abc 2011 2012 respiratory disorders
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TRANSCRIPT
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RESPIRATORY DISORDERS
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DIFFERENCE OF A CHILD’S AIRWAY ANATOMY FROM AN ADULT
The back of the head of a child is slightly larger, so positioning requires more care
The tongue is proportionately larger and more anterior in the mouth
The trachea is smaller in diameter and more flexible
The airway itself is lower and narrower
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ACUTE RESPIRATORY FAILURE
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ACUTE RESPIRATORY FAILURE
A clinical condition in which the pulmonary system fails to maintain adequate gas exchange
Most common organ failure in the ICU Mortality rate: 22% to 75% Results from a deficiency in the performance of the
pulmonary system Usually occurs secondary to another disorder that has
altered the normal function of the pulmonary system in such a way as to decrease the ventilatory drive, decrease muscle strength, decrease chest wall elasticity, decrease lung’s capacity for gas exchange, increase airway resistance, or increase metabolic O2 requirements
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ETIOLOGY - EXTRAPULMONARY
Brain – drug overdose, brain trauma or lesion, post-op anesthesia depression
Spinal cord – Guillain-Barre syndrome, poliomyelitis, spinal cord trauma or lesion
Neuromuscular system – Myasthenia gravis, Multiple sclerosis, neuromuscular-blocking agents, organophosphate poisoning
Thorax – massive obesity, chest trauma Pleura – pleural effusion, pneumothorax Upper airways – sleep apnea, tracheal obstruction,
epiglottitis
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ETIOLOGY - INTRAPULMONARY
Lower airways and alveoli – COPD, asthma, bronchiolitis, pneumonia
Pulmonary circulation – pulmomary emboli
Alveolar-capillary membrane – acute lung injury, inhalation of toxic gases, near-drowning
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Extrapulmonary and intrapulmonary disorders
Insufficient oxygen to meet metabolic demands
Hypoxemia
Blood passes through alveoli that are underventilated
V/Q mismatch
Blood reaches the arterial system without participating in gas exchange
Mixing of unoxygenated and oxygenated blood
Alveolar hypoventilation
Blood passes through a portion of a lung that is not ventilated
Intrapulmonary shunting
Hypercapnia
Acidosis
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ASSESSMENT AND DIAGNOSIS
Clinical manifestations are related to the development of hypoxemia, hypercapnia, and acidosis
Clinical manifestations are so varied that they considered unreliable in predicting the degree of hypoxemia or hypercapnia or the severity
ABG: PaO2 less than 60 mm Hg and the PaCO2 is greater than 45 mm Hg
Bronchoscopy, chest X-ray, thoracic CT
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NURSING DIAGNOSIS PRIORITIES
Impaired gas exchange related to alveolar hypoventilation
Impaired gas exchange related to ventilation/perfusion mismatching or intrapulmonary shunting
Ineffective breathing pattern related to musculoskeletal fatigue or neuromuscular impairment
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MEDICAL MANAGEMENT
Aimed at treating the underlying cause, promoting adequate gas exchange, correcting acidosis, initiating nutrition support, and preventing complications
Medical interventions to promote gas exchange are aimed at improving oxygenation and ventilation
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1. OXYGENATION
Purpose is to correct hypoxemia – aim is to keep the arterial hemoglobin oxygen saturation greater than 90%
Goal is to keep the tissues’ needs satisfied but not produce hypercapnia or oxygen toxicity
Supplemental oxygenation administration is effective in treating hypoxemia related to alveolar hypoventilation and V/Q mismatching
Positive pressure is necessary when there is intrapulmonary shunting (to open collapsed alveoli) can be delivered via nasal or oronasal mask (to avoid intubation)
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2. VENTILATION
Depending on the underlying cause and severity, the patient may be initially treated with noninvasive ventilation
Mechanical ventilation PEEP – positive end expiratory pressure
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PEEP
Opens collapsed alveoli Stabilizes flooded alveoli Increases FRC However, Decreases cardiac output, decreasing venous
return secondary to increased intrathoracic pressure
Barotrauma, as a result of gas escaping into the surrounding spaces secondary to alveolar rupture
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3. PHARMACOLOGY
Bronchodilators – Beta-agonists and antocholinergic agents
Steroids Sedation can be used to comfort the patient
and decrease the work of breathing, particularly if the patient is fighting the ventilator
