critical pt's

8/13/2019 Critical Pt's

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PE (not to be confused withpulmonary edema)is a collection of matter(solids, liquids, or gaseous

substances) that entersvenous

circulation and lodgesin thepulmonary artery

Large emboliobstructpulmonary blood flow, leadingto decreased systemicoxygenation, pulmonary tissue

hypoxia, and potential death.


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Pulmonary Embolism most common acute pulmonary disease (90%)

among hospitalized clients. In most people

a blood clot from a DVT breaks loose from one ofthe veins in the legs or pelvis.


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The thrombus breaks off, travels through the vena

cava and R side of the heart, then lodges in a

smaller blood vessel off of the pulmonary artery


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Major factors

Prolongedimmobilization

Surgery

Obesity

Advancing age

Hypercoagulability

Hx of thromboembolism

Additional factors Smoking

Pregnancy

Estrogen therapy CHF

Stroke

Malignant neoplasms

(esp lung or prostate) Major trauma


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Interventions Administer O2 via nasal cannula or mask. Intubation and mechanical

ventilation are used in cases of severe hypoxemia

Check vital signs, pulse oximetry, lung sounds, and cardiac and respiratory

status every hour Document increasing dysrhythmias, distended neck veins

Give anticoagulation or fibrinolytic therapy

Give intravenous heparin (bolus followed by continuous infusion) duringthe acute phase, give warfarin (Coumadin) orally when the heparin drip isdiscontinued

Thrombolytics may be used to break an existing clot if the PE is massiveor the client is hemodynamically unstable.

Monitor partial thromboplastin time before therapy is started

Frequently assess the client for bleeding and protect from situations thatcould lead to bleeding


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Symptoms Sudden onset of

dyspnea

Pleuritic chest pain Apprehension,

restlessness

Feeling of impending

doom Cough

Hemoptysis

Signs Tachypnea

Crackles

Pleural friction rub Tacycardia

S3or S4 heart sound

Diaphoresis

Low grade fever Petechiae over chest &

axillae

SAO2


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Respiratory Cardiovascular assessment ABGs. pulse ox Chest xray

Many times are normal

May show some infiltration around site Lung scan Be particularly cautious of patients at high risk Patients with DVT

Post op orthopaedic surgery Immobilized patients

Patients may be on low dose heparin prophylaxis


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ARDS is a form of

acute respiratoryfailure characterized

by hypoxia,decreased

pulmonary

compliance,

dyspnea, noncardiacbilateral pulmonaryedema, and the

presence of

pulmonary


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The majorsite of

injury inthe lung isthealveolarcapillarymembran


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Chest injuries are responsible for about 25% for allcivilian traumatic deaths

More than 50% of the injured die before arriving at

health care facilities Only 5% to 15% of all chest injuries require

thoractomy. The remainder can be treated with basic

resuscitation, intubation, or chest tube placement. The initial emergency approach to all chest injuries

is ABCs followed by rapid assessment andtreatment of life-threatening conditions


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Physical exam Chest x-ray

CBC, clotting studies, type & cross match,UA, electrolytes & osmolality Oxygen saturation, ABGs & an ECG


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After chest-wall contusion, rib fracturesare the next most common injury to thechest wall

Rib fractures most often result for directblunt trauma to the chest

Direct force applied to the ribs fracturesthem and drives the bone ends into thethorax

Risk for injury such as pulmonarycontusion or pneumothorax, whichoccurs most often if ribs one throughfour are fractured


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The inward movement of thethorax during inspiration withoutward movement duringexpiration ( usually involving

one side of the chest) Blunt trauma results in

hemothorax and rib fractures,causing a loose segment of thechest wall to become

paradoxical to the expansionand contraction of the rest ofthe chest wall

Gas exchange, the ability to cough,

and secretion removal are impaired


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Medical Management

Providing ventilatory support

Clearing secretions from the lungsControlling painThe specifics for the above three

areas depends on the degree ofrespiratory dysfunction


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An accumulation of atmospheric air in thepleural space, resulting in intrathoracic pressureand reduced vital capacity

Assess Reduced breath sounds Prominence of the involved side of the chest,

which moves poorly with respiration

Pleuritic chest pain Tachypnea Deviation of the trachea away from (closed) or

toward (open) the affected side (shift)


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Interventions are aimed at rapidremoval of trapped atmospheric air,

including insertion of large bore needle

and chest tubes to ensure lung inflation


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Results from an air leak into the lung orchest wall

Air forced into the cavity causes complete

collapse of the affected lung Air that enters the pleural space during

expiration does not exit during inspiration. Air continues to accumulate under pressure,

compressing blood vessels, and limitingvenous return


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Because thisprocess leads todecreased filling

of the heart,cardiac output isreduced.

