CARE OF THE ACUTE PATIENT WITH RESPIRATORY PROBLEMS

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CARE OF THE ACUTE PATIENT WITH RESPIRATORY
PROBLEMS

• By Patricia Speaks, RN, MSN, APRN-BC
• Nursing 422

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Oxygen Delivery Systems

• Nasal Cannula
• Simple Face Mask
• Partial Rebreather Mask
• Non-rebreather Mask
• Venturi Mask
• Other High-Flow Systems

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TRACHEOSTOMY

• Surgical incision
• Temporary or Permanent

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INDICATIONS FOR TRACHEOSTOMY

• Acute airway obstruction
• Airway protection
• Prolonged intubation or need for mechanical
  ventilation
• Control of pulmonary secretions
• Airway reconstruction after laryngeal trauma or
  cancer
• Obstructive sleep apnea

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NURSING DIAGNOSES

• Impaired Verbal Communication
• Imbalanced Nutrition
• Risk for infection
• Impaired oral mucous membrane
• Impaired social interaction

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Postoperative Care

• Ensuring airway
• Confirm bilateral breath sounds
• Assess for complications

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COMPLICATIONS

• Tracheomalacia
• Tracheal stenosis
• Tracheoesophageal fistula
• Trachea-innominate artery fistula

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SEVERE ACUTE RESPIRATORY SYNDROME (SARS)

• New respiratory infection identified in China in
  2002
• Considered an emerging infectious disease as
  identified by the CDC that is expected to
  increase in human incidences in the near future
• More than 8,400 cases reported since 2003

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PATHOPHYSIOLOGY

• A mutated virus from the family called
  coronaviruses
• Have RNA as their genetic material
• Same virus causes many forms of the common cold
• Infects cells of the respiratory tract causing
  inflammation
• Spread via airborne droplets via sneezing,
  coughing and talking
• People at greatest risk for SARS are those in
  close direct contact with an infected person
• Portals of entry are eyes, nose, and mouth

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MANIFESTATIONS

• Fever usually greater than 100.4F
• Headache
• General body aches
• Mild cold symptoms
• Within 2 to 7 days see dry cough and difficulty
  breathing
• Hypoxia with cyanosis
• Low oxygen saturation
• Feeling of breathlessness indicates more severe
  illness
• CXR shows a pattern similar to pneumonia
• Diagnosis made by ruling out other causes
• After 28 days, blood test for antibodies to the
  virus or pieces of the RNA confirms the diagnosis

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INTERVENTIONS

• No known effective treatment
• Standard antibiotics and antiviral drugs are not
  able to kill the virus
• Interventions are to support the clients own
  immune system
• O2 if needed for hypoxia
• Respiratory treatments to dilate the bronchioles
  and move respiratory secretions
• Antibiotics are used to treat a bacterial
  pneumonia that may occur with SARS

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ACUTE RESPIRATORY FAILURE

• Classified by blood gas abnormalities
• PaO2 less than 60 mm Hg SaO2 less than 90
  PaCO2 greater than 50 mm Hg occurring with
  acidemia (pH lt7.30)
• It is ventilatory failure, oxygenation failure,
  or a combination of both

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VENTILATORY FAILURE

• Type of ventilation-perfusion (V/Q) mismatch in
  which perfusion is normal but ventilation is
  inadequate
• Occurs when the thoracic pressure does not change
  sufficiently to permit air movement into and out
  from the lungs
• Too little oxygen reaches the alveoli and carbon
  dioxide is retained
• Leads to hypoxemia
• Result of mechanical abnormality of the lungs, or
  chest wall, a defect in the respiratory control
  center in the brain, or impaired ventilatory
  muscle function especially the diaphragm
• Ventilatory failure is defined by a PaCO2 level
  above 45 mm Hg in clients who have otherwise
  healthy lungs

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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
• Lung perfusion is decreased

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COMBINED VENTILATORY AND OXYGENATION FAILURE

• Poor respiratory movements (hypoventilation)
• Gas exchange at the alveolar-capillary membrane
  is inadequate
• Too little oxygen reaches the blood and carbon
  dioxide is retained

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CAUSES OF VENTILATORY FAILURE

• Multiple sclerosis
• Myasthenia gravis
• Guillain-Barre syndrome
• Poliomyelitis
• Spinal cord injuries
• CVA
• Cerebral edema
• ICP
• Meningitis
• Kyphoscoliosis
• Massive obesity
• COPD

