T2 Respiratory Problems Ch.32 Flashcards Preview

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Flashcards in T2 Respiratory Problems Ch.32 Deck (75)
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Gas exchange is the process by which oxygen is transported to cells and carbon dioxide is transported from CELLs

Gas exchange

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Adequate arterial blood flow through the peripheral tissues (peripheral perfusion) and organs (central perfusion) Act of blood flowing

Perfusion

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Gas exchange and perfusion -

Acute or chronic problems more common?

Which is worse ? Why?

How to prevent ?

Chronic problems are more common

but acute problems can cause issues with gas exchange and perfusion and cause death

Prompt recognition is critical in preventing serious long term complications to patients

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an inadequate blood supply to an organ or part of the body

Ischemia

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deficiency in the amount of oxygen reaching the tissues

Hypoxia

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an absence or deficiency of oxygen reaching the tissues; severe hypoxia

Anoxia

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the spreading of something more widely

Diffusion

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occurs when the diffusion of gases (oxygen and carbon dioxide) becomes impaired because of
Ineffective ventilation
Reduced capacity for gas transportation (reduced hemoglobin and/or red blood cells)*
Increased need for oxygen
Inadequate perfusion

Prompt recognitions is essential!!

Impairment of gas exchange

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Slide 6

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10

Slide 7

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Causes of impaired gas exchange

Pulmonary embolism
Acute respiratory failure
Acute respiratory distress syndrome
Chest trauma

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Collection of particulate (blood clot, fat, air, oil etc) that enters the venous circulation and becomes lodged in the pulmonary vessels*

If large enough can Cause: emboli obstruct pulmonary blood flow and leads to impaired gas exchange, hypoxia

Any substance can form an embolism but blood clot is most common*

Common preventable death!- often with decreases mobility after surgery

Pulmonary embolism

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Collection of particulate matter—solids, liquids, air—that enters venous circulation and lodges in pulmonary vessels usually occurs when a blood clot from a venous thromboembolism in leg or pelvic vein breaks off and travels through the vena cava into the right side of the heart.

Clot then lodges in pulmonary artery or one if its branches causing impaired gas exchange. Unoxygenated blood travels through body causing hypoxemia.

May be most common preventable death but often misdiagnosed

Pulmonary embolism with infarction.

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Risk factors for pulmonary embolism

Prolonged immobilization
-Central venous catheters
Surgery
-Obesity
-Advancing age
Conditions that increase blood clotting
History of thromboembolism

Also smoking, pregnancy, birth control (estrogen), heart failure, cancer and trauma

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long bone fracture (femur)**

Risks?

Fat embolism risk

Fat emboli don’t block blood flow but injure blood vessels and cause ARDS risk

Femur is most common

Can happen with humorous break

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A nurse is caring for an older adult client who had a femoral head fracture 24 hours ago and is in skin traction. The client has sudden onset of dyspnea, confusion, and tachycardia. The nurse suspects the client developed which of the following complications?
A. Pneumothorax
B. Pneumonia
C. Fat embolism
D. Mucoid plug in the airway

C.

(Long bone fracture)

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Pulmonary embolism prevention?

Tx

Smoking cessation

Weight reduction

Increased physical activity

Ambulate soon after surgery

If traveling or sitting for long periods, get up frequently and drink plenty of fluids

Refrain from massaging/compressing leg muscles

Stop smoking especially women on birth control

Patients at risk for VTE: preventative heparin, IVC filter
Chart 32-1 Prevention of PE*

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Pulmonary embolism s/s

Respiratory-

Cardiac-

Mental-

Respiratory:
Dyspnea, tachypnea, pleuritic chest pain (deep breaths hurts), dry cough-blood may be present, hemoptysis, crackles

Cardiac-

Tachycardia, distended neck veins, syncope(loc), cyanosis, systemic hypotension, abnormal heart sounds (S3 or S4), abnormal ECG, chest pain

Hypoxemia-can trigger anxiety, restlessness and sense of impending doom

Chart 32-2

PE patients are critically ill

Range from vague, nonspecific discomforts to hemodynamic collapse, cardiac arrest, and death

Symptoms relate to decrease gas exchange

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PE dx?

