If patient has kidney problems, which test would replace CT scan to rule out Pulmonary Embolism?
What is a PE?
(It IS the #1 reason for rapid unexplained deaths)
What is the most common type?
An accumulation of fluids, solids that enters into lungs.
Blood clots are most common
What are some risk factors associated with developing a PE?
- FX in long bones
- prolonged immobilization (like on a plane)
- oral contraception
- CVC (central venous cath) placement
Causes of PE?
- taking steroids
- foreign objects
- pus (yummy) :)
Classic Hallmark manifestations of PE?
What are some signs of a PE?
- apprehension, restlessness
- dyspnea (trouble breathing)
- Feeling impending doom
- Hemoptysis (bloody sputum with cough)
- Sharp and stabbing chest pain
- decreased SaO2
- S3 and S4 heart sounds
- low grade fever
- petechiae over chest and axilla
How to medically manage patients with PE?
non-surgical and how about surgically?
- Anticoagulants, like heparin
- IF suspected large enough...fibrinloytic
- Surgery...embolectomy (removes clot)
- inferior vena cava filtration. (this is put in if a DVT is suspected)
What should you know about giving heparin therapy?
what to monitor?
bleeding...gums, bruising, black stools, leaky IV site, decrease LOC if bleeding on brain.
- Lab values?
- Ptt and/or aPTT ...need a baseline first
start hep drip, then lab draws 6 hrs later.
Sooooo, if coming on shift, ask when was last pTT drawn? last adjustment made? figure when next lab needs to be drawn.
Teaching pt regarding taking coumadin at home?
- get INR/PT drawn
- bleeding precautions... soft toothbrush, electric shaver, blah blah
- keep diet choices consistant
- avoid NSAIDS
PE nursing interventions?
- Elevalute HOB
- O2 nasel cannula , start at 2L
- Monitoring VS, auscultate lungs and breathing
- make sure IV access, in case ct scan= place in AC, at least 20 gauge for dye insertion pushed in with force.
- PT hypotensive? give vasopressors like epi, dopamine
- order labs
- MONITOR anticoagulant use
- Call RT if patient condition declines
ABG's review what ROME means.
what are the normal ranges?
PCO2= 35-45 (the higher number more acidic)
What is happening with Acute Respiratory Failure?
Qxygenation failure=perfusion is somehow off. blood flow to the lungs is impeded.
Ventilatory Failure= air movement moving in and out.
Acute Respiratory Failure...What are the critical ABG values?
- PaO2= <60
- PaCo2= >45, occuring with low pH
- O2 Saturation= <90 in both cases.
note- understand the true measure of 02 sat monitoring is only takes in consideration of oxygen bound to hemoglobin. If pt. has low HgB, not a true reflection. look at whole patient.
Ventilatory failure can be a result from...
- lungs or chest wall not working properly, like SCI patients above C5
- defect in resp centers of brain, like from TBI
- Poor function of res muscles and diaphragm
What does Capnography measure?
ventilation, not oxygenation
ventilation is how we get rid of carbon dioxide.
When should we measure EtCO2( End-Tidal CO2)?
what are the normal values?
Whenever respiratory depression is a possibility (ex patients on PCA, sedation issues and history of sleep sleep apnea)
Normal values is 35-45
Abnormal values and what they mean?
- EtCO2 <35 mmHg=hyperventilating/hypocapnia...think perfusion, psychological problem when this is low
- EtCO2 >45 mmHg= hypoventilation/hypercapnia (or not breathing)....think respiratory failure when ETCO2 is high
What should you do if the EtCO2 is elevated (like 45 or 50) like in a COPD pt.
- First, try to arose them, if they do, monitor every 15 min.
- assess all Vital signs, looking for decompensation
- assess pain and consider maybe decreasing narcotic dose or frequency
- reposition sampling line
- IF STILL <45, call physician
- IF after 5 min, no improvement, call rapid response
- consider getting ABG's
- need narcan now to reverse sedation?
what does Oxygenation Failure mean?
