Care of Critically Ill Patients with Respiratory Problems

Chapter 34 Care of Critically Ill Patients with Respiratory Problems



Ronald L. Hickman



Learning Outcomes



Safe and Effective Care Environment



1. Protect the patient receiving mechanical ventilation.


2. Ensure safe management of endotracheal tubes, tracheostomy tubes, and mechanical ventilators.


3. Modify the environment to protect patients receiving anticlotting therapy (which includes anticoagulation, fibrinolytic, and antiplatelet therapies).


Health Promotion and Maintenance



4. Identify hospitalized patients at risk for a pulmonary embolism.


5. Teach people at risk for pulmonary embolism techniques to reduce the risk.


6. Teach patients and family members how to avoid injury during anticlotting therapy.


Psychosocial Integrity



7. Support the patient and family in coping with changes in breathing status and the need for mechanical ventilation.


8. Use an appropriate nonverbal form of communication for a patient who is intubated.


9. Provide emotional support to patients experiencing acute respiratory difficulties.


Physiological Integrity



10. Assess the respiratory status of any patient who develops sudden-onset respiratory difficulty or acute confusion.


11. Use laboratory data and clinical manifestations to evaluate the adequacy of oxygenation and ventilatory interventions.


12. Coordinate nursing care for the patient being mechanically ventilated.


13. Maintain a patent airway on anyone who has experienced chest trauma.


14. Schedule essential patient care and diagnostic activities to promote rest and sleep.


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Animation: Endotracheal Intubation


Animation: Pulmonary Embolism


Answer Key for NCLEX Examination Challenges and Decision-Making Challenges


Audio Clip: Stridor


Audio Glossary


Audio Key Points


Concept Map Creator


Review Questions for the NCLEX® Examination


Respiratory problems can progress to an emergency and death, even with prompt treatment. These problems interfere with oxygenation and tissue perfusion and may overwhelm the adaptive responses of the cardiac and blood oxygen delivery systems (Fig. 34-1). Thus prompt recognition and interventions are needed to prevent serious complications and death.


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FIG. 34-1 Rapid-onset acute respiratory problems overwhelm the ability of the cardiac oxygen delivery system to adapt and restore balance. The red blood cell (RBC) oxygen delivery system cannot begin to adapt to the acute respiratory problem.


An acute injury or problem that results in severe respiratory impairment can occur at any age. Older adults, however, are more at risk for developing critical respiratory problems. The patient who is short of breath is also anxious and fearful. Be prepared to manage both the physical and emotional needs of the patient during any respiratory emergency.



Pulmonary Embolism



Pathophysiology


A pulmonary embolism (PE) is a collection of particulate matter (solids, liquids, or air) that enters venous circulation and lodges in the pulmonary vessels. Large emboli obstruct pulmonary blood flow, leading to reduced oxygenation, pulmonary tissue hypoxia, and potential death. Any substance can cause an embolism, but a blood clot is the most common (McCance et al., 2010). PE is common, especially among hospitalized patients, and many die within 1 hour of the onset of symptoms or before the diagnosis has even been suspected (Farley et al., 2009).


Most often, a PE occurs when a blood clot from a venous thromboembolism (VTE), especially a deep vein thrombosis (DVT) in a vein in the legs or the pelvis, breaks off and travels through the vena cava into the right side of the heart. The clot then lodges in the pulmonary artery or within one or more of its branches. Platelets collect on the embolus, triggering the release of substances that cause blood vessel constriction. Widespread pulmonary vessel constriction and pulmonary hypertension impair gas exchange. Deoxygenated blood is moved into the arterial circulation, causing hypoxemia (low arterial blood oxygen level), although some patients with PE do not have hypoxemia.


Major risk factors for VTE leading to PE are:



• Prolonged immobility


• Central venous catheters


• Surgery


• Obesity


• Advancing age


• Conditions that increase blood clotting


• History of thromboembolism


In addition, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), Trousseau’s syndrome, and trauma increase the risk for VTE and PE (Gay, 2010).


Fat, oil, air, tumor cells, amniotic fluid, foreign objects (e.g., broken IV catheters), injected particles, and infected clots or pus can enter a vein and cause PE. Fat emboli from fracture of a long bone and oil emboli from diagnostic procedures do not impede blood flow in the lungs; instead, they cause blood vessel injury and acute respiratory distress syndrome (ARDS) (Powers & Talbot, 2011). Amniotic fluid embolus occurs in women as a rare complication of childbirth, abortion, or amniocentesis. Septic clots often arise from a pelvic abscess, an infected IV catheter, and injections of illegal drugs. The effects of sepsis are more serious than the venous blockage.



