Respiratory Stressors II

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Respiratory Stressors II

• Chest Trauma
• Respiratory Failure
• ARDS
• Ventilators

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Chest Trauma

• About 25 of all traumatic deaths result from
  chest injuries
• - Pulmonary contusion
• - Rib fracture
• - Flail chest
• - Pneumothorax
• - Tension Pneumothorax
• - Hemothorax
• - Tracheobronchial trauma

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Assessment

• Assessment of overall condition and type of
  injury
• Car accident-blunt trauma
• Assess for blood loss
• Assess for underlying structures
• Monitor for airway obstruction, tension
  pneumothorax,open pneumothorax, flail chest with
  pulmonary contusion

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Emergency Assessment

• Maintain ABCs
• Obtain a quick hx
• What happened? What was the mechanism of
  injury?
• How long ago did it happen?
• Where is the pain?
• What does it feel like? Pain scale? Does it
  radiate?
• Is there anything that makes the pain better
  or worse?
• Medical hx?

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Emergency 1 Minute Assessment

• Shortness of breath and cyanosis
• VS, Heart sounds, skin color and temp
• Wound size and location
• Look and listen for sucking chest sounds
• Bilateral breath sounds, stridor, paradoxical
  chest movement (flail chest), use of accessory
  muscles
• Tracheal deviation
• SQ emphysema
• Assess for bowel sounds in the chest-ruptured
  diaphragm

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Emergency Interventions

• O2 therapy
• Prepare for chest tube insertion
• Start IV lines
• Prepare for STAT portable CXR
• Prepare for intubation for flail chest
• Monitor for arrhythmias

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Pathophysiology

• Hypoxia
• Hypovolemia
• Pulmonary ventilation/perfusion mismatch
• Changes in intrathoracic pressure relationships
• Respiratory acidosis, Hypercarbia
• Metabolic acidosis

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Flail Chest

• Complication of blunt trauma, 2 or more ribs next
  to each other are broken in half
• Inward movement of thorax during inspiration and
  outward during expiration
• Fractured ribs
• Fractured sternum-blunt deceleration
• May occur after CPR

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Flail Chest Assessment

• Chest wall is unstable and leads to repiratory
  distress, dyspnea, anxiety
• Breath sounds diminished and crackles may be
  heard
• Hypoventilation and hypoxemia
• Hypotension/ inadequate tissue perfusion and
  metabolic acidosisshock
• Pain assessment

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Management of Flail Chest

• Depending on the amount of distress
• Mild-moderate
• Humidified O2
• Pain management
• Promotion of lung expansion through DB and
  positioning
• Severe
• Mechanical ventilation
• IV hydration
• Monitor ABGs, pulse ox, pain management
• Psychosocial support

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Pulmonary Contusion

• Due to blunt trauma-potentially lethal
• Damage leading to lung tissue hemorrhage and
  local edema
• Damage to the lung leads to leakage of serum
  proteins and plasma
• Increased oncotic pressure pulls fluid into
  lungs. Results in hypoxemia and CO2 retention
• May not be evident for 12-24hrs

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SS of Pulmonary Contusion

• MILD
• Tachypnea
• Tachycardia
• Pleuritic chest pain
• Hypoxemia
• Blood tinged sputum

• SEVERE
• Tachypnea
• Tachycardia
• Severe hypoxemia
• Crackles
• Respiratory acidosis
• Mental changes

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Management of Pulmonary Contusion

• CXR for diagnosis
• Insure adequate ventilation
• Maintain airway O2,chest PT, postural drainage,
  suctioning,
• Intubation and mechanical ventilation with PEEP
  for severe symptoms
• IO adequate hydration and prevention of overload
• Pain management
• NG tube
• Antibiotics
• Extensive damage can lead to ARDS

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Diaphragmatic Rupture

• Herniation of the abdominal viscera into the
  chest
• Most often occurs on left side

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SS Diaphragmatic Rupture

• Dyspnea
• Cyanosis
• Dysphagia
• Sharp shoulder pain
• Bowel sounds in lower to middle chest
• Decreased breath sounds

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Management

• Maintain adequate oxygenation with endotracheal
  tube placement and mechanical ventilation
• NGT
• Immediate surgical repair