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ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)

• Acute respiratory failure with the following
  indicators
• 1. Hypoxemia that persists even when 100 O2
  is given
• 2. Decreased pulmonary compliance
• 3. Dyspnea
• 4. Noncardiac-associated bilateral pulmonary
  edema
• 5. Dense pulmonary infiltrates on x-ray
• May occur after an acute traumatic even in people
  with no previous pulmonary disease
• Usually a systemic inflammatory response
• The major site of injury in the lung is the
  alveolar-capillary membrane

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ETIOLOGY

• Causes may be due to direct injury to lung tissue
  or indirectly involving the respiratory system
• Direct causes include near-drowning or aspiration
  of gastric contents
• Indirect causes include nervous system injury
  such as head or spinal trauma, strokes, tumors

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MANIFESTATIONS

• Cyanosis
• Pallor
• Retraction intercostally (between ribs)
  substernally (below ribs)
• No abnormal lung sounds are present on
  auscultation because the edema of ARDS occurs
  first in the interstitial spaces and not in the
  airways

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DIAGNOSTIC ASSESSMENT

• The diagnosis is established by a lowered partial
  pressure of arterial oxygen value, determined by
  ABG measurements
• Progressive need for higher concentrations of O2
  due to increased shunting of blood and widening
  alveolar oxygen gradient (increased fraction of
  inspired oxygen FIO2)
• CXR shows whited-out or ground-glass (haziness)

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INTERVENTIONS

• Corticosteriods to decrease WBC movement and
  stabilize the capillary membrane
• RBC transfusion may expand vascular volume
• Diuretics may help to decrease lung edema
• Tube feeding or hyperalimentation may be started
  due to malnutrition

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Arterial Blood Gases

• PaO2 normal 83-100 mm Hg
• Elevation indicates excessive O2 administration
• Decrease indicates COPD, asthma, CA of the
  bronchi/lungs, cystic fibrosis, respiratory
  distress syndrome, anemias
• PaCO2 normal 35-48 mm Hg
• Elevation indicates COPE, asthma, pneumonia, use
  of opiods (respiratory acidosis)
• Decrease indicates hyperventilation/respiratory
  alkalosis
• pH 7.35-7.45
• Elevation indicates metabolic or respiratory
  alkalosis
• Decreased levels indicate metabolic or
  respiratory acidosis
• HCO3 22-26 mEq/L
• Elevation indicates possible respiratory acidosis
  as compensation for a primary metabolic alkalosis
• Decrease indicate possible respiratory alkalosis
  as compensation for a primary metabolic acidosis
• SaO2 94-98
• Decreased levels indicate possible impaired
  ability of hemoglobin to release O2 to tissue

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INTUBATION AND VENTILATION

• Clients with severe problems of gas exchanged
• Usually temporary life-support technique
• Lifelong for clients with chronic, reduced
  ventilation

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NURSING DIAGNOSIS

• Impaired Verbal Communication
• Disturbed Sleep Pattern
• Death Anxiety
• Impaired Oral Mucous Membrane
• Potential for Ventilator-Associated Pneumonia

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INTERVENTIONS

• Endotracheal Intubation (ET tube)
• Preparing for Intubation
• Verifying Tube Placement
• Stabilizing the Tube
• Nursing Care

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TYPES OF VENTILATORS

• Negative-Pressure Ventilators
• Positive Pressure Ventilators
• a. Pressure-cycled
• b. Time-cycled
• c. Volume-cycled

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MODES OF VENTILATION

• Assist control ventilation
• Synchronized intermittent mandatory ventilation
  (SIMV)
• Bi-level Positive airway pressure (BiPAP)

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Ventilator Controls and Settings

• Tidal Volume (Less is better)
• Rate/breaths per minute
• Fraction of inspired O2
• Signs
• Peek airway (inspiratory) pressure
• Continuous positive airy pressure
• Positive end-expiratory pressure
• Flow

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NURSING MANAGEMENT

• Monitor Clients Response
• Manage ventilatory system

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COMPLICATIONS

• Hypotension
• Fluid retention
• Barotrauma
• Volutrauma
• Stress ulcers
• Malnutrition
• Infection
• Muscle deconditioning
• Ventilator dependence