It means that air moves in and out, but unable to oxygenate blood, due to perfusion problems. (VQ mismatch)
What are the causes of oxygenation failure?
- breathing air w a low oxygen level (change of altitudes, closed in spaces, carbon monoxide)
- VQ mismatch (ARDS)
- impaired gas exchange
How do we measure oxygenation?
- Spo2 (pulse ox) Saturation
- and PaO2
What is a normal PTT?
BUT, if you are at risk for DVT, then your PTT should be what?
We want their PTT to be 1.5-2.5 seconds x the normal. (longer to prevent clotting)
What are 2 reasons someone would have a inferior vena cava filtration device inserted?
1. for some reason, the patient is unable to take anticoagulants.
2. someone frail or elderly and are at risk of falling. So if she falls on an anticoagulant they will bleed too much.
What percentage rate should we keep the FiO2 below?
If ABG's show that a PaCO2 is 30, how would you adjust the setting on the ventilator? why?
Carbon dioxide is low (very basic), so I would decrease the RR rate so that my patient retains more carbon dioxide.
What ventilator changes would you make?
I would look at the fiO2 and the peep because its an oxygenation issue. If the FiO2 is 60% and the PEEP is at 5, I would have wiggle room to increase PEEP.
If I have a problem with PaC
What is Acute Respiratory Failure (ARF)
how is it caused?
- impaired gas exchange
- combined ventilatory & oxygenation failure
- VQ mismatch=PE
- Profound hypoxemia
What are some signs and symptoms of respiratory compromise?
- *Hallmark sign=dyspnea
- shallow, irregular breathing
- elevated BP
- rapid RR
- abdominal and intercostal muscle use
- irritability and HA and lethargy are indications of poor perfusion to brain.
- *cyanosis and hypotension=late signs
Someone in acute resp failure, what do you do?
what meds are probably given?
- Sit-up and apply oxygen
- have a patent IV
- Meds..brochodialator (albuteral)
- or corticosteroids (solumedral)
Acute res failure tests?
- chest xray
- cardiac markers
- have pneumonia?-get lactic acid
Would you see Resp alkalosis or Resp acidosis with PE?
What are some nursing interventions necessary for your pt on heparin?
- Monitor PTT
- monitor platelets (watch for heparin induced thrombocytopenia
- bleeding precautions
- have antidote protamine sulfate on hand
What are some nursing actions that can help prevent a PE in patients?
- ambulate patients as soon as possible
- use compression stockings if appropriate
- evaluate patient criteria to be on anticoagulants?
- avoid pressure under the popliteal space,do not place pillow
- instruct patient to not cross their legs
- do ROM exercises of extremities especially if patients are immobililzed or post surgical
- administer low dose anticoagulant and anti platelet drugs
- avoid restricting clothing
- encourage smoking cessation
- do not massage legs
- change position q 2 hours or ambulate as tolerated.
What are the criteria of having ARDS ? (acute respiratory distress syndrome)
- hypoxemia despite being on 100% oxygen
- difficulty breathing
- dense pulmonary infiltrates (called ground glass) on xray
- see mostly blk on xray
- decrease lung compliance
- pulmonary edema, not cardiac related
What are the 2 types of CAUSES of ARDS?
1 Indirect lung injury
2.Direct lung injury
What are some ARDS indirect causes?
- SEPSIS most common
- serious nervous system damage
What is the importance of surfactant in the alveoli?
hold the shape, keeps lungs(alveoli) open and from collapsing
What are some ARDS DIRECT causes?
damage to lung tissue directly
- BAD pnuemonia
- toxic fumes
- aspiration of acidic gastric contents
- fat and amniotic fluid emboli
- multiple blood transfusions
What are key assessment of ARDS? 3 of them
- work of breathing
- mental status
- vital signs
What are the diagnostic tests for ARDS?
- sputum cultures
- PA catheter to evauate fluid and heart status
What is PaO2 mean?
what is normal Pa02 range?