Health Promotion and Maintenance


Although pulmonary embolism (PE) can occur in healthy people and may give no warning, it occurs more often in some situations. Thus prevention of conditions that lead to PE is a major nursing concern. Preventive actions for PE are those that also prevent venous stasis and VTE. Best nursing practices for PE prevention are outlined in Chart 34-1. Also see Chapter 16 for more information about core measures for VTE prevention.



Chart 34-1 Best Practice for Patient Safety & Quality Care


Prevention of Pulmonary Embolism




• Start passive and active range-of-motion exercises for the extremities of immobilized and postoperative patients.


• Ambulate patients soon after surgery.


• Use antiembolism and pneumatic compression stockings and devices after surgery.


• Avoid the use of tight garters, girdles, and constricting clothing.


• Prevent pressure under the popliteal space (e.g., do not place a pillow under the knee).


• Perform a comprehensive assessment of peripheral circulation.


• Elevate the affected limb 20 degrees or more above the level of the heart to improve venous return, as appropriate.


• Change patient position every 2 hours, or ambulate as tolerated.


• Prevent injury to the vessel lumen by preventing local pressure, trauma, infection, or sepsis.


• Refrain from massaging leg muscles.


• Instruct patient not to cross legs.


• Administer prescribed prophylactic low-dose anticoagulant and antiplatelet drugs.


• Teach the patient to avoid activities that result in the Valsalva maneuver (e.g., breath-holding, bearing down for bowel movements, coughing).


• Administer prescribed drugs, such as stool softeners, that will prevent episodes of the Valsalva maneuver.


• Teach the patient and family about precautions.


• Encourage smoking cessation.


Lifestyle changes can help reduce the risk for PE. Urge patients to stop smoking cigarettes, especially women who take oral contraceptives. Reducing weight and becoming more physically active, such as walking one or more miles each day, can reduce risk for PE. Teach patients who are traveling for long periods to drink plenty of water, change positions often, avoid crossing the legs, and get up from the sitting position at least 5 minutes out of every hour.


For patients known to be at risk for PE, small doses of heparin, low molecular weight heparin, or a similar drug may be prescribed every 8 to 12 hours. Heparin prevents excessive clotting in patients after trauma or surgery or when restricted to bedrest. Occasionally, an antiplatelet drug such as clopidogrel (Plavix) is used in place of heparin.



Patient-Centered Collaborative Care



Assessment



History


Assess any patient with sudden onset of breathing difficulty for the risk factors of PE, such as previous VTE, recent surgery, or immobility (Farley et al., 2009; Winkelman, 2009).



Physical Assessment/Clinical Manifestations


Respiratory manifestations are outlined in Chart 34-2. Assess the patient for difficulty breathing (dyspnea) occurring with a rapid heart rate and pleuritic chest pain (sharp, stabbing-type pain on inspiration). Other symptoms vary depending on the size and the type of embolism. Breath sounds may be normal, but crackles usually occur. Often a dry cough is present. Hemoptysis (bloody sputum) may result from pulmonary infarction.



Chart 34-2 Key Features


Pulmonary Embolism



Classic Symptoms




• Dyspnea, sudden onset


• Sharp, stabbing chest pain


• Apprehension, restlessness


• Feeling of impending doom


• Cough


• Hemoptysis



Signs




• Tachypnea


• Crackles


• Pleural friction rub


• Tachycardia


• S3 or S4 heart sound


• Diaphoresis


• Fever, low-grade


• Petechiae over chest and axillae


• Decreased arterial oxygen saturation (SaO2)


Cardiac manifestations include tachycardiac, distended neck veins, syncope (fainting or loss of consciousness), cyanosis, and hypotension. Systemic hypotension results from acute pulmonary hypertension and reduced forward blood flow. Abnormal heart sounds, such as an S3 or S4, may occur. Electrocardiogram (ECG) findings are abnormal, nonspecific, and transient. T-wave and ST-segment changes occur in many patients; left-axis or right-axis deviations are also common.



image Nursing Safety Priority


Critical Rescue


Assess patients at risk for PE for the symptom cluster of distended neck veins, syncope, cyanosis, and hypotension. If this cluster is present, notify the Rapid Response Team.