If not promptlydetected andtreated this willbe fatal


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Causes Blunt chest trauma Mechanical ventilation Medical interventions

Chest tubes Central venous access catheters

Assessment Asymmetry of the thorax Tracheal deviation to the unaffected side

Respiratory distress Absence of breath sounds on one side Distended neck veins Cyanosis

Detectable on chest x-ray


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Interventions

A large bore needle is inserted into the secondintercostal space in the midclavicular line of the

affected area as initial treatment for tensionpneumothorax.

After this, a chest tube is placed into the 4thintercostal space

Monitor pulmonary function

Monitor the clients vital signs

Monitor for increase blood loss

Assess the clients response to chest tubes


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A common problem occurringafter blunt chest trauma orpenetrating injury.

Simple hemothorax

blood loss < 1500ml into thechest cavity

Massive hemothorax

blood loss > 1500ml.

Bleeding - caused by injury tolung tissue, such as pulmonarycontusions or lacerations, thatcan occur with rib and sternal fractures.


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A chest tube is inserted into the pleural space tomaintain the normal negative pressure and facilitaterespiration. It is inserted when the pleural space is

opened. It is also inserted as treatment forpneumothorax or hemothorax

Drainage system; A water seal system assists inmaintaining negative pressures (chest tube).

The chest drainage uses a water seal mechanismthat acts as a one-way valve to prevent air or liquidfrom moving back into the chest cavity


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Check all connections are tight (to prevent accidentaldisconnections), insertion site to the chest drainagesystem (keep sterile dressing at bedside in case ofaccidental dislodging), suction control chamber to the

suction unit (padded clamps at bedside to use if thedrainage system is interrupted) Assess that the dressing over insertion site is dry and

intact Auscultate breath sounds Observe color and consistency of fluid in the collecting

tubing, mark fluid level on the drainage system. Recordamount of hourly drainage, assess drainage at least every8 hours

Assess drainage system for proper functioning Check suction control ( suction is on, if ordered)


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Check the water seal chamber for unexpectedbubbling created by an air leak in the system

Bubbling is normal during forceful expiration or

coughing because air in the chest is being expelled Continuous bubbling indicates an air leak that must

be identified. Notify the physician if bubbling occurs continuously

in the water seal chamber.


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Occurs when an openingin the chest wall is largeenough to allow air to

pass freely in and out ofthe thoracic cavity witheach attempted

respiration.

Termed Sucking Wound


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Provide humidification Use aseptic technique with upper airways Use sterile technique with lower airways

Suction as indicated Postural drainage, percussion, vibration

also used Provide method of communication

Most significant stressor of intubatedpatients


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Tidal volume

The volume of air moved in and out of the lungswith each normal breath Average prescribed is 7-

10mL/kg of body weight Adding a zero to the weight in kilograms gives

an estimate of tidal volume Fraction of inspired oxygen (FIO2)

The oxygen concentration delivered to the patient Determined by ABG results

Ventilators can provide 21%-100%


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Volume cycled Most widely used ventilator Designed to deliver a

preset tidal volume

Independent of changesin airway resistance orlung compliance

Safety valves that can be

set to terminateinspiration when peakinspiratory pressures areexcessive

Pressures limits 10-20 cmH2O


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Pressure cycled

Terminates inspiration once

a preset pressure is reached

Patient then exhales

passively

Airway resistance or

compliance effect tidalvolume

Only for stable patients

w/normal lung compliance


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Modes of ventilation

Controlled mechanical ventilation (CMV)

Delivers a preset tidal volume At a preset rate

Ignoring pts own ventilatory drive

Patient cannot trigger the machine

Utilized w/CNS dysfunction, drug-inducedparalysis, severe chest trauma

Least utilized mode


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Modes of Ventilation

Assist-controlled ventilation (ACV)

Delivers a preset tidal volume upon ptinspiration or independently if preset limitis not reached.


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Modes of Ventilation

Synchronized intermittent mandatory

ventilation (SIMV) Occurs when an opening in the chest wall is

large enough to allow air to pass freely in and

out of the thoracic cavity with eachattempted respiration


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Definition: Positive pressure exertedduring expiration

PEEP improves oxygenation byenhancing gas exchange and preventingatelectasis

PEEP prevents alveoli from collapsing Lungs are kept partially inflated so alveoli-

capillary gas exchange is facilitated throughoutthe ventilatory cycle


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Definition: application of positiveairway pressure throughout the entirerespiratory cycle for spontaneously

breathing clients CPAP keeps the alveoli open during

inspiration and prevents alveolar

collapse during expiration Results infunctional residual capacity,

improved gas exchange and improved

oxygenation


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If pt tolerates T-piece trial

Second set of ABGs is drawn 20 min. after

spontaneous ventilation at a constant FiO2 Alveolar-arterial equilibration takes 15-20 minutes

If clinically stable, usually extubated 2-3 hours of

weaning


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Successful weaning is supplemented by intensivepulmonary care O2 therapy

ABG evaluation Pulse oximetry

Bronchodilator therapy

Chest physiotherapy

Adequate nutrition, hydration and humidification Incentive spirometry


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VS, evidence of hypoxia - restlessness,anxