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DAY 7
PULMONARY EDEMA,PULMONARY EMBOLISM,
ADULT RESPIRATORY DISTRESS SYNDROME
Rebecca Maier, BSNOctober 23, 2015Adult Health Nursing 7th EdATI PN Adult Medical Surgical Nursing Ed 9.0ATI Pharmacology for Nurses Ed 6.0
PULMONARY EDEMA Etiology/Pathophysiology -accumulation of serous fluid in the interstitial lung tissue and alveoli -Severe left ventricular failure. -Inhalation of irritating gases. -Rapid administration of IV fluids -whole blood -plasma -fluids) -Barbiturate or opiate overdose.
PULMONARY EDEMA -Cardiogenic pulmonary edema -usually accompanies cardiac disease -failure of the left ventricle -pooling of fluid -back up into the left atrium, pulmonary veins and capillaries. -pulmonary capillary pressure exceeds the intravascular pressure -serous fluid is rapidly forced into the alveoli. -fluid then reaches the bronchioles -“drown” in their own secretions. -symptoms of respiratory distress.
CLINICAL MANIFESTATIONS -Dyspnea -Tachypnea -Tachycardia -Cyanosis -Pink-tinged(or blood-tinged) frothy sputum -Restless/agitation -secondary to hypoxia
BLOODY AND PINK-TINGED SPUTUM
ASSESSMENT SUBJECTIVE: -complaints of: -severe dyspnea -feeling of impending doom.
ASSESSMENT OBJECTIVE: -observe for signs of respiratory distress: -nasal flaring -sternal retractions with inspiration -hypertension -restlessness -tachycardia -Auscultation -wheezes and crackles -Sudden weight gain -fluid retention -Decreased urinary output -retained fluid). -Productive cough of frothy, pink sputum.
DIAGNOSTIC TESTS -Chest x-ray -fluid infiltrates -enlarged heart -increased pleural space fluid -ABG -PaO2 and PaCO2 levels may be altered -Sputum culture
-Pulse oximetry -decreased oxygen saturation levels
MEDICAL MANAGEMENT
-Oxygen therapy -Intubation/ mechanical ventilation -IV infusion -D5LR -less than 30ml/hr
MEDICAL MANAGEMENT -Medications: -diuretic to reduce systemic and alveolar edema -Lasix -opioid analgesic -Morphine Sulfate -decreases anxiety -decreases the respiratory rate -reduces venous return -dilate both the pulmonary and systemic blood vessels -improving the exchange of gases
MEDICAL MANAGEMENT -cardiotonic glycoside -Digoxin -treats the underlying causative conditions
NURSING INTERVENTIONS -Accurate assessment/documentation -identify any changes in the patient condition: -respiratory rate and rhythm -I & O -Vital signs -ABG's -pulse oximetry -electrolyte values. -Oxygen therapy -Venturi mask (40-70%)
NURSING INTERVENTIONS CONT.
-Mechanical ventilation -oral care -tracheostomy care -High-Fowler’s position -Patent IV line -keep the vein open -fluid infusing at 30mL/hr. -Monitor cardiac status -I & O
PATIENT AND FAMILY TEACHING
-Effective breathing techniques. -Medications -Low-sodium diet -refer to a dietitian -Signs/symptoms that would indicate a change in health status: -productive cough -activity intolerance -dyspnea -Emotional support/reassurance
PULMONARY EMBOLUS Etiology/Pathophysiology -Passage of a foreign substance, into the pulmonary artery or its branches -obstruction of blood supply to lung tissue and subsequent collapse of the lung -blood clot -fat -air -amniotic fluid Patients at risk: -prior thrombophlebitis. -recent surgery -pregnancy/birth. -long-term contraceptive usage -long-term history of congestive heart failure -obesity -immobilization from fracture
WHAT CAUSES THIS PULMONARY EMBOLUS? -Venous stasis/venous wall injury -increased coagulability of blood -formation of a venous thrombosis. -deep veins of the legs -dislodges and travels through the veins -right side of the heart -lodged into a pulmonary artery.
WHAT CAUSES THIS PULMONARY EMBOLUS? -pulmonary embolus obstructs blood flow -ventilation/perfusion mismatch
occurs -area of lung is ventilated, but not
perfused -obstruction hinders oxygenation of the
blood. -atelectasis develops -pulmonary vascular resistance increases -arterial hypoxia develops
PULMONARY EMBOLUS
CLINICAL MANIFESTATIONS -Sudden, sharp, constant, non- radiating, pleuritic chest pain -worsens with inspiration -Acute, unexplained dyspnea -Tachypnea -Small areas of pulmonary infarction -hemoptysis -increased temperature -increased WBC count -pleuritic chest pain
CLINICAL MANIFESTATIONS -Large areas of infarction: -hypoxia -hypotension -tachypnea -diaphoresis -Regional bronchoconstriction -Atelectasis -Pulmonary edema develop -Decreased pulmonary surfactant production -Wheezes/decreased breath sounds
ASSESSMENT SUBJECTIVE: -Dyspnea -presence and degree -Chest pain -Associated risk factors
ASSESSMENT OBJECTIVE: -Asses pleuritic pain -Cough -Breath sounds -crackles -decreased breath sounds -pleural friction rub over the affected area -Vital signs -tachycardia and tachypnea -Air hunger -level of anxiety.