Analgesics for pain control Methylxanthines and mucolytics are no longer
used because of their negative side effects
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4. ACIDOSIS - TREATMENT
Once the patient is adequately oxygenated and ventilated, the acidosis should correct itself
Use of sodium bicarbonate has been shown to be of minimal benefit and is no longer recommended, even in the presence of severe acidosis
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5. NUTRITION SUPPORT
Goals are to meet the overall nutritional needs of the patient, while avoiding overfeeding, to prevent nutrition delivery-related complications and to improve patient outcomes
The enteral route is the preferred method of nutrition administration
Parenteral nutrition for those who cannot tolerate enteral feedings or cannot receive enough nutrients enterally
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6. COMPLICATIONS - TREATMENT
Maintaining oxygenation, normalizing electrolytes, and monitoring drug levels will facilitate the prevention and treatment of encephalopathy and dysrhythmias
Venous thromboembolism can be prevented by using compression stockings and low-dose unfractionated heparin or low-molecular weight heparin
GIT bleeding can be prevented through the use of histamine-2 antagonists, cytoprotective agents, or gastric proton pump inhibitors
Patient is at risk of developing complications associated with artificial airway, mechanical ventilation, enteral and parenteral nutrition, and peripheral cannulation
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GUIDELINE VALUES FOR ESTIMATING FIO2 WITH LOW FLOW O2 DEVICES
100% Flow Rate (L/Min) FIO2 (%)
Nasal Cannula or Catheter123456Oxygen Mask5 - 66 - 77- 8 Mask With Reservoir Bag678910
242832364044
405060
6070809099+
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NURSING MANAGEMENT
Optimizing oxygenation and ventilation Providing comfort and emotional
support Maintaining surveillance for
complications Providing patient education
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1. OPTIMIZING OXYGENATION AND VENTILATION
Positioning – the goal is to place the least affected area of the affected lung in the most dependent position
– gravity normally facilitates preferential ventilation and perfusion to the dependent areas of the lungs
- the best gas exchange would take place in the dependent areas of the lungs
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1. OPTIMIZING OXYGENATION AND VENTILATION
Positioning1. Patients with diffuse lung disease may benefit from
being positioned with the right lung down, because it is larger and more vascular than the left lung
2. For those with alveolar hypoventilation, a nonrecumbent position (sitting or semierect) may be beneficial
3. Semirecumbency position can help prevent aspiration and inhibit the development of hospital-associated pneumonia
4. Frequent positioning (at least every 2 hours) is beneficial in optimizing the patient’s ventilatory pattern and V/Q matching
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1. OPTIMIZING OXYGENATION AND VENTILATION
Preventing desaturation – performing procedures as needed: oxygenating before suctioning, providing adequate rest and recovery time between various procedures, and minimizing oxygen consumption
Promoting secretion clearance – providing adequate systemic hydration, humidifying supplemental oxygen, coughing, and suctioning
Note: postural drainage and chest percussion and vibration have been found to be of little benefit in the critically ill patient; to facilitate breathing, the thorax should be maintained in alignment and the head of the bed elevated 30 to 45 degrees
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2. PATIENT EDUCATION
Pathophysiology of the disease Specific etiology Precipitating factor modification Importance of taking medications Breathing techniques (e.g., pursed-lip
breathing diaphragmatic breathing) Energy conservation techniques
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2. PATIENT EDUCATION
Measures to prevent pulmonary infections (e.g., proper nutrition, hand washing, immunization against S. pneumoniae and influenza viruses)
Signs and symptoms of pulmonary infections (e.g., sputum color change, shortness of breath, fever)
Cough enhancement techniques
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COLLABORATIVE MANAGEMENT
Identify and treat underlying cause Administer oxygen therapy Intubate patient Administer medications Position patient to optimize
ventilation/perfusion matching Suction as needed
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COLLABORATIVE MANAGEMENT
Provide adequate rest and recovery time between various procedures
Correct acidosis Initiate nutritional support Maintain surveillance for complications:
encephalopathy, dysrhythmias, venous thromboembolism, GI bleeding