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Acute Respiratory Failure

• Pressure of arterial oxygen lt 60 mm Hg
• Pressure of arterial carbon dioxide gt 50 mm Hg
• pH lt 7.30
• O2 sats lt 90
• Ventilatory failure, oxygenation failure, or a
  combination of both ventilatory and oxygenation
  failure
• Mortality rate is 50-60

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Acute Respiratory FailureClassification

• 1.Ventilatory Failure-perfusion is normal but
  ventilation is inadequate
• Causes extrapulmonary
• intrapulmonary
• 2.Oxygenation Failure
• 3. Combined Ventilatory and Oxygenation Failure

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Ventilatory Failure

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

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Causes of Ventilatory Failure

• Decreased respiratory drive
• Brain disorders
• Dysfunction of the chest wall

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Oxygenation Failure

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

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Causes of Oxygenation Failure

• Dysfunction of the lung parenchyma, conditions of
  the lung that interfere with ventilation by
  preventing expansion of the lung
• Pain-restricting chest movement
• Ascites
• Upper airway obstruction

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Combined Ventilatory and Oxygenation Failure

• Hypoventilation involves poor respiratory
  movements.
• Gas exchange at the alveolar-capillary membrane
  is inadequatetoo little oxygen reaches the blood
  and carbon dioxide is retained.

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Causes of Ventilation/Oxygenation Failure

• CAL
• Cardiac failure- cant reverse hypoxia by
  increasing CO

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Dyspnea

• Encourage deep breathing exercises.
• Assess for
• Perceived difficulty breathing
• Orthopnea client finds it easier to breathe when
  in upright position
• Oxygen
• Position of comfort
• Energy-conserving measures
• Pulmonary drugs

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Assessment of ARF

• HYPOXEMIA
• Dyspnea
• Tachypnea
• Cyanosis
• Restlessness
• Apprehension
• Confusion
• Impaired judgement
• Tachycardia
• Dysrhythmias
• Hypertension

• HYPERCAPNIA
• Dyspnea
• Respiratory depression
• Headache
• Pailedema
• Tachycardia
• Hypertension
• Drowsiness
• Coma
• Heart failure

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Management of ARF

• GOALS treat the underlying cause and restore
  adequate gas exchange
• Keep O2 gt60
• CDB, respiratory tx
• Prevent complications of immobility
• Monitor ABGs and pulse Ox
• Maintain endotracheal intubation and mechanical
  ventilation
• Relaxation techniques
• Energy conserving measures

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ARDSAcute Respiratory Distress Syndrome

• Other names-wet lung, shock lung
• Form of acute respiratory failure
• Pathophysiology is complex and not clearly
  understood
• Acute respiratory failure occurs 1-96hrs after a
  pulmonary or non pulmonary event
• Chemical mediators and endotoxins are released by
  the body which cause increased capillary
  permeability and pansystemic microvascular injury
• Alveoli fill with RBCs, neutrophils and
  protein-rich fluid which impairs perfusion and
  damages surfactant
• Decreased surfactant
• Blood in capillaries pass damaged alveoli
  shunting
• Hypoxemia not responsive to O2 tx

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Acute Respiratory Distress Syndrome

• Refractory Hypoxemia that persists even when
  oxygen is administered at 100
• Severe dyspnea, with air hunger, retractions and
  cyanosis. Works at breathing
• Noncardiac-associated bilateral pulmonary edema
• Dense pulmonary infiltrates seen on x-ray
• Decreased lung compliance (stiff lung)

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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.
• Leaky capillaries- increased permeability leads
  to alveolar flooding and collapse

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Common Causes Of ARDSDamage directly or
indirectly to the Lung

• Shock, trauma
• Cardiopulmonary bypass
• Serious nerve injury
• Pancreatitis
• Fat and amniotic fluid emboli
• Pulmonary infections
• Sepsis and multi-system failure (30-40
  mortality)
• Inhalation of toxic gases
• Pulmonary aspiration
• Drug ingestion (opioids, heroin, ASA)
• Hemolytic disorders
• Multiple transfusions
• Near drowning

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Diagnostic Assessment

• Severely impaired gas exchange
• Lower PaO2 value on arterial blood gas lt60mm/Hg
• PaCo2 over 45mm/Hg
• Poor response to refractory hypoxemia
• Ground-glass appearance to chest x-ray
• No cardiac involvement on ECG
• Low to normal PCWP
• PFTs to determine decreased lung compliance
• Normal Swan-Ganz pressures

