Chapter 34
Care of Critically Ill Patients with
Respiratory Problems
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Chapter 34 Care of Critically Ill Patients with
Respiratory Problems Learning Outcomes
1. Protect the patient receiving mechanical ventilation.
2. Ensure safe management of endotracheal tubes,
tracheostomy tubes, and mechanical ventilators.
3. Identify hospitalized patients at risk for a pulmonary
embolism.
4. Teach people at risk for pulmonary embolism
techniques to reduce the risk.
5. Support the patient and family in coping with changes
in breathing status and the need for mechanical
ventilation.
6. Provide emotional support to patients experiencing
acute respiratory difficulties.
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Chapter 34 Care of Critically Ill Patients with
Respiratory Problems Learning Outcomes (Continued)
7. Assess the respiratory status of any patient who
develops sudden-onset respiratory difficulty or acute
confusion.
8. Use laboratory data and clinical manifestations to
evaluate the adequacy of oxygenation and ventilatory
interventions.
9. Coordinate nursing care for the patient being
mechanically ventilated.
10. Maintain a patent airway on anyone who has
experienced chest trauma.
11. Describe a variety of conditions that result from chest
trauma and their common treatments.
12. Describe critically ill patients and the related nursing
interventions and rationales.
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Chapter 34 Care of Critically Ill Patients with
Respiratory Problems
*Pulmonary embolism*
Acute respiratory failure
Acute respiratory distress syndrome
The patient requiring intubation and
ventilation
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Chapter 34 Care of Critically Ill Patients with
Respiratory Problems (Continued)
Chest Trauma
Pulmonary contusion
Rib fracture
Flail chest
Pneumothorax
Tension pneumothorax
Hemothorax
Tracheobronchial trauma
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Pulmonary Embolism
• Collection of particulate matter—solids,
liquids, air—that enters venous circulation
and lodges in pulmonary vessels
• Usually occurs when blood clot from a VTE
in leg or pelvic vein breaks off; travels
through vena cava into right side of heart
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Pulmonary Embolus
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Risk Factors
•
•
•
•
•
•
•
Prolonged immobilization
Central venous catheters
Surgery
Obesity
Advancing age
Conditions that increase blood clotting
History of thromboembolism
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Health Promotion & Illness
Prevention
•
•
•
•
Smoking cessation
Weight reduction
Increased physical activity
If traveling or sitting for long periods,
get up frequently and drink plenty of
fluids
• Refrain from massaging
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Clinical Manifestations
• Respiratory
– Dyspnea, tachypnea, tachycardia,
pleuritic chest pain, dry cough,
hemoptysis
• Cardiac
– Distended neck veins, syncope, cyanosis,
systemic hypotension, abnormal heart
sounds, abnormal ECG, tachycardia
• Low grade fever, petechiae, flu-like
symptoms
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Laboratory Assessment
• ABGs -> alkalosis then acidosis
• PaO2 – FiO2 ratio falls
• Imaging assessment
– Chest x-ray
– Computed tomography
– Transesophageal Echocardiography
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Laboratory Assessment (cont)
• D-dimer:
A fragment produced during the degradation of a clot. The D
here stands for domain. Dimer indicates two identical units, in
this case two identical domains. D-dimer result from complete
breakdown of the clot. Monoclonal antibody to the D-dimer
fragment provide the basis for the main methods of detecting
it. The presence of D-dimers in the blood is a reliable clue that
clotting has begun. Sometimes used as a clinical marker for
pulmonary embolism blood clot in the lung) or deep venous
thrombosis (DVT) (blood clot in the leg) Sometimes written ddimer or D-Dimer
http://www.medterms.com/script/main/art.asp?articlekey=2
4476)
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Nonsurgical Management
•
•
•
•
•
Oxygen therapy (nasal cannula, mask)
Continuous patient monitoring
Obtain adequate venous access
Continuous monitoring of pulse oximetry
Drug therapy
– Anticoagulants
– Fibrinolytics
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Interventions
• Ensure appropriate antidotes are present
on the nursing unit!