Miscellaneous manifestations include a low-grade fever and petechiae on the skin over the chest and in the axillae. It is important to remember that many patients with PE do not have the “classic” manifestations but instead have vague symptoms resembling the flu, such as nausea, vomiting, and general malaise (Bahloul et al., 2010).



Psychosocial Assessment


Symptom onset of PE often is abrupt, and the patient is anxious. Hypoxemia may stimulate a sense of impending doom and cause increased restlessness. The life-threatening nature of PE and admission to an intensive care unit increase the patient’s anxiety and fear.



Laboratory Assessment


The hyperventilation triggered by hypoxia and pain first leads to respiratory alkalosis, indicated by low partial pressure of arterial carbon dioxide (PaCO2) values on arterial blood gas (ABG) analysis. The PaO2-FiO2 (fraction of inspired oxygen) ratio falls as a result of “shunting” of blood from the right side of the heart to the left without picking up oxygen from the lungs. Shunting causes the PaCO2 level to rise, resulting in respiratory acidosis (McCance et al., 2010). Later, metabolic acidosis results from buildup of lactic acid due to tissue hypoxia. (See Chapter 14 for a discussion.)


Even if ABG studies and pulse oximetry show hypoxemia, these results alone are not sufficient for the diagnosis of PE (Bahloul et al., 2010; McCance et al., 2010).A patient with a small embolus may not be hypoxemic, and PE is not the only cause of hypoxemia.



Imaging Assessment


A chest x-ray may show a PE if it is large. Some lung infiltration may be present around the embolism site. However, the chest x-ray may not show any acute changes. Computed tomography (CT) scans are most often used to diagnose PE. A newer diagnostic method is high-resolution multidetector computer tomographic angiography (MDCTA), which is very specific but is not available at all acute care settings.


The physician may perform a transesophageal echocardiography (TEE) (see Chapter 35) to help detect PE. Doppler ultrasound studies or impedance plethysmography (IPG) may be used to document the presence of VTE and to support a diagnosis of PE.



image Decision-Making Challenge


Patient-Centered Care; Safety; Evidence-Based Practice


The patient is a 66-year-old truck driver who had a prostatectomy yesterday for prostate cancer. He had urinary dribbling for months and was not able to participate in his usual jogging program. He stopped smoking a year ago and uses nicotine gum daily to inhibit his ongoing urge to smoke. He drinks a can of beer per day but, overall, has reduced his fluid intake to prevent dribbling or incontinence. When you assess him this morning, he reports nausea and some chest pain.



1. What should be your first action?


2. What risk factors does he have for a pulmonary embolism?


3. For what other manifestations should you assess?


4. Is oxygen by mask or nasal cannula appropriate for this patient? Why or why not?


5. What other actions should you take?



Analysis


The priority problems for patients with PE are:



1. Hypoxemia related to mismatch of lung perfusion and alveolar oxygenation


2. Hypotension related to inadequate circulation to the left ventricle


3. Potential for bleeding related to anticoagulation or fibrinolytic therapy


4. Anxiety related to hypoxemia and fear of death



Planning and Implementation



Managing Hypoxemia


When a patient has a sudden onset of dyspnea and chest pain, immediately notify the Rapid Response Team. Reassure the patient, and elevate the head of the bed. Prepare for oxygen therapy and blood gas analysis while continuing to monitor and assess for other changes.



Planning: Expected Outcomes.


The patient with PE is expected to have adequate tissue perfusion in all major organs. Indicators of adequate perfusion are:



• ABGs within normal limits


• Pulse oximetry above 95% or the patient’s baseline


• Cognitive status unimpaired compared with baseline


• Absence of pallor and cyanosis



Interventions.


Nonsurgical management of PE is most common. In some cases, surgery also may be needed. Best nursing care practices for the patient with PE are listed in Chart 34-3.



Chart 34-3 Best Practice for Patient Safety & Quality Care


Care of the Patient with a Pulmonary Embolism




• Reassure patient that the correct measures are being taken.


• Apply oxygen by nasal cannula or mask.


• Place patient in high-Fowler’s position.


• Apply telemetry monitoring equipment.


• Obtain an adequate venous access.


