries, narcotic overdose, ALS, Guillain-Bare, Muscular Dystrophy.
Treatment for ARF? Pharmacologic Management: Bronchodilators (Beta2 agonists, Anticholinergics). Steroids
Nursing Interventions for ARF Provide supplemental oxygen. Intubation, mechanical ventilation. Treat the underlying cause. Assess ABG’s For chronic CO2 retainer, keep pH normal do not go by SaO2. Keep 02 > 90%. Prevent Complications.
Nursing Goal for ARF? Maintain pH homeostasis
Further nursing intervention for ARF? Minimize oxygen consumption Sedation Neuromuscular paralysis Promote secretion clearance and facilitate removal Assess need for suctioning Hydration: Provide adequate hydration, humidification Chest percussion, postural drainage
Positioning for ARF Pt Position with good lung down. Elevate at least 30º degrees. Frequent turns.
Nutrition for ARF Pts TPN, goal is to change to enteral as soon as possible. Monitor prealbumin levels.
Complications of ARF Hypoxia - Anoxic encephalopathy (lack of 02 to the brain). Cardiac dysrhythmias.
Complication of ARF with Pts on ventilation? DVT. GI bleeding
The acronym SARS is what? Severe Acute Respiratory Syndrome
Etiology of SARS? Mutated and virulent form of the coronavirus
How is SARS spread? Airborne droplets from infected people.
Upon entry via portal of entry, where do the coronal virus invade? pulmonary tissue --> Inflammatory response
Where does the corona virus that causes SARS not enter? Bloodstream
SARS prevention? Hand washing, Airborne & Contact Isolation, Gown, gloves, Eye protection, Disposable particulate mask respirator such as N-95, N-99, N-100.
Why is SARS difficult to diagnos Because it takes a while for the result to be out say 2 to 3 weeks.
SARS Symptoms? Fever, Headache, body ache. Cold symptoms: Runny nose, sore throat, watery eyes.
SARS symptoms in day 2 - 7? Dry cough, SOB, Hypoxia w/ cyanosis.
SARS Dx? CXR: infiltrates, Accurate history (looking for travellers or being around travellers), Ruling out other causes.
SARS Treatment? Supportive care, Air-borne/droplet isolation
What is the acronym ALI? Acute Lung Injury
What is ALI? Injury to the pulmonary vasculature or the airways which results in noncardiac pulmonary edema and disruption of the alveolar-capillary membrane.
What is the acronym ARD?S Acute respiratory distress syndrome
The severest of ALI is called what? ARDS
What is the Patho of ARDS? Inflammatory syndrome disrupting alveolar-capillary membrane
1st phase of ALI 1st 72 hours after injury, Mediators are causing injury to pulmonary capillaries. Increased capillary membrane permeability. Development of microemboli. Increased pulmonary pressures, but PAOP can remain low or normal.
What is the result ALI in 1st phase? Interstitial edema, alveolar edema
What happens to type I & II cells of the lungs in ALI Pt? Cells are damaged, leading to alveolar collapse
2nd phase of ALI? Fibroproliferative phase --> decreased lund compliance. Disordered healing begins. Cellular granulation, collagen deposition Fibrotic alveoli, pulmonary capillaries scarred. Increased stiffening and increased pulmonary HTN.
3rd phase of ALI? Resolution phase: Structural and vascular remodeling. Restoration of the alveolus. Macrophages remove debri.
In phase III ALI, what happens to type I & II cells in lungs? Type II cells multiply & some convert to Type I.
Acute Lung Injury: Pathophysiology Activation of neutrophils and macrophages, and release of endotoxins. Release mediators. Tumor necrosis factor, Interleukin 1, proteases.
What drug is for pulmonary HTN? Flolan
Etiology of ALI? (Direst injury)? Pulmonary contusion, Gastric aspiration, Near drowning, Inhalation injuries, Some infections, Radiation, Oxygen toxicity.
Etiology of ALI? (indirest injury)? Septicemia, Shock, prolonged hypotension, Nonthoracic trauma, CABG, Drug overdose, Head injury, Pancreatitis, Diabetic coma, Multiple blood transfusion, Fat embolus, Amniotic fluid embolus.
