Interventions for Critically Ill Clients with Respiratory Problems

1. Interventions for Critically Ill Clients with Respiratory Problems

2. Pulmonary Embolism • A collection of particulate matter (solids, liquids, or gases) that enters venous circulation and lodges in the pulmonary vessels. • Large emboli obstruct pulmonary circulation, leading to decreased systemic oxygenation, pulmonary tissue hypoxia, and potential death. Any substance can cause an embolism, but a blood clot is the most common. • In most people with pulmonary embolism, a blood clot from a deep vein thrombosis breaks loose from one of the veins in the legs or the pelvis.

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

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

5. Clinical Manifestations • Assess the client for: • Respiratory manifestations: dyspnea, tachypnea, tachycardia, pleuritic chest pain, dry cough, hemoptysis • Cardiac manifestations: distended neck veins, syncope, cyanosis, hypotension, abnormal heart sounds, abnormal electrocardiogram findings • Low-grade fever, petechiae, symptoms of flu

6. Interventions • Evaluate chest pain • Auscultate breath sounds • Encourage good ventilation and relaxation (Continued)

7. Interventions (Continued) • Monitor the following: • respiratory pattern • tissue oxygenation • symptoms of respiratory failure • laboratory values • effects of anticoagulant medications • Surgery

8. Decreased Cardiac Output • Interventions include: • Intravenous fluid therapy • Drug therapy • Positive inotropic agents • Vasodilators

9. Anxiety • Interventions include: • Oxygen therapy • Communication • Drug therapy: antianxiety agents

10. Risk for Injury (Bleeding) • Interventions include: • Protect client from situations that could lead to bleeding. • Closely monitor amount of bleeding. • Assess often for bleeding, ecchymoses, petechiae, or purpura. • Examine all stool, urine, nasogastric drainage, and vomitus and test for occult blood.

11. Acute Respiratory Failure • Pressure of arterial oxygen < 60 mm Hg • Pressure of arterial carbon dioxide > 50 mm Hg • pH < 7.3 • Ventilatory failure, oxygenation failure, or a combination of both ventilatory and oxygenation failure

12. Ventilatory Failure • Type of mismatch in which perfusion is normal but ventilation is inadequate • Thoracic pressure insufficiently changed to permit air movement into and out of the lungs • Mechanical abnormality of the lungs or chest wall • Defect in the brain’s respiratory control center • Impaired ventilatory muscle function

13. Oxygenation Failure • Thoracic pressure changes are normal, and air moves in and out without difficulty, but does not oxygenate the pulmonary blood sufficiently. • Ventilation is normal but lung perfusion is decreased.

14. Combined Ventilatory and Oxygenation Failure • Hypoventilation involves poor respiratory movements. • Gas exchange at the alveolar-capillary membrane is inadequate—too little oxygen reaches the blood and carbon dioxide is retained.

15. Etiology COMMON CAUSES OF VENTILATORY FAILURE COMMON CAUSES OF OXYGENATION FAILURE

16. Etiology COMBINED VENTILATORY AND OXYGENATION FAILURE • A combination of ventilatory failure and oxygenation failure occurs in clients who have abnormal lungs, such as those who have any form of chronic airflow limitation (CAL), such as chronic bronchitis, emphysema, or asthma). • The bronchioles and alveoli are diseased (causing oxygenation failure), and the work of breathing increases until the respiratory muscles are unable to continue (causing ventilatory failure). Acute respiratory failure results. • This process can also occur in clients who have cardiac failure, as well as respiratory failure. • This is a very dangerous situation because the cardiac system cannot compensate for the decreased oxygen by increasing the cardiac output

17. Assessment • The nurse assesses for dyspnea (difficulty breathing), the hallmark of respiratory failure • Dyspnea tends to be more intense when it develops rapidly. • Slowly progressive respiratory failure may first manifest as dyspnea on exertion (DOE) or when lying down. • The client notes orthopnea, finding it is easier to breathe in an upright position. In the client with chronic respiratory problems, a minor increase in dyspnea from the baseline condition may represent severe gas exchange abnormalities

18. Assessment • The nurse assesses for a change in the client's respiratory rate or pattern, a change in lung sounds, and the signs and symptoms of hypoxemia and hypercapnia. • Pulse oximetry may indicate decreased oxygen saturation, but an arterial blood gas (ABG) analysis is needed for adequate assessment of oxygenation status. The health care provider reviews the ABG studies to identify the degree of hypercapnia and hypoxemia

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

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

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

23. Causes of Lung Injury in Acute Respiratory Distress Syndrome • Systemic inflammatory response is the common pathway. • Intrinsically the alveolar-capillary membrane is injured from conditions such as sepsis and shock. • Extrinsically the alveolar-capillary membrane is injured from conditions such as aspiration or inhalation injury.