• Assess oxygenation continuously with pulse oximetry.


• Assess respiratory status at least every 30 minutes by:


• Listening with a stethoscope for presence or absence of breath sounds, crackles, or rubs.

• Measuring the rate, rhythm, and ease of respirations.

• Checking skin color and capillary refill.

• Checking position of trachea.

• Assess cardiac status by:


• Comparing blood pressures in right and left arms.

• Checking pulse for quality.

• Checking cardiac monitor for dysrhythmias.

• Checking for distention of neck veins.

• Ensure prescribed chest imaging and laboratory tests are obtained immediately (may include complete blood count with differential, platelet count, prothrombin time, partial thromboplastin time, D-dimer level, arterial blood gases).


• Examine the thorax for presence of petechiae.


• Administer prescribed anticoagulants.


• Assess for bleeding.


• Handle patient gently.


• Institute Bleeding Precautions.



Nonsurgical Management.

Management activities for PE focus on increasing gas exchange, improving lung perfusion, reducing risk for further clot formation, and preventing complications. Priority nursing interventions include implementing oxygen therapy, administering anticoagulation or fibrinolytic therapy, monitoring the patient’s responses to the interventions, and providing psychosocial support.


Oxygen therapy is critical for the patient with PE. The severely hypoxemic patient may need mechanical ventilation and close monitoring with ABG studies. In less severe cases, oxygen may be applied by nasal cannula or mask. Use pulse oximetry to monitor oxygen saturation and hypoxemia.


Monitor the patient continually for any changes in status. Check vital signs, lung sounds, and cardiac and respiratory status at least every 1 to 2 hours. Document increasing dyspnea, dysrhythmias, distended neck veins, and pedal or sacral edema. Assess for crackles and other abnormal lung sounds along with cyanosis of the lips, conjunctiva, oral mucosa, and nail beds.


Drug therapy with anticoagulants may be prescribed to prevent embolus enlargement and to prevent new clots from forming. Active bleeding, stroke, and recent trauma are reasons to avoid this therapy. Each patient is evaluated to determine the risk versus the benefit of anticoagulant therapy.


Heparin is usually used unless the PE is massive or occurs with hemodynamic instability. A fibrinolytic drug may then be used to break up the existing clot. Review the patient’s partial thromboplastin time (PTT)—also called activated partial thromboplastin time (aPTT)—before therapy is started, every 4 hours when therapy begins, and daily thereafter. Therapeutic PTT values usually range between 1.5 and 2.5 times the control value for this health problem.


Fibrinolytic drugs, such as alteplase (Activase, tPA), are used for PE when specific criteria are met. These include massive PE (obstructing blood flow to a lobe or more than one segment) and hemodynamic instability in which blood pressure cannot be maintained without supportive measures.


Both heparin and fibrinolytic drugs are high alert drugs. These drugs have a high risk to cause harm if given at too high a dose, too low a dose, or to the wrong patient.



image Nursing Safety Priority


Drug Alert


Heparin comes in a variety of concentrations. Check the prescribed dose carefully and ensure the correct concentration is being used to prevent overdosing or underdosing. Enoxaparin (Lovenox) can be given only subcutaneously or intravenously, NOT intramuscularly.


Heparin therapy usually continues for 5 to 10 days. Most patients are started on an oral anticoagulant, such as warfarin (Coumadin, Jantoven, Warfilone image), on the third day of heparin use. Therapy with both heparin and warfarin continues until the international normalized ratio (INR) reaches 2.0 to 3.0. A low–molecular-weight heparin (e.g., dalteparin or enoxaparin) is often used with the warfarin. Monitor the INR daily. Warfarin use continues for 3 to 6 weeks, but some patients may take warfarin indefinitely. Charts 34-4 and 34-5 list common drugs used and the laboratory tests to monitor. These drugs and the associated nursing care are discussed in Chapters 38, 40, and 41.



Chart 34-4 Common Examples of Drug Therapy


Pulmonary Embolism




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INR, International normalized ratio; PTT, partial thromboplastin time.



Chart 34-5 Laboratory Profile


Blood Tests Used to Monitor Anticoagulation Therapy

















TEST NORMAL RANGE SIGNIFICANCE OF ABNORMAL FINDINGS
Partial thromboplastin time (PTT, aPTT [APTT])

Normal values for each local laboratory may vary.