• Assess for bleeding every 2 hr
• Examine all stool, urine, drainage, vomitus
for gross blood; test for occult blood
• Monitor laboratory values
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Surgical Management
• Embolectomy
• Inferior vena cava filtration (example –
Greenfield http://emedicine.medscape.com/article/419796-overview )
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Community-Based Care
• Home care management
• Teaching for self-management
• Health care resources
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Acute Respiratory Failure
• ABG value of
PaO2 <60 mm Hg, SaO2; <90%; or
PaCO2 >50 mm Hg with pH <7.30
• 3 types of ARF- see next slides
• Patient is always hypoxemic regardless of
the underlying problem
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Ventilatory Failure
• Physical problem of lungs or chest wall
• Defect in respiratory control center in brain
• Poor function of respiratory muscles,
especially diaphragm
• Extrapulmonary causes
• Intrapulmonary causes
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Oxygenation Failure
• Insufficient oxygenation of pulmonary
blood at alveolar level
• Ventilation normal, lung perfusion
decreased
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Combined Ventilatory/Oxygenation
Failure
• Often occurs in patients with abnormal
lungs (e.g., chronic bronchitis, emphysema,
asthma attack)
• Diseased bronchioles and alveoli cause
oxygenation failure; work of breathing
increases; respiratory muscles unable to
function effectively and therefore causes
ventilator failure
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Dyspnea Interventions
• Oxygen therapy
• Position of comfort
• Relaxation, diversion, guided imagery
• Energy-conserving measures
• Drugs
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Acute Respiratory Distress Syndrome
(ARDS)
• Persisting hypoxia
• Decreased pulmonary compliance
• Dyspnea
• Noncardiac-associated bilateral pulmonary
edema
• Dense pulmonary infiltrates seen on x-ray
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Causes of Lung Injury in ARDS
• Systemic inflammatory response is
common pathway
• Alveolar-capillary membrane injured
– Intrinsic causes—sepsis, shock
– Extrinsic causes—aspiration, inhalation injury
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Diagnostic Assessment
• Lower PaO2 value on ABG
– refractory hypoxemia -Increasing supplemental
oxygen does not cause an increase in PaO2
levels
• “Whited-out” (ground glass) appearance to
chest x-ray
• Sputum culture
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Interventions
• ET intubation and conventional mechanical
ventilation
• Drug – corticosteroids – when to initiate
and how much to give is controversial
• Fluid therapy – controversial – how much is
too much
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Interventions (cont)
• Nutrition therapy
• Case management
– Phase 1 to Phase 4
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Endotracheal Tube
A, Endotracheal tubes. B, Correct placement of an oral endotracheal tube.
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Verifying Tube Placement
• End-tidal carbon dioxide levels
• Chest x-ray
• Assess for breath sounds bilaterally,
symmetrical chest movement, air emerging
from ET tube
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Stabilizing the Tube
Do not tape the tube too tightly to the nose or skin
breakdown will occur on the naris.
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Endotracheal Tubes: Nursing Care
• Assess tube placement, minimal cuff leak,
breath sounds, chest wall movement
• Prevent movement of tube by patient
• Check pilot balloon
• Soft wrist restraints – last resort and all laws
apply
• Mechanical sedation
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Mechanical Ventilation
• Purpose is to support and maintain
gas exchange
• Ventilation does not cure diseased
lungs
• Variety of ventilators used
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Nursing Management
• Always assess patient first, ventilator
second
• Monitor patient response
• Manage ventilator system
• Prevent complications!
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Complications
• Cardiac:
– Hypotension 2⁰ positive pressure that
increases chest pressure thereby
inhibiting venous blood return to the
heart
– Fluid retention 2⁰ decreased cardiac
output
– Valsalva maneuver - avoid
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Complications (cont’d)
• GI – stress ulcers
• Nutritional – malnutrition – effects muscles
– diaphragm and intercostals
• Infections—ventilator-associated
pneumonia (VAP)
• Muscle deconditioning
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Weaning
• Process of going from ventilator
dependence to spontaneous breathing
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Extubation
•
•
•
•
•
•
Hyperoxygenate patient
Thoroughly suction ET and oral cavity
Rapidly deflate ET cuff
Remove tube at peak inspiration
Instruct patient to cough
Monitor patient every 5 min; assess
ventilatory pattern for respiratory distress
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Chest Trauma
• About 25% of traumatic deaths result from
chest injuries
– Pulmonary contusion
– Rib fracture
– Flail chest
– Pneumothorax
– Tension pneumothorax
– Hemothorax
– Tracheobronchial trauma
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Pulmonary Contusion
• Potentially lethal injury
• May be asymptomatic at first, later develop
respiratory failure
• Bloody sputum, decreased breath sounds,
crackles, wheezes
• Treatment—maintenance of ventilation and
oxygenation
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Rib Fracture
• Chest usually not splinted by tape or other
materials
• Main focus—decrease pain so adequate
ventilation is maintained
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Flail Chest
• Paradoxical chest movement—“sucking
inward” of loose chest area during
inspiration, “puffing out” of same area
during expiration
• Treatment: humidified oxygen, pain
management and promotion of lung
expansion
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Flail chest. Normal respiration: A, Inspiration; B, Expiration. Paradoxic
motion: C, Inspiration—area of the lung underlying unstable chest wall
sucks in on inspiration; D, Expiration—unstable area balloons out. Note
movement of mediastinum toward opposite lung during inspiration.