AND, what is the minimum percentage needed to prevent ischemia in tissues?
- is the actual amount of oxygen in arterial blood.
- Normal range is between 90-100
minimum, of 60mmHg
How can the nurse help an ARD patient?
- help with intubation and mechanical ventilation
- Administer nutrition (more protein, less carbs please)
- administrate drugs (antibiotics, steroids, etc)
- Position patient for optimal oxygenation.
- Maintain optimal fluid balance
- supine with HOB up
- prone too, helps with better lung expansion.
How would you know a patient has a gag reflex?
if they can cough, the patient has a gag reflex.
if you insert an airway adjunct, they could vomit and aspirate.
How to open the airway?
especially with a patient that had a trauma?
What is the series of actions?
- First sedate pt. with versed or ketamine.
- paralyze pt. ..then bag valve mask pt while doc intubates
- get a chest xray to verify placement
What are the some bedside checks?
- check bilateral lung sounds
- equal rise & fall of chest
- tube misting?
- absent abdominal sounds
- CO2 device.."Gold is good"
- stabilize tub per hospital protocol
- document size of tub, level of tube,placement was verified.
What are the 3 goals of mechanical ventilation?
- Improve oxygenation
- improve ventilation
- help decrease work of breathing
INTUBATION is an invasive procedure, what do you need to do?
- restraint limbs
- adequate nutrition
- ROM exercises
- reposition Q2
What are the 2 non invasive modes of ventilation?
BiPAP and CPAP
What is mechanical ventilation?
a device that generates flow of gas into a patients airways
BiPAP (Bi-level Airway Pressure)
What does it work?
What condition could benefit from using this?
- **Think external ventilator because it can be set to one pressure for inhaling and exhaling.
- requires patient compliance because you have to have a tight seal.
HF..do diuretics, then BiPAP them
CPAP (Continuous Positive Airway Pressure)
How does it work?
What type of patient usually benefits from this?
- puts a constant steady stream of air pushed into lungs. (positive pressure)
- It keeps tongue from obstructing airway
What 2 modes of ventilation used most often?
Assist Control (AC)
Synchronized intermittent mandatory ventilation (SIMV)
What does an Assist-control work?
What is stacking and barotrauma?
Should the patient be continuously sedated?
- preset tidal volume and respiratory rate
- TAKES OVER THE WORK OF BREATHING
Stacking is when patient breaths along with ventilator, cause barotrauma (alveoli rupture) sooo yes SEDATE them always.
SIMV (the weening mode)
How does it work?
- Ventilator works with patients breathing
- It is set to let patient breathe on their own at their own tidal volume, lessoning chance of barotrauma
what is pressure support ventilation (PSV)? (think like a CPAP)
How does it help the patient?
It provides pressure on inspiration.
VENTILATOR CONTROLS AND SETTINGS...
What is tidal volume? and its FORMULA setting?
What is the setting for an ARDS patient?
The amount of air transported in and out of the lungs during the resp cycle.
FORMULA- 7-10 x the persons weight in kg.
6 x kg=tidal volume for ARDS pt.
VENTILATOR CONTROLS AND SETTINGS...
Set Breathes per minute (BPM) to?
What is the I/E ratio?
- BPM= 10-14
- Ratio 1:2
- *How much oxygen is determeind by ABG's.
PEEP (Positive End Expiratory Pressure)...allows for longer periods of gas exchange to occur.
What is the setting that is started?
With pulmonary embolism, would you see RESPIRATORY ACIDOSIS OR ALKALOSIS?
you would see alkalosis, and decrease in O2.
With Acute Respiratory Failure, will your CO2 be going up or down?
What about your pH?
CO2 will INCREASE, because you are hypoventilating. <45
pH will decrease.
ACUTE RESPIRATORY FAILURE
What are the critical ABG values to meet this criteria?
PaO2 (partial pressure of arterial oxygen= <60 OR PaCO2 is >45
AND O2 sat of <90%
- Patient is ALWAYS hypoxic!