S/S of ALI Severe dyspnea, using accessory muscles, Altered LOC, restlessness, anxiety, confusion Lung expansion reduced, Vocal fremitus increased - Increased density from diffuse pulmonary edema.
Further S/S of ALI? Dry cough (not pneumonia, not infectious),Bronchiovesicular Breath Sounds over most lung fields. Adventitious sounds-diffuse crackles over all lung fields.
Is ALI an infectious disease? No! This is an inflammatory syndrome due to injury, not infection.
ALI Dx? (Specific for ARDS) Acute in onset. Ratio of PaO2 to FiO2 is ≤200mm Hg. PaO2/FIO2 (normal is 286-350). Bilateral chest infiltrates on CXR. PAWP ≤18 mmHg.
ALI Diagnostic tool? ABGs, CXR, Pulmonary function, Hemodynamics.
ALI Diagnostic tool, what is seen in ABGs? Hypoxemia, (refractory) due to the intrapulmonary shunting. Respiratory alkalosis (early phase due to hyperventilation). Hypercapnia not usually seen (but ominous if present). Resp acidosis: Underventilation. V/Q mismatch, shunting.
ALI Diagnostic tool, what is seen in CXR? Diffuse bilateral interstitial and alveolar infiltrates. Fine or coarse reticular pattern in the chronic phase.
ALI Diagnostic tool, what is seen in pulmonaryfunction? Reduced pulmonary compliance. Reduced FRC due to microatelectasis and edema. Large right to left shunt, >20%. Increased dead space ventilation. Increased A-a gradient.
ALI Diagnostic tool, what is seen in hemodynamics? PAWP normal or low, Pulmonary pressures elevated. Non Cardiogenic Pulmonary Edema, Pulmonary HTN. May develop (R )heart failure due to Pulmonary HTN, Decreased CO.
ALI treatment? Mechanical ventilation
In ALI treatment, what seting will ventilator be set? O2 at the lowest level needed. FIO2: Goal SaO2 90 with FIO2 <65%.
In ALI treatment, what mode will ventilator be set? Assist Control Allows vent to do most of the work. Pressure Control for worsening ARDS
In ALI treatment, what will TV of ventilator be set? Smaller tidal volumes with higher respiratory rates. 6-10 ml/kg.
In ALI treatment, what does PEEP do? Recruits collapsed alveoli, decreases pulmonary shunting and improves gas exchange.
In ALI treatment, what does inverse ratio do? Prolongs inspiratory time, shortens expiratory time.
What is the goal of inverse ratio? Intentional air trapping.
In ALI treatment, what does permissive hypercapnea do? Reduces atelectrauma & biotrauma.
In ALI treatment, what does pressure comtrol ventilator do? Preset amount of inspiratory pressure used to deliver tidal volume. Reduces volutrauma.
In ALI treatment, Inhaled nitric oxide functions as what? Bronchodilator, pulmonary vasodilator. Improved V/Q matching and improved oxygenation.
In ALI treatment, what does partial liquid ventilation do? Decreases alveolar surface tension. Helps open collapsed alveoli.
What is the acronym ECMO? Extracorporeal membrane oxygenation
What does ECMO do in the treatment ALI? Provides method for lungs to rest, artificial lung
Normal PAWP is? 5 - 12 mmHg
PAWP ≤18 mmHg is indicative of what? Heart problem, left ventricular problem.
What are the complication of PEEP? Pneumothorax. Hypotension.
Why does PEEP cause drop in blood pressures Pneomothorax presses against the great vessels which hinders venous return --> decreased B/P. Barotrauma.
How does prone positioning help ALI Pts? Dependent areas of lungs are more heavily damaged than nondependent areas. So position to to use the less damaged area of the lung.
When is prone positioning more effective in ALI? In the early stage of disease.
NDx for ARDS? Impaired Gas Exchange
In he treament of ALI, what do you FIRST before paralyzing Pts? Sedate.