When activator reagents are used by the laboratory, the normal clotting time is shortened.


Common normal ranges are 20-30 sec in some laboratories and 30-40 sec in others.


Therapeutic range for PE is 1.5-2.5 times the normal value (e.g., if normal is 20-30 sec, then therapeutic range is 40-75 sec).

Subtherapeutic times may signify that the patient is not receiving enough heparin to prevent extension of the blood clot. An increase in the dosage or rate of infusion is usually indicated.


Therapeutic times mean that the clotting time is increased from normal but this increase is indicated in the case of PE.


Prolonged times in patients with PE (i.e., >75 sec) indicate that the patient is at risk for serious spontaneous bleeding. Heparin is usually held or decreased until the PTT drops back into the therapeutic range.

Prothrombin time (pro time, PT)

Common normal range is 11-12.5 sec. Therapeutic range for anticoagulant therapy in PE is 1.5-2 times the normal or control value in seconds.


Control values can vary day to day because reagents used may vary.


If INR values are reported with the PT, therapeutic range for PE is 2.5-3.0, or 3.0-4.5 for recurrent PE.

Subtherapeutic values may signify that the patient is not receiving enough warfarin. An increase in the dosage is usually indicated.


Therapeutic values mean that the pro time is increased from normal but this increase is indicated in the case of PE.


Prolonged values in the treatment of PE indicate that the patient is at risk for bleeding. The warfarin dose is usually decreased or held, the patient is instructed to eat foods high in vitamin K, or an injection of vitamin K may be given.


aPTT or APTT, Activated partial thromboplastin time; INR, international normalized ratio; PE, pulmonary embolism.



Genetic/Genomic Considerations


Many agencies are performing genetic tests before starting warfarin therapy. These tests check for variation in two specific genes. One gene, VKORC1, produces an enzyme that alters vitamin K so that it can help activate the vitamin K–dependent clotting factors. Warfarin interferes with the activity of this enzyme. Patients who have a variation in the enzyme are resistant to the effects of warfarin, and much higher doses are needed to achieve coagulation. On the other hand, the gene CYP2C19 produces an enzyme that metabolizes warfarin and prepares it for elimination. Patients who have a variation in this gene do not metabolize warfarin well, so that higher blood levels remain and more severe side effects are possible. The dosage of warfarin needs to be much lower in patients with this gene variation.



image Nclex Examination Challenge


Physiological Integrity


A client who has been receiving heparin subcutaneously for 10 days has all of the following laboratory blood test values. Which value does the nurse report immediately to the prescriber?



A. Activated partial thromboplastin time 1.5


B. International normalized ratio 1.7


C. Red blood cells 4.2 million/mm3


D. Platelets 20,000/mm3


Anticoagulation and fibrinolytic therapy can lead to excessive bleeding. Also, even when clotting times are in the target ranges, other problems may develop that require invasive therapy and a return to normal coagulation responses. The antidote for heparin is protamine sulfate; the antidote for warfarin is injectable phytonadione, vitamin K1 (AquaMEPHYTON, Mephyton). Antidotes for fibrinolytic therapy include clotting factors, fresh frozen plasma, and aminocaproic acid (Amicar).



image Nursing Safety Priority


Drug Alert


Keep antidotes to anticoagulant drugs and fibrinolytic drugs on the unit for patients undergoing these therapies.



Surgical Management.

Two surgical procedures for the management of PE are embolectomy and inferior vena cava filtration.


Embolectomy is the surgical removal of the embolus from pulmonary blood vessels. It may be performed when fibrinolytic therapy cannot be used for a patient who has massive or multiple large pulmonary emboli with shock. Special thrombectomy catheters that mechanically break up clots, such as the AngioJet, allow effective reduction of clots with or without the use of thrombolytic drugs. Earlier use of embolectomy for PE is being evaluated (Le & Dewan, 2009).


Inferior vena cava filtration with placement of a vena cava filter is a lifesaving measure by preventing further embolus formation for some patients. Some filters are removable, allowing filter placement before symptoms develop in patients who are at high risk for clots. These filters can be removed when the risk for clot formation decreases, or they can be left in place permanently. Patients for whom filter placement is considered less risky than drug therapy include those with recurrent or major bleeding while receiving anticoagulants, those with septic PE, and those undergoing pulmonary embolectomy. Placement of a vena cava filter is detailed in Chapter 38.