DIAGNOSTIC TESTS -ABG test -shows hypoxia -Chest x-ray. -initially, it is normal -after 24 hours, it will show small infiltrates -secondary to atelectasis -enlarged pulmonary artery. -Helical or spiral CT scan -pulmonary vasculature. -Pulmonary arteriogram -D-dimer test -fibrin degradation -changes to a less complex form
DIAGNOSTIC TESTS
-Plasma D-dimer -normal -68-494 mg/mL -thrombus or embolus is
present -> than 1591 mg/mL -venous Doppler study (ultrasound) -venous scanning -look for a DVT.
VENOUS DOPPLER
MEDICAL MANAGEMENT
-Oxygen -Inferior vena cava filter -retains the emboli, -prevents their migration to
other parts of the body -Anticoagulant therapy -per MD order
NURSING INTERVENTIONS
-Thromboembolic disease stockings (TEDs) -elevate the legs. -check the peripheral pulses frequently -every 2-4 hours -measure and compare the calf
circumferences -elevate the head of the bed slightly -30 degrees -Oxygen -mask or cannula. -deep breathing and coughing.
NURSING INTERVENTIONS -encourage fluids -restrict activity to bathroom privileges for a few days, then gradually increase activity. -assess for bleeding: -hemoptysis -nosebleed -excessive bruising -bleeding from gums or rectum.
PATIENT AND FAMILY TEACHING -Medication teaching -Oral anticoagulants -lifelong regimen -assess the patient’s knowledge base -expand on it. -Prevention of venous pooling: -position changes -wearing nonrestrictive clothing -not crossing the legs for a prolonged period of time -avoiding standing in one place for a prolonged period of time
PATIENT AND FAMILY TEACHING CONT. -TED hose -reason for usage -on in the morning before getting out of bed -off at bedtime (unless ordered otherwise)-signs/symptoms of pulmonary embolism: -dyspnea -chest pain -blood-tinged sputum -blood in the urine -report these findings to the PCP.
COMPRESSION STOCKINGS
ADULT RESPIRATORY DISTRESS SYNDROME (ARDS)
Etiology/Pathophysiology -complication that occurs as a result of other disease processes. -causes: -viral -bacterial pneumonia -chest trauma -sepsis -fat emboli -near drowning -sepsis is the most common precursor of ARDS. -sequelae of ARDS -remains the same no matter what the cause is
ARDS -increased capillary permeability in the alveolar capillary membrane. -fluid leaks into the interstitial spaces/alveoli -pulmonary edema and hypoxia -alveoli lose their elasticity and collapse -blood to be shunted through the impaired alveoli -interferes with O2 transport -damaged capillaries allow plasma and RBCs to leak out, resulting in hemorrhage. -process results from vasoconstriction -pulmonary artery HTN
PULMONARY HEMORRHAGE
CLINICAL MANIFESTATIONS -12-24 hours after the injury -hypovolemic shock -lung tissue damage -5-10 days after sepsis -respiratory distress -altered breath sounds -changes in level of consciousness -hypoxia. -tachycardia -hypotension -decreased urinary output
ASSESSMENT SUBJECTIVE: -background information -history of the present illness.
OBJECTIVE: -assess for any change in the patient’s condition -small or large -respirations -rate, rhythm, and effort -dyspnea -nasal flaring -substernal/subclavicular retractions -cyanosis
ASSESSMENT -Auscultate the lungs: -crackles -wheezing. -Level of consciousness (LOC) -increased restlessness/lethargy -assess at least every 2-4 hours
DIAGNOSTIC TESTS
1. Pulmonary function tests (spirometry test)
2. ABG test 3. Chest X-ray
MEDICAL MANAGEMENT -adequate oxygenation. -treat the cause. -medications -corticosteroids -diuretics -morphine sulfate -digoxin -antibiotics -Nitric oxide -experimental treatment -inhaled gas -local vasodilatation -maximizes perfusion in ventilated areas of the lungs
NURSING INTERVENTIONS
-adequate oxygenation/ventilation -treat the multisystem responses -pulse oximetry -prone position -some patients respond better -assess cardiac function -rate and rhythm -vital signs and temperature -every 2-4 hours -sputum cultures -if the temperature increases
PATIENT AND FAMILY TEACHING -effective breathing and coughing techniques -frequent position changes. -medications -purposes -side effects -inform patient and family of any procedures -intubation