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Pneumothorax
• Air in the pleural space around the
lungs
• Severity depends on the amount of
the lung collapsed
• Treatment: chest tube to allow the
air to escape and allow the lung to
re-inflate
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Tension Pneumothorax (cont’d)
• Category of Pneumothorax
• Air leak in the lung or chest wall that
can’t exit on expiration
• If it gets bad enough, there is tracheal
movement away from the midline
toward the unaffected side.
• Treatment
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Tension Pneumothorax
Left: Pneumothorax.
Right: Tension pneumothorax on the left with mediastinal shift to the right.
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Hemothorax
Left: Hemothorax. The amount of blood that can accumulate in the thoracic cavity (leading to
hypovolemia) is a much more severe condition than the amount of lung compressed by this blood
loss.
Right: Right hemothorax.
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Tracheobronchial Trauma
• Caused by blunt trauma, rapid deceleration
• Tracheal lacerations
• Upper airway obstruction
• Cricothyroidotomy, tracheotomy
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A 65-year-old woman is brought to the ED by
her husband with new onset shortness of
breath. She had an abdominal hysterectomy 5
days ago. Her husband states that she stayed
in bed since she was discharged from her
surgery 48 hours ago, because she feels very
short of breath when she gets up.
What risk factors are present for DVT?
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• Prolonged immobility; advancing age; recent
surgery
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(cont’d)
During triage, the following vital signs and
assessments are noted:
Temp – 99.6° F
BP – 80/44 mm Hg
P – 126 (sinus tachycardia)
R – 28 and labored
O2 saturation – 84% (room air) Crackles bilaterally
Petechiae across chest and in axillae
Based on these findings, what do you suspect might
be happening with the patient?
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• The patient may have a pulmonary embolism. She
could also have pneumonia based on her recent
surgery and immobility. Further assessment should
be performed to ascertain the specifics of her
symptoms.
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(cont’d)
When the ED physician is notified of the patient’s manifestations,
she is moved immediately to a treatment room. The physician
writes the following orders:
– O2 at 2 L per nasal cannula
– Stat CBC, BMP, D-dimer, aPTT, INR
– Stat CT of the chest
– Start a saline lock
Which order takes priority at this time?
1. Oxygen
2. Saline lock
3. Labs
4. CT
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• Based on the patient’s pulse oximetry reading,
the priority order is the administration of
oxygen. Next, the saline lock should be
started. Once the vein is accessed, blood can
also be obtained for the CBC, BMP, D-dimer,
PTT, and INR. After the laboratory specimens
are sent, the radiology department can be
notified to perform the stat CT of the chest.
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(cont’d)
While in the treatment room, the patient says she needs to use the
bathroom. The nursing assistant is delegated this task.
What is the best approach for the nursing assistant to take?
A. A. Place the patient on a bedpan and stay with her until she is
finished.
B. B. Ambulate her into the hall bathroom on room air and stand
outside the door until she is done.
C. C. Ask the provider for an indwelling catheter because of her
shortness of breath when she ambulates.
D. D. Tell her to try to wait until the shortness of breath subsides.
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• ANS: A
• The nursing assistant should place the patient on
a bedpan and stay with her. She is too short of
breath to ambulate to the bathroom and she
should remain on the oxygen at all times. The
nursing assistant should not ask the provider
about an indwelling catheter because this would
only increase the possibility of a UTI. The patient
should never be told to try to wait, because this
could also increase the risk for UTI.
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(cont’d)
Two hours later, the patient is admitted to the medical unit
where she is started on a continuous IV heparin weightbased protocol.