P.E. results when...? Bits of thrombi occlude pulmonary artery DVT’s Iliofemoral System
P.E. outme on V/Q Lung ventilated but not perfused
Etiology of P.E. Virchow’s triad: 1. Hypercoagualbility 2. Injury to vascular endothelium and 3. Venous stasis
P.E. NDx? Altered Tissue Perfusion related to Ventilation Perfusion Mismatch or Shunting
P.E. assessment? (CNS) Apprehension.
P.E. assessment? (Resp.) Dyspnea, Tachypnea, Hypoxemia, cough, decreased BS on affected side, Pleuritic chest pain, Pulmonary HTN.
P.E. assessment? CV collapse) Tachycardia, Right ventricular failure, Decreased L ventricular preload, hypotension, shock, P pulmonale on ECG.
P.E. assessment? (Dx confirmed) Pulmonary angiogram, Ventilation/perfusion lung scan, CXR.
P.E S/S? Pulmonary hypertension. Mechanical obstruction. Pulmonary vasoconstriction. Workload of right ventricle increases. Right ventricular failure. Decrease in left ventricular preload. Decrease in CO. Decrease in BP……shock.
P.E Diagnostics confirmed? Pulmonary angiogram. V/Q lung scan. CXR.
P.E Management? O2. Positive Inotropic drugs, fluids. Systemic Thrombolytic Therapy. Pulmonary Embolectomy.
P.E management? (Prophylaxis) Anticoagulation: Greenfield Filter: Umbrella shaped filter placed in inferior vena cava to catch traveling blood clots from lower extremities.
P.E Pt education? Signs and symptoms of P. E. Smoking cessation. Birth control pills. Hormone replacement therapy. Medication education. Watch for signs of bleeding. Monitor INR if on warfarin therapy.
Normal V/Q ratio? 0.8
Describe air leak disorder? Conditions that result in extraalveolar air accumulation
What is pneumothorax? Air in the pleural space that causes lung collapse
What is tension pneumothorax? Air enters in the pleural space via a one-way valve and is unable to exit
What is a hemothorax? An accumulation of blood in the pleural space --> lung collapse.
What is Barotrauma/volutrauma? Air in the lung interstitial space .
Assessment: Air Leak Disorders? (Resp.) Dyspnea,Cyanosis, Hyperresonance, Decreased or absent breath sounds on affected side.
Assessment: Air Leak Disorders? (ABGs) Hypoxemia with hypercapnia.
Assessment: Air Leak Disorders? (Trachea) Tracheal deviation away from affected side, Mediastinal shift.
Assessment: Air Leak Disorders? (CV collapse) Compression great vessels, Hypotension, Shock.
Assessment: Air Leak Disorders? (hemodynamics) Decreased CO, increased CVP, Tachycardia.
Assessment: Air Leak Disorders? (Diagnostics) CXR: Increased translucency evident on the affected side.
In performing air leak assessment, what is the most important thing to do? Perform good Lung Assessments to note a change early
Air Leak disorders: (early findingd) Chest pain. Dyspnea. Anxiety. Tachypnea. Tachycardia. Hyperresonance of the chest wall on the affected side. Diminished breath sounds on the affected side.
Air Leak disorders: (late findings) Decreased level of consciousness. Tracheal deviation toward the contralateral side. Hypotension. Distension of neck veins (may not be present if hypotension is severe). Cyanosis. Increased PA pressures & decreased CO or CI
Explain Chest trauma Tension pneumothorax? Air admitted in pleural space through rupture in lung or hole in chest wall. Flap of tissue in lung or hole acts as flutter valve allowing air in and not out. Pressure in pleural space increases.
What else about Tension pneumothorax? Lung compressed and collapsed Shifts mediastinal structures and impede venous return to the heart. May be caused by mechanical ventilation, thorax pierced by needle
With Tension pneumothorax, treatment reqiured is ...? An emergency treatment
Tension pneumothorax treatment procedure? 100% oxygen, and ventilate the patient if necessary. Insert a large-bore (ie, 14-gauge or 16-gauge) needle. Prep the area with betadine first.