Managing Hypotension



Planning: Expected Outcomes.


The patient with PE is expected to have adequate circulation. Indicators of adequate circulation are:



• Maintenance of pulse rate and blood pressure within the normal ranges


• Maintenance of a urine output of at least 30 mL/hr


• Absence of cyanosis



Interventions.


In addition to the interventions used for hypoxemia, IV fluid therapy and drug therapy are used to increase cardiac output and maintain blood pressure.


IV fluid therapy involves giving crystalloid solutions to restore plasma volume and prevent shock (see Chapter 39). Continuously monitor the ECG and pulmonary artery and central venous/right atrial pressures of the patient receiving IV fluids because increased fluids can worsen pulmonary hypertension and lead to right-sided heart failure. Also monitor indicators of fluid adequacy, including urine output, skin turgor, and moisture of mucous membranes.


Drug therapy with agents that increase myocardial contractility (positive inotropic agents) may be prescribed when IV therapy alone does not improve cardiac output. Common drugs include milrinone (Primacor) and dobutamine (Dobutrex). Assess the patient’s cardiac status hourly during therapy with inotropic drugs. Vasodilators, such as nitroprusside (Nipride, Nitropress), may be used to decrease pulmonary artery pressure if it is impeding cardiac contractility.



Minimizing Bleeding



Planning: Expected Outcomes.


The patient with PE is expected to remain free from bleeding. Indicators are:



• Absence of bruising or petechiae


• Maintenance of hematocrit and hemoglobin within the normal range



Interventions.


As a result of drug therapy that disrupts clots or prevents their formation, the patient’s ability to start and continue the blood-clotting cascade when injured is impaired, increasing the risk for bleeding. Priority nursing actions are ensuring that appropriate antidotes are present on the nursing unit, protecting the patient from situations that could lead to bleeding, and monitoring closely the amount of bleeding that is occurring.


Assess at least every 2 hours for evidence of bleeding (e.g., oozing, bruises that cluster, petechiae, or purpura). Examine all stools, urine, drainage, and vomitus for gross blood, and test for occult blood. Measure any blood loss as accurately as possible. Measure the patient’s abdominal girth every 8 hours (increasing girth can indicate internal bleeding). Best practices to prevent bleeding are listed in Chart 34-6.



Chart 34-6 Best Practice for Patient Safety & Quality Care


Prevention of Injury for the Patient Receiving Anticoagulant, Fibrinolytic, or Antiplatelet Therapy




• Handle the patient gently.


• Use and teach UAP to use a lift sheet when moving and positioning the patient in bed.


• Avoid IM injections and venipunctures.


• When injections or venipunctures are necessary, use the smallest-gauge needle for the task.


• Apply firm pressure to the needle stick site for 10 minutes or until the site no longer oozes blood.


• Apply ice to areas of trauma.


• Test all urine, vomitus, and stool for occult blood.


• Observe IV sites every 4 hours for bleeding.


• Instruct alert patients to notify nursing personnel immediately if any trauma occurs and if bleeding or bruising is noticed.


• Avoid trauma to rectal tissues:


• Do not administer enemas.

• If suppositories are prescribed, lubricate liberally and administer with caution.

• Instruct the patient and UAP to use an electric shaver rather than a razor.


• When providing mouth care or supervising others in providing mouth care:


• Use a soft-bristled toothbrush or tooth sponges

• Do not use floss

• Check to make certain that dentures fit and do not rub

• Instruct the patient not to blow the nose forcefully or insert objects into the nose.


• Ensure the patient wears shoes with firm soles whenever he or she is ambulating.


• Ensure that antidotes to anticoagulation therapy are on the unit.


UAP, Unlicensed assistive personnel.


Monitor laboratory values daily. Review the complete blood count (CBC) results to determine the risk for bleeding and whether actual blood loss has occurred. If the patient has severe blood loss, packed red blood cells may be prescribed (see Transfusion Therapy in Chapter 42). Monitor the platelet count. A decreasing count may indicate ongoing clotting or heparin-induced thrombocytopenia (HIT) caused by the formation of anti-heparin antibodies.



Minimizing Anxiety



Planning: Expected Outcomes.