Provide comfort and emotional support
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PNEUMONIA
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PNEUMONIA
An acute inflammation of the lung parenchyma that is caused by an infectious agent that can lead to alveolar consolidation
CAP – community acquired pneumonia HAP – hospital acquired pneumonia VAP – ventilator-associated pneumonia
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PRECIPITATING CONDITIONS OF PNEUMONIA
Condition Etiology
Depressed epiglottal and cough reflexes
Decreased cilia activity
Increased secretions
Atelectasis
Unconsciousness, neurologic disease, endotracheal or tracheal tubes, anesthesia
Smoke inhalation, smoking history, oxygen toxicity, hypoventilation, intubation, viral infections, aging COPD
COPD, viral infections, bronchiectasis, general anesthesia, endotracheal intubation, smoking
Trauma, foreign body obstruction, tumor, splinting, shallow ventilations, general anesthesia
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PRECIPITATING CONDITIONS OF PNEUMONIA
Condition Etiology
Decreased lymphatic flow
Fluid in alveoli
Abnormal phagocytosis and humoral activity
Impaired alveolar macrophages
Heart failure, tumor
Heart failure, aspiration, trauma
Neutropenia, immunocompetent disorders, patients receiving chemotherapy
Hypoxemia, metabolic acidosis, cigarette smoking history, hypoxia, alcohol use, viral infections, aging
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Microorganisms/noninfectious agents
Lower airways
Loss of cough reflex, damage to cilia of the respiratory tract, impaired host defenses
Colonization of the lower respiratory tract
Release of histamine and other vasoactive chemical
mediators
Inhalation/aspiration
Vasodilation
Stage of congestion More and more exudates accumulate
Lung tissue reacts to accumulating exudates and
microorganisms
Hepatization Lung tissue attempts to
undergo healing
Stage of fibrosis
Pulmonary function impaired
Clinical manifestations
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ETIOLOGY
Severe CAP – S. pneumoniae, Legionella species, H. influenzae, S. aureus, M. pneumoniae, respiratory viruses, Chlamydia pneumoniae, and P. aerugionosa
HAP – S. aureus, S. pneumoniae, P. aeruginosa, Acinetobacter baumannii, Klebsiella species, Proteus species, Serratia species, fungi, and respiratory viruses
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ASSESSMENT AND DIAGNOSIS
Ineffective airway clearance related to excessive secretions or abnormal viscosity of mucus
Impaired gas exchange related to ventilatory/perfusion mismatching or intrapulmonary shunting
Risk for infection, risk factor: invasive monitoring devices
Powerlessness related to lack of control over current situation or disease progression
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ASSESSMENT AND DIAGNOSIS
Chest radiograph Sputum Gram stain and culture Diagnostic bronchoscopy CBC with differential count Chemistry panel Blood cultures ABG
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MEDICAL MANAGEMENT
Antibiotic therapy Oxygen therapy Fluid management Nutritional support Treatment of associated medical
problems and complications Therapeutic bronchoscopy may be
necessary in patients who have difficulty mobilizing secretions
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NURSING MANAGEMENT
Optimizing oxygenation and ventilation Preventing the spread of infection Providing comfort and emotional
support Maintaining surveillance for
complications
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COLLABORATIVE MANAGEMENT
Administer oxygen therapy Initiate mechanical ventilation as required Administer medications: antibiotics, bronchodilators Position patient to optimize ventilation/perfusion
matching Suction as needed Provide adequate rest and recovery time between
various procedures Maintain surveillance for complications: acute
respiratory failure Provide comfort and emotional support
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PULMONARY EMBOLISM
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PULMONARY EMBOLISM (PE)
Occurs when a clot (thrombotic emboli) or other matter (nonthrombotic emboli) lodges in the pulmonary arterial system, disrupting the blood flow to a region of the lungs
Majority come form the deep leg veins, particularly the iliac, femoral, and popliteal veins
Other sources: RV, the upper extremities, and the pelvic veins
Nonthrombotic emboli: fat, tumors, amniotic fluid, air, and foreign bodies
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ETIOLOGY
Three predisposing factors: hypercoagulability, injury to the vascular endothelium and venous stasis (Virchow’s triad)
Venous stasis: AF, decreased CO, immobility
Injury to the vascular endothelium: local vessel injury, infection, incision, atherosclerosis
Hypercoagulability: polycythemia
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