ABGs
Hyperventilation leads to resp alkalosis

Shunting causes increases PaCo2 leading to resp acidosis with out oxygen gas exchange.

Tissue hypoxia can cause metabolic acidosis

Labs: troponin(to rule out cardiac with chest pain symptoms), d-dimer- determines clotting factors in blood

Imaging assessment

Pulmonary angiography (gold standard)*

CT- (cat scan with contrast) next best

VQ Scan- if allergic to contrast dye

Chest X-ray- rule out other s/s

Doppler ultrasound-find source of blood clot

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- Pulmonary embolism

moving blood from right to left side of heart without picking up oxygen (decreased gas exchange)

____doesn’t diagnose PE but if its low, can usually be ruled out. If its high then more testing needs to be done

_______Is gold standard but not always available

_____is next best option

VQ scan is not commonly performed but is useful in some situations (allergy to contrast)

CXR can rule out other causes but not diagnose PE

Doppler: check for VTE

Shunting

D-dimmer

Pulmonary angio- gold standard

CT - next best

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Major complications of PE

______decrease exchange
_______inadequate blood circulation to left ventricle
_______from anticoagulation
_______due to hypoxemia

Hypoxemia
Hypotension
Potential for excessive bleeding
Anxiety

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Tx of PE?

Oxygen therapy (nasal cannula, mask, possible mechanical ventilation)

Continuous patient monitoring

Obtain adequate venous access

Continuous monitoring of pulse oximetry

Drug therapy*
Anticoagulants
Fibrinolytics- emergency situation - breaks down clots much faster.

PTT - lab to monitor with heparin before starting med. infusion - check frequently until reach goal level. While on patient is transfered to Coumadin or something more long term.

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PE nursing interventions

Antidotes for heparin, protamine sulfate, Coumadin

Lab to check before starting heparin

Notify rapid response, reassure patient, elevate head of bed, o2 therapy

Usually nonsurgical but in some cases invasive procedures are needed.

Monitor: assessment, vital signs, lung sounds, dysrhythmias, JVD, edema

Anticoagulants: heparin, lovenox, arixtra: check patients PTT before and during
Heparin 5-10 days then Coumadin or xarelto

Fibrinolytics: alteplase for use when patient in shock or hemodynamic collapse

Know antidotes:

Heparin-protamine sulfate

Warfarin vitamin K

fibrinolytics- clotting factors, FFP, and aminocaproic acid.

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PE-

Discuss assigned anticoagulation/ fibrinolytic medication and find answers to the following questions:

Benefits vs risks
Monitoring
Safety considerations
Patient education
Antidote

Heparin
Warfarin
Lovenox
Xarelto
Alteplase

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How to manage hypotension in PE?

IV fluid

Medications to increase cardiac output

Medications to maintain blood pressure
Goals:

Normal pulse and BP

U/O of at least 0.5-1 mL/kg/hr - adequate perfusion

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Manage risk for excessive bleeding in PE how?

At risk for bleeding due to anticoagulant or fibrinolytic therapy

Ensure antidotes to anticoagulant or fibrinolytic are available

Assess appropriate lab values

Assess for evidence of bleeding

Watch for Petechiae, bruising, oozing, etc


Great resources for bleeding precautions in book

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Minimize anxiety in PE how?

Oxygen therapy
Therapeutic communication
Antianxiety medications

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Surgical interventions for PE


Useful when patients are contraindicated for fibrinolytics-


Used in high risk patients and when anticoagulation can’t be used-

Embolectomy-
Useful when patients are contraindicated for fibrinolytics

Placement of IVC filter-
Used in high risk patients and when anticoagulation can’t be used

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Either ventilation or perfusion is mismatched, gas exchange reduced

Can be ventilator failure, oxygenation failure, or combination

Classified by ABG values

Patient is always hypoxemic

Acute Respiratory Failure

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ABG values*
Pao2 <60 mm Hg
OR
Paco2 >45 mm Hg with pH <7.35
With
Sao2 <90%;

Either ventilation or perfusion is mismatch= reduced gas exchange

Acute respiratory failure -resp acidosis