The patient with PE is expected to have anxiety reduced to an acceptable level. Indicators include that he or she consistently demonstrates these behaviors:



• States that anxiety is reduced


• Has no distress, irritability, or facial tension


• Uses coping strategies effectively



Interventions.


The patient with PE is anxious and fearful for many reasons, including the presence of pain. Interventions for reducing anxiety in those with PE include oxygen therapy (see Interventions discussion on pp. 664-667 in the Managing Hypoxemia section), communication, and drug therapy.


Communication is critical in allaying anxiety. Acknowledge the anxiety and the patient’s perception of a life-threatening situation. Stay with him or her, and speak calmly and clearly, providing assurance that appropriate measures are being taken. When giving drugs, changing position, taking vital signs, or assessing the patient, explain the rationale and share information.


Drug therapy with an antianxiety drug may be prescribed if the patient’s anxiety increases or prevents adequate rest. Unless he or she is mechanically ventilated, sedating agents are avoided to reduce the risk for hypoventilation. When pain is present, pharmacologic therapy is used for pain management. Care is taken to avoid suppressing the respiratory response.



image Nclex Examination Challenge


Safe and Effective Care Environment


A client who has a pulmonary embolism and a venous thromboembolism is to be started on oral warfarin (Coumadin) while still receiving intravenous heparin. What is the nurse’s best action?



A. Administer the medications as prescribed.


B. Remind the prescriber that two anticoagulants should not be administered concurrently.


C. Hold the dose of warfarin until the client’s partial thromboplastin time is the same as the control value.


D. Monitor the client for clinical manifestations of internal or external bleeding at least every 2 hours.



Community-Based Care


The patient with a PE is discharged when hypoxemia and hemodynamic instability are resolved and adequate anticoagulation has been achieved. Anticoagulation therapy usually continues after discharge.



Home Care Management


Some patients are discharged to home with minimal risk for recurrence and no permanent physiologic changes. Others have heart or lung damage that requires home and lifestyle modification.


Patients with extensive lung damage may have activity intolerance and become fatigued easily. The living arrangements may need to be modified so that patients can spend all or most of the time on one floor and avoid climbing stairs. Depending on the degree of impairment, patients may require some or much assistance with ADLs.



Teaching for Self-Management


The patient with a PE may continue anticoagulation therapy for weeks, months, or years after discharge, depending on the risks for PE. Teach him or her and the family about Bleeding Precautions, activities to reduce the risk for venous thromboembolism (VTE) and recurrence of PE, complications, and the need for follow-up care (Chart 34-7).



Chart 34-7 Patient and Family Education


preparing for self-management: Preventing Injury and Bleeding




During the time you are taking anticoagulants:


• Use an electric shaver.

• Use a soft-bristled toothbrush, and do not floss.

• Do not have dental work performed without consulting your health care provider.

• Do not take aspirin or any aspirin-containing products. Read the label to be sure that the product does not contain aspirin or salicylates.

• Do not participate in contact sports or any activity likely to result in your being bumped, scratched, or scraped.

• If you are bumped, apply ice to the site for at least 1 hour.

• Avoid hard foods that would scrape the inside of your mouth.

• Eat warm, cool, or cold foods to avoid burning your mouth.

• Check your skin and mouth daily for bruises, swelling, or areas with small, reddish purple marks that may indicate bleeding.

• Notify your health care provider if you:

• Are injured and persistent bleeding results

• Have excessive menstrual bleeding

• See blood in your urine or bowel movement

• Avoid anal intercourse.

• Take a stool softener to prevent straining during a bowel movement.

• Do not use enemas or rectal suppositories.

• Do not wear clothing or shoes that are tight or that rub.

• Avoid blowing your nose forcefully or placing objects in your nose. If you must blow your nose, do so gently without blocking either nasal passage.

• Avoid playing musical instruments that raise the pressure inside your head, such as brass wind instruments and woodwinds or reed instruments.

• Keep all appointments for laboratory tests.


Health Care Resources


Patients using anticoagulation therapy are usually seen in a clinic or health care provider’s office weekly for blood drawing and assessment. Those who are homebound may have a home care nurse perform these actions (see Chart 34-8 for a focused assessment guide). Patients with severe dyspnea may need home oxygen therapy. Respiratory therapy treatments can be performed in the home. The nurse or case manager coordinates arrangements for oxygen and other respiratory therapy equipment to be available if needed at home.