Which finding indicates that the heparin infusion is
therapeutic?
A.
B.
C.
D.
INR is less than 1
INR is between 2 and 3
aPTT is the same as the control
aPTT is 1.5 to 2.5 times the control
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• ANS: D
• When a patient is started on continuous
heparin, the aPTT is drawn before therapy is
started and then every 4 hours until a
therapeutic range of 1.5 to 2.5 times the
control is reached. Thereafter, the aPTT is
checked daily.
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(cont’d)
Three days later, the provider prepares to discharge the patient on
warfarin (Coumadin).
Which teaching points do you include about this therapy? (Select all that
apply.)
A. “Be sure to have follow-up INR laboratory tests done.”
B. “Report any bruising or bleeding to your provider.”
C. “Consume lots of foods that are rich in vitamin K, such as green leafy
vegetables.”
D. “Use a soft toothbrush to brush your teeth and an electric razor to
shave your legs.”
E.
“A skin rash is expected while you are taking this drug.”
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• ANS: A, B, D
• It will be important for the patient to have followup INR laboratory tests done, reporting any
bruising or bleeding, and use a soft toothbrush
and electric razor while on warfarin therapy.
Vitamin K is the antidote for warfarin, so patients
should not consume a great deal of foods that are
high in this vitamin. A skin rash is a sign of an
adverse drug reaction and should be reported to
the provider immediately.
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Question 1
Which patient is at greatest risk of developing acute
respiratory distress syndrome (ARDS)?
A.
B.
C.
D.
24-year-old male admitted with blunt chest trauma and aspiration
at the scene
56-year-old male with a history of alcohol abuse and chronic
pancreatitis
72-year-old male post heart valve surgery receiving 1 unit of packed
red blood cells
82-year-old female on antibiotics for pneumonia
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• Answer: A
• Rationale: All patient scenarios create a risk for ARDS.
However, the trauma patient with direct chest injury and
known aspiration is at greatest risk. ARDS risk factors
include direct lung injury (most commonly aspiration of
gastric contents), systemic illnesses, and injuries. The most
common risk factor for ARDS is sepsis. Other risk factors
include bacteremia, trauma with or without pulmonary
contusion, multiple fractures, burns, massive transfusion,
near drowning, post-perfusion injury after cardiopulmonary
bypass surgery, pancreatitis, and fat embolism.
• (Source: Accessed August 2, 2011, from
http://emedicine.medscape.com/article/165139overview#aw2aab6b2b3)
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Question 2
A patient is going home on warfarin (Coumadin) therapy to
manage an acute pulmonary embolism. Which patient
response indicates further discharge teaching is needed?
A.
B.
C.
D.
“I should make a doctor’s appointment for weekly blood draws.”
“I should take the medication at the same time every day.”
“I should eat more green leafy vegetables like spinach.”
“I should limit my alcohol consumption.”
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• Answer: C
• Rationale: Patients who experience a
venothromboembolism/pulmonary embolism are
frequently discharged on anticoagulant therapy (e.g.,
warfarin [Coumadin]). The patient should be educated to
understand the risks and monitoring of this drug to include
weekly monitoring for therapeutic levels, consistency in
dosing regimens, and foods to avoid (e.g., leafy green
vegetables, green tea, alcohol, cranberry juice, etc.).
• (Source: Accessed August 2, 2011, from
http://circ.ahajournals.org/content/119/8/e220.full;
http://www.mayoclinic.com/print/warfarin/AN00455/MET
HOD=print)
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Question 3
A patient in acute respiratory failure is
classified as having ventilatory failure. A
potential cause of ventilatory failure is:
A.
B.
C.
D.
Opioid analgesic overdose
Pulmonary embolus
Hypovolemic shock
Pulmonary edema
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• Answer: A
• Rationale: Acute ventilatory failure is the type of
problem in oxygen intake and carbon dioxide removal
(ventilation) and blood delivery (perfusion) that causes
a ventilation-perfusion (V/Q) mismatch in which
perfusion is normal but ventilation is inadequate. It
occurs when chest pressure does not change enough to
permit air movement into and out of the lungs. As a
result, too little oxygen reaches the alveoli and carbon
dioxide is retained. Opioid analgesic overdose is a
possible cause of ventilatory failure. The others listed
are related to oxygenation failure.
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