Furhter tension pneumothorax procedures? 2nd intercostal space, just superior to the third rib at the midclavicular line, 1-2 cm from the sternal edge (ie, to avoid injury to the internal thoracic artery). Use a 3-6 cm long needle, and hold it perpendicular to the chest wall when inserting.
Furhter tension pneumothorax procedures? con't Once the needle is in the pleural space, listen for the hissing sound of air escaping, and remove the needle while leaving the catheter in place. Secure the catheter in place, and install a flutter valve. Prepare the patient for tube thoracostomy.
Nursing Interventions: Air Leak Disorders? Evaluate lung for re-expansion. Serial CXR. Auscultate breath sounds. Observe pleuravac for signs of re-expansion.
Nursing Interventions: Air Leak Disorders? (medical management for Pneumothorax less than 15%) No interventions are needed. Watch & wait.
Nursing Interventions: Air Leak Disorders? (medical management for Pneumothorax greater than 15%) Requires evacuation of air from pleural space. Decompression with a needle. Heimlich valve. Chest tube.
Hemothrax etiology? Chest trauma, complication of anticoagulant therapy, lung malignancy.
Hemothrax assessment Respiratory distress. Chest pain. Cough. Absent breath sounds over affected area.
Hemothorax diagnosis? CXR. Thoracentesis (a one time procedure, a liter at one time).
Air Leak Disorders, Nursing Goals? Manage chest tube. Observe for re-expansion of lung.
Position of CT with Pneumothorax vs Hemothorax, What will be seen in Waterseal Chamber for each? Which will expect more drainage? little bubbles. The newer ones will drain more
Normal neg pressure for chest tube drainages ? - 20
Name components of a Chest tube drainage system? Collection chamber. Water seal. Suction control chamber. Tidaling (ball goes up & down w/ Pt's breath but still remains in the negative area). Air leak. Normal intrathoracic pressures.
Air Leak Disorders patho? (Barotrauma/volutrauma) Air travels from pulmonary interstitium to other thoracic structures: pulmonary interstitial emphysema, pneumomediastinum, subcutaneous emphysema, pneumopericardium, pneumoperitoneum, pneumoretroperitoneum.
Air Leak Disorders? (Barotrauma/volutrauma)Symptoms Symptoms are more subtle. Air in subcutaneous tissues. Air in mediastinal space causes stabbing pain
Air Leak Disorders? Hamman’s sign symptoms Clicking/crunching sound synchronous with heart, heard over apex of heart
Air Leak Disorders, confirm diagnosis? (Bartrauma) Chest radiograph
Flail Chest etiology? Caused by fractured ribs due to trauma. Leads to chest wall instability. Results in opposite chest movement with respirations. Prevents adequate ventilation of injured area.
Assessment: Flail Chest Altered breathing pattern. During inspiration affected portion sucked in. During expiration affected portion balloons out. Rapid, shallow respirations. Cyanosis. Tachycardia.
Nursing goals: Flail Chest? Adequate oxygenation. Re-expand lungs with Chest Tube & Mechanical Ventilation.
Flail Chest treatment? Thoracic surgery: Surgical procedure involves opening up the thoracic cavity: “Thoracotomy”
What is Pneumonectomy? Removal of entire lung with or without resection of mediastinal lymph nodes. Lung cancer, malignancy, abscess.
What is Lobectomy? Resection of one or more lobes of lung. Lung cancer, lung abscesses or cysts.
What is Wedge resection? Removal of small wedge shaped section of lung tissue.
In pneomonectomy, what may Pt have and not have? No Chest Tube, but may have some type of drainage device.
In lobectomy, what may nurse or RTs do? Monitor Chest Tube to re-expand other portions of Lung on the operated side.
Complications of thoracic surgery? Hemorrhage. Cardiac dysrhythmias. Pulmonary edema. Atelectasis. Hypoxia. Pain. Infection.
Nursing Goals: Thoracic Surgery? Pain management. PCA, Epidural. Splinting incision. Prevent Atelectasis. T,C&DB; keep pain under control. Incentive spirometry, 10x hour. Early ambulation. Promote secretion removal.