Chart 34-8 Home Care Assessment


The Patient After Pulmonary Embolism




Assess respiratory status:


• Observe rate and depth of ventilation.

• Auscultate lungs.

• Examine nail beds and mucous membranes for evidence of cyanosis.

• Take a pulse oximetry reading.

• Ask the patient if chest pain or shortness of breath is experienced in any position.

• Ask the patient about the presence of sputum and its color and character.

Assess cardiovascular status:


• Take vital signs, including apical pulse, pulse pressure; assess for presence or absence of orthostatic hypotension and quality and rhythm of peripheral pulses.

• Note presence or absence of peripheral edema.

• Examine hand vein filling in the dependent position.

• Examine neck vein filling in the recumbent and sitting positions.

Assess lower extremities for deep vein thrombosis:


• Examine lower legs and compare with each other for:

• General edema

• Calf swelling

• Surface temperature

• Presence of red streaks or cordlike, palpable structure

Measure calf circumference:


• Ask the patient to dorsiflex and plantarflex each foot. Note the ease with which the patient can do this, and ask whether pain is experienced in either position.

• Gently squeeze the calf of each leg laterally and from front to back. Ask the patient whether pain or tenderness is experienced with either maneuver.

Assess for evidence of bleeding:


• Examine the mouth and gums for oozing or frank bleeding.

• Examine all skin areas, especially old puncture sites and wounds, for bleeding, bruising, or petechiae.

• If the patient voids during the visit, test the urine for occult blood.

Assess cognition and mental status:


• Level of consciousness

• Orientation to time, place, and person

• Can the patient accurately read a seven-word sentence containing no words with more than three syllables?

Assess the patient’s understanding of illness and adherence to treatment:


• Manifestations to report to health care provider

• Drug therapy plan (correct timing and dose)

• Bleeding Precautions

• Prevention of venous thromboembolism


Evaluation: Outcomes


Evaluate the care of the patient with PE on the basis of the identified priority patient problems. The expected outcomes are that he or she:



• Attains and maintains adequate gas exchange and oxygenation


• Does not experience hypovolemia and shock


• Remains free from bleeding episodes


• States the level of anxiety is reduced


• Uses effective coping strategies


Specific indicators for these outcomes are listed for each patient problem under the Planning and Implementation section (see earlier).



Acute Respiratory Failure



Pathophysiology


Acute respiratory failure is classified by blood gas abnormalities. The critical values are partial pressure of arterial oxygen (PaO2) less than 60 mm Hg, arterial oxygen saturation (SaO2) less than 90%, or partial pressure of arterial carbon dioxide (PaCO2) more than 50 mm Hg occurring with acidemia (pH <7.30). Respiratory failure is further defined as ventilatory failure, oxygenation failure, or a combination of both ventilatory and oxygenation failure. Whatever the underlying problem, the patient in acute respiratory failure is always hypoxemic (has low arterial blood oxygen levels).



Ventilatory Failure


Ventilatory failure is a problem in oxygen intake (ventilation) and blood delivery (perfusion) that causes a ventilation-perfusion (image) mismatch in which perfusion is normal but ventilation is inadequate. It occurs when the 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. Either inadequate oxygen intake or carbon dioxide retention leads to hypoxemia.


Ventilatory failure usually results from any of these problems: a physical problem of the lungs or chest wall; a defect in the respiratory control center in the brain; or poor function of the respiratory muscles, especially the diaphragm. The problem is defined by a PaCO2 level above 45 mm Hg in patients who have otherwise healthy lungs.


Causes of ventitatory failure are either extrapulmonary (involving nonpulmonary tissues but affecting respiratory function) or intrapulmonary (disorders of the respiratory tract). Table 34-1 lists causes of ventilatory failure.


TABLE 34-1 COMMON CAUSES OF VENTILATORY FAILURE








Extrapulmonary Causes Intrapulmonary Causes


• Neuromuscular disorders:


• Myasthenia gravis

• Guillain-Barré syndrome

• Poliomyelitis

• Spinal cord injuries affecting nerves to intercostal muscles


• Central nervous system dysfunction:


• Stroke

• Increased intracranial pressure

• Meningitis

• Chemical depression:


• Opioid analgesics, sedatives, anesthetics
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Jul 18, 2016 | Posted by in NURSING | Comments Off on Care of Critically Ill Patients with Respiratory Problems

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