- Iggy (p 610)
ACUTE RESPIRATORY FAILURE
What is the difference between ventilatory failure and oxygenation failure
Ventilation failure is when there is some problem with getting air into lungs.
Oxygenation is a gas exchange failure. Perfusion is decreased or absent
ACUTE RESPIRATORY FAILURE
What are examples that could cause ventilatory failure?
What are examples that could cause oxygenation failure?
- broken ribs
- defect in resp control center in brain
- poor function of resp muscles, like diaphragm.
- Lung disorders
Why doesnt 100% oxygen not help a person with Acute Respiratory Failure?
Because getting the air in is intact, however having it perfuse to the body is impaired.
What does End-Tidal CO2 (Capnography) measure?
What are common causes of oxygenation failure?
- abnormal hemoglobin
- CHF with pulmonary edema
- High altitudes
- smoke inhalation
- carbon monoxide poisoning
- R to L shunting of blood in the pulmonary vessels
With Acute Respiratory distress syndrome (ARDS), think inflammatory and 100% oxygen doesnt help.(refractory hypoxemia)
What should you do for them?
What ABG's would indicate that a client is in early ARDS?
- B) pH 7.50, PaO2 59, CO2 32, HCO3 22
- EARLY ARDS, it will be a Respiratory Alklosis.
- Pt breathing fast, trying to bring in oxygen.
What ABG's would indicate that a client is in late ARDS?
C) pH 7.20, PaO2 50, CO2 64, HCO3 18
What are the mechanical ventilation oxygenation goals with ARDS?
We want PaO2 @ 55-80 or SpO2 @88-95%
Use minimum of PEEP at 5 at first. Use of incremental FiO2/PEEP combinations.
What are ARDS protocol (like GWTG)
- TV at 6mL/kg
- PEEP start at 5cm H20
- Want the Fio2 less than 70%. Adjust to ABG readings
- O2 Sat at 88-95%
- Steriods, in small doses over short period of time.
- If O2 Sat is dropping, increase PEEP
- ** As you increase PEEP, monitor BP!!
What does a low pressure alarm usually mean?
a disconnection or a cuff leak in the ET tube
When a patient has a rib fracture, what are they at high risk for and why?
High risk of developing pneumonia because it is painful to breath and therefore do not do so, which can lead to statis of bacteria, causing pneumonia.
What is a flail chest?
Fractures of 2 or more neighboring ribs in 2 or more areas.
they are hypotensive and tachycardic.
What is Tracheal Bronchial Trauma? how is it usually caused? how do we treat?
there are lacerations in the trachea, can result in a tension pneumothorax and usually caused by MVA's. Must intubate below the area of injury.
If you have an elevated CO2 reading >45, what does that mean and what do you do?
essentially means that there is no air movement in and out of your patient.
- First stimulate, assess VS and check patient
- consider reducing opiod.
- reposition the sampling.
- IF it remains >45, call MD.
What does a high pressure alarm indicate?
- could be too much secretions in airway
- patient fights the ventilator
- patient coughs, gags or bites ET tube
- tubing kink
- pneumothorax occurs
- an increasing PIP which indicates decreased lung compliance.
If your RR is slow, your pH is more likely to be high or low? acid or basic? why?
pH would be low....acidotic, because you are retaining a lot of carbon dioxide.
on the contrary if RR is very high, you are more likely to be alkaline (or high pH)because you are blowing too much CO2 off.
When intubating, what are the sequence of events?
How to prepare?
How to verify placement?
- Prepare ...
- Airway, if not breathing then bag patient
- Sedate with versed or ketamine and paralyze.
- set up bedside with intubation kit and suction equipment
have bil breath sounds?
- equal rise and fall of chest?
- tube misting?
- absent bowel sounds?
- CO2 detector is GOLD! yay!
- Direct verification if CXR
- stabilize tube (per hospital P&P)
- Document size of tube, level of tube, placement verification