24. Etiology

25. Diagnostic Assessment • The nurse assesses the client's respirations and notes whether increased work of breathing is evident, as indicated by hyperpnea, grunting respiration, cyanosis, pallor, and retraction intercostally (between the ribs) or suprasternally (above the ribs). • The presence of diaphoresis and any change in mental status is documented. • No abnormal lung sounds are present on auscultation because the edema of acute respiratory distress syndrome (ARDS) occurs first in the interstitial spaces and not in the airways. • Vital signs are monitored at least hourly to assess for hypotension, tachycardia, and dysrhythmias • Lower PaO2 value on arterial blood gas • Poor response to refractory hypoxemia • Ground-glass appearance to chest x-ray • No cardiac involvement on ECG • The placement of a Swan-Ganz hemodynamic monitoring catheter: the pulmonary capillary wedge pressure(PCWP) is usually low to normal

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

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

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

29. Endotracheal Intubation • The goals of intubation include maintaining a patent airway, reducing the work of breathing, providing a means to remove secretions, and providing ventilation and oxygen • Components of the endotracheal tube: • The shaft of the tube contains a radiopaque vertical line for the length of the tube, which permits demonstration of correct placement by chest x-ray examination. • Short horizontal lines (depth markings) are used to designate correct placement of the tube at the nares or mouth (at the incisor tooth) and to identify how far the tube has been inserted.

30. Endotracheal Intubation • The cuff at the distal end of the tube, with proper inflation, produces a seal between the trachea and the cuffsures delivery of a set tidal volume when mechanical ventilation is used. When the cuff is inflated to an adequate sealing volume, no air can pass through the cuff to the vocal cords, nose, or mouth; therefore the client is not able to talk when the cuff is inflated. The cuff should be inflated to a pressure of 20 to 25 cm H2O using minimal-leak or no-leak techniques • The pilot balloon with a one-way valve permits air to be inserted into the cuff and yet prevents air from escaping. This balloon is used as a general guideline for determining the absence or presence of air in the cuff, although it will not show how much or how little air is present. • The universal adaptor, which is 15 mm in diameter, enables attachment to ventilator tubing or other types of oxygen delivery systems. The tubing size is indicated on the adaptor or the shaft of the tube. Adult tube sizes range from 5 to 10 mm. Sizes used are 8.0 to 9.0 for large adults, 7.0 to 8.0 for medium-size adults, and 6.0 to 7.0 for small adults

32. MAJOR INDICATIONS FOR INTUBATION

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

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

36. Mechanical Ventilation • Types of ventilators: • Negative-pressure ventilators • Positive-pressure ventilators • Pressure-cycled ventilators • Time-cycled ventilators • Microprocessor ventilators

37. Modes of Ventilation • The ways in which the client receives breath from the ventilator include: • Assist-control ventilation (AC) • Synchronized intermittent mandatory ventilation (SIMV) • Bi-level positive airway pressure (BiPAP) and others

38. Ventilator Controls and Settings • Tidal volume (Vt) is the volume of air that the client receives with each breath; it can be measured on either inspiration or expiration. The average prescribed Vt ranges between 7 and 10 mL/kg of body weight. Adding a zero to the weight of clients in kilograms gives an estimate of tidal volume • Rate: breaths per minute – is the number of ventilator breaths delivered per minute. The rate is usually set between 10 and 14 breaths per minute. • Fraction of inspired oxygen (Fio2) is the oxygen concentration delivered to the client. The prescribed Fio2 is determined by the arterial blood gas (ABG) value and the condition. Ventilators can provide 21% to 100% oxygen, depending on need. The oxygen delivered to the client is warmed to body temperature (98.6° F [37° C]) and humidified to 100%. Humidification and warming are necessary because upper air passages of the respiratory tree, which normally warm, humidify, and filter air, are bypassed by the endotracheal (ET) tube or tracheostomy tube. Humidification and warming prevent mucosal damage and facilitate clearance of secretions

39. Ventilator Controls and Settings • Sighs are volumes of air that are 1.5 to 2 times the set tidal volume, delivered 6 to 10 times per hour. These may be used to prevent atelectasis in special circumstances. Sighs are rarely used, however, because they can cause barotrauma (lung damage from excessive pressure) and have not been shown to be useful • Peak airway (inspiratory) pressure (PIP) indicates the pressure needed by the ventilator to deliver a set tidal volume at a given dynamic compliance • Continuous positive airway pressure (CPAP) is the application of positive airway pressure throughout the entire respiratory cycle for spontaneously breathing clients. CPAP keeps the alveoli open during inspiration and prevents alveolar collapse during expiration. This process results in increased functional residual capacity (FRC), improved gas exchange, and improved oxygenation • Positive end-expiratory pressure (PEEP) is positive pressure exerted during the expiratory phase of ventilation. PEEP improves oxygenation by enhancing gas exchange and preventing atelectasis

40. Ventilator Controls and Settings • Flow is how fast the ventilator delivers each breath. It is usually set at 40 L/min. If a client is agitated, is restless, has a widely fluctuating pressure reading on inspiration, or has other signs of air hunger, the flow may be set too low. Increasing the flow should be tried before using chemical restraints. • Other Settings. Other settings may be used, depending on the type of ventilator and mode of ventilation. Examples of additional settings include inspiratory and expiratory cycle, waveform, expiratory resistance, and plateau

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

42. Complications • Complications can include: • Lung • Cardiac • Gastrointestinal and nutritional • Infection • Muscular complications • Ventilator dependence

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