Nursing Goals: Thoracic Surgery? Pneumonectomy. Position supine or on Operative side initially with HOB elevated. Prevents drainage of fluid from operative side into good lung. Promotes splinting of incision and facilitates deep breathing.
Nursing Goals: Thoracic Surgery? Lobectomy Position on Non-operative side to promote V/Q matching. Blood flow greater to “good lung” or dependant side.
Nursing Goals: Thoracic Surgery? Maintain chest tube. Chest tubes remove air and fluid. No stripping, gentle milking “only” if needed. Monitor for air leak. Observe for excessive bloody drainage. Monitor q 15 min for first 1-2 hours.
Nursing Goals: Thoracic Surgery? Maintain of chest tube in pneumonectomy. No chest tube w/ pneumonectomy: No lung to re-expand
Nursing Goals: Thoracic Surgery. CV Loss of lung lobe or tissue…..increases pressure in the remaining pulmonary system….backs up pressure in right side of heart, increased CVP, increases R ventricular workload and can cause R Heart Failure.
Nursing Goals: Thoracic Surgery. CV (con't) ……increased chance of pulmonary edema and dysrhythmias.
Nursing Goals: Thoracic Surgery. Activity level? Range of motion with the operative side arm and shoulder. Encourage use of pain control. May need Physical Therapy.
What is the hallmark sign of ARF? Hypoxemia.
What do we need to monitor prealbumin level in AFR pts? To regain strenght of their musculature.
What intervention for chronic CO2 retainer in ARF? Keep pH normal, do not go by SaO2, keep O2 Sat. > 90%
What arterial BG reading would be indicative of ARF? pH 7.18, PcO2 70, PO2 43, HCO2 28.
What are the preventive measure for ARF complications? Low dose anticoagulant. Compression stockings or other device as such. Proton Pump inhibitors.
What kind or infection is SARS Viral
Why does SARS virus not go systemic? Because it favors the temp. of the pulmonary system
SARS poratl of entry? Eye, nose & mouth.
N-95, N-99, N-100, What does the numbers signify? %age of particles filtered.
True or False: The inflammatory response syndrome in ALI/ARDS is as a result of an infectious disease? False
What are the two mostly used term for ARDS CXR? Ground glass. White out.
To achieve inverse ratio treatment, what must you do? Neuromuscular blockade.
Why does inverse ratio require a neuromuscular blockade. It works against the normal processes of the lungs.
What is the problem with ECMO? The use of a lot of anticoagulants
How often is ECMO used on pts with ALI/ARDS Not often
Why do nurses prone posistion pts with ALI/ARDS? So Pt can reperfuse using their nondependent area of lungs since the dependent areas are heavily damaged
Nursing Goals for ARDS? Improve tissue perfusion: Maintain PCWP 5- 8 mmHg. Diuretics, fluid restrictions to prevent fluid leakage. Steroids to reduce inflammatory response. Maintain adequate CO with Vasoactives and Inotropics.
Causes of DVTs? Hypercoagulability. Venous stasis. Injury to vascular endothelium.
Hypercoagulability, Venous stasis & Injury to vascular endothelium are also known as? Virchow's Triad.
If you suspect P.E in you patient, what tests do you order? ABGs. D-dimer. ECG. Echocardiogram. V/Q lung scan. Spiral CT scan. Pulmonary angiogram
If a Pt have had an P.E, what is he at risk of? Another P. E.
What can be done to prevent another P. E.? Surgically implant a Grenfiled filter.
Describe Greenfiled filter? An umbrella shaped filter palced in inferior vena cava to catch travelling blood clots from lower extremity.
What is the rationale for not incerting a chest tube in pt that has just undergone a pneumonectomy? No lungs to re-expand
What is the effect of thoracic surgery on the cardiovascular system? Loss of lobe increases pressure on the remaining lungs which in tuen will increase pressure to the right side of heart --> increased CVP --> R.ventricular workload & cause R. side HF. Increased pulmonary edema ---> dysrhythmia.
Activity level after a thoracic surgery? ROM with operative side arm & shoulder. May need PT
What can help thoracic surgery pts participate in ROM Adequate pain control, not too much so they can participate & not sedated.
Created by: nze