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Treatment Goals

• Prompt recognition and tx
• Optimize gas exchange
• Maintain tissue perfusion and cardiac output
• Manage underlying pathology
• Adequate fluid and nutrional support

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Medical Management

• Endotracheal intubation and mechanical
  ventilation (PEEP, CPAP)
• Monitor for complications of PEEP
• Neuromuscular blocking drugs
• Sedation
• Corticosteroids
• Antibiotics
• Fluid volume
• Induced diuresis
• TPN or enteral feedings
• Prone position prn
• Surfactant and nitrous oxide
• NSAIDS

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Phase I

• Dyspnea and Tachypnea
• Tx Support
• Provide O2

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Phase II Interventions Increasing Pulmonary Edema

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

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Phase III

• Occurs over 2-10 days
• Progressive hypoxemia not responsive to high
  levels O2
• Support failing lung until it can heal

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Phase IV

• Occurs after 10 days
• Pulmonary fibrosis- irreversible
• Late or chronic ARDS
• Goals To prevent sepsis, PN, MODS
• May require long term ventilation

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Mechanical VentilationIndications

• Airway protection when the pt loses reflexes
• To provide positive pressure or high O2
  concentration
• To bypass airway obstruction
• Facilitating pulmonary hygiene and suctioning of
  secretions when the client cant handle secretions

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Mechanical Ventilation Requires Endotracheal
IntubationArtificial Airway

• Components of the endotracheal tube
• Preparation for intubation
• Verifying tube placement
• Stabilizing the tube
• Nursing care

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Mechanical Ventilation

• Types of ventilators
• Negative-pressure ventilators
• Positive-pressure ventilators
  1.Pressure-cycled ventilators
  2.Time-cycled ventilators
• 3.Microprocessor ventilators
• 4.Volume-cycled (most common)

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Modes of Ventilation

• How the machine will ventilate the patient in
  relation to the pts own repiratory efforts
• 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), CPAP
  and others

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Ventilator Settings

• Settings are adjusted towards pt needs and
  include
• Mode of ventilation
• Tidal Volume- Normal 7-10ml/kg
• FiO2- 21-100
• Rate- breaths per minute
• Sighs- increases air 1.5-2x
• Specialized delivery modes CPAP or PEEP
• PEEP is used if FiO2 isgt50

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Nursing Management

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

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Nursing ManagementMonitor/evaluate response to
ventilation

• Monitor respiratory patterns and lung sounds
• Does pt assist/buck vent
• Assess airway tubes frequently, minimal leak
  technique
• BP and HR
• CXR, observe for SQ emphysema
• ABGs/Pulse ox
• Plan methods for communication
• Sedation/anti-anxiety meds as needed
• Observe for ICU psychosis

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Nursing ManagementManage the ventilator system
safely

• Monitor ventilator settings
• Suction prn- preoxygenate, when?/
• Provide humidification
• Check alarms-always have alarms activiated
• Remove condensation in tubing

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Nursing Management PreventComplications

• Complications can include
• Pulmonary
• Cardiac
• Gastrointestinal and nutritional
• Infection
• Muscular complications
• Ventilator dependence
• Inadvertant Extubation

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Complications

• Ventilator associated PN
• Elevation of HOB 30-45 degrees
• Daily sedation vacation and assessment for
  readiness to wean
• Peptic ulcer prophylaxis
• DVT prophylaxis

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Complications

• Malnutrition is major reason why pts cannot be
  weaned
• Nutrition daily weights
• maintain TF or TPN
• GI Bleed- stress ulcer prevention
• Nose, lip, trachea problems
• Decreased saliva and mouth ulcers
• Barotrauma-hypoxemia,crepitus,no breath sounds
• Pneumothorax
• Ventilator dependence

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Troubleshooting the VentCHECK PT FIRSTDO NOT
IGNORE ALARMS

• HIGH PRESSURE ALARM
• 1.pt needs to be suctioned
• 2.pt bucking/fighting the vent
• 3.displacement of ET tube
• 4.pt coughing when machine gives breath
• 5.water in the tubing

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Troubleshooting

• LOW PRESSURE ALARM
• Leak-in the system
• Disconnected tubing

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Weaning From A VentilatorGOAL SPONTANEOUS
BREATHING

• Factors related to weaning
• 1. Pre-existing lung condition
• 2. Duration of mechanical ventilation
• 3. Pt physical and psychological condition
• Short term vs long term

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Weaning From A Ventilator

• Ability to sustain spontaneous ventilation
• Monitor for respiratory distress
• Position to facilitate breathing
• Energy conservation-assist with care
• Avoid sedatives and respiratory depressant meds

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The Big Moment Has ArrivedEXTUBATION TIME

• Explain procedure
• Have O2 available
• Suction ET/oral
• Deflate cuff
• Have pt cough while tube is pulled
• Assess for respiratory fatigue and obstruction
• Assess voice/sore throat

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ABG Interpretation

• What is acidosis???
• What is alkalosis???
• Lets look at
• pH acidotic or alkalotic?
• PaO2
• PaCO2
• HCO3
• O2 Saturation
• Remember ROME !

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ABG Normal Ranges
pH 7.35-7.45
PaCO2 35-45 mm Hg
PaO2 80-100 mm Hg
SaO2 95-100
HCO3 22-26 mEq/L
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Acid/Base MnemonicRemember ROME

• R Respiratory
• O Opposite pH up PCO2 down
  Alkalosis pH down PCO2 up Acidosis
• M Metabolic
• E Equal pH up HCO3 up
  Alkalosis pH down HCO3 down Acidosis

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NCLEX Time

• Of the following clients, which would be
  appropriate to assign to an LPN?
• A.A 20-year-old man on a ventilator with a
  history of tension pneumothorax and currently
  awaiting transport to another hospital
• B.A 59-year-old postoperative woman with a
  history of pulmonary embolism who is receiving
  subcutaneous heparin
• C.A 65-year-old woman with acute respiratory
  distress syndrome who is on a ventilator and has
  a history of gastrointestinal bleeding
• D.An 80-year-old man with a history of cancer of
  the larynx who is receiving CPAP ventilation
  through his tracheostomy

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NCLEX Time

• Of the following orders which would the nurse do
  first on a client who was intubated 30 minutes
  ago for acute respiratory distress syndrome?
• A.Hang Levaquin 500 mg IV and D5 ½ normal saline.
• B.Obtain aerobic and anaerobic sputum culture.
• C.Increase ventilator rate as needed to keep
  between 16 and 20 breaths/min.
• D.Obtain arterial blood gases (ABGs) and
  pulmonary wedge pressure via the arterial line.

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NCLEX Time

• Of the following tasks, which is appropriate to
  delegate to a new graduate nurse working with
  you?
• A.Assessing respiratory system on a ventilated
  client with a history of barotrauma
• B.Telephoning the cardiologist regarding a client
  you have just assessed who is complaining of
  shortness of breath and has noted ST depression
• C.Administering Plavix to a client with a
  pulmonary embolism and paraplegia secondary to a
  spinal cord injury
• D.Stripping the chest tube on a client with a
  left hemothorax from a motor vehicle collision
  sustained 12 hours earlier

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NCLEX Time

• Which of the following patients need immediate
  attention?
• A.The 89-year-old male ventilated patient
  intermittently coughing
• B.The 74-year-old female ventilated patient with
  noted tracheal deviation
• C.The 57-year-old male patient recently extubated
  and complaining of a sore throat
• D.The 40-year-old woman on BiPAP for asthma and
  with increased anxiety

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NCLEX Time

• Which of the following clients should the
  medical-surgical nurse consider transferring to
  the intensive care unit?
• A.The 75-year-old client with a diagnosed
  pulmonary embolism who is receiving heparin and
  who currently is experiencing hemoptysis
• B.The 63-year-old client with deep vein
  thrombosis receiving lowmolecular-weight heparin
  and who has no calf pain
• C.The 59-year-old client with a right
  pneumothorax currently being treated with a chest
  tube and oximetry of 96 on room air
• D.The 30-year-old client with a history of being
  intubated 3 days ago and is currently on nasal
  cannula oxygen with clear lung sounds
  bilaterally

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NCLEX Time

• After starting oxygen 40 by face mask to a
  client with respiratory failure, an arterial
  blood gas is obtained. Which change would require
  immediate attention?
• A.pH changes from 7.37 to 7.32
• B.PaO2 increases from 56 to 60
• C.PaCO2 increases from 47 to 55
• D.O2 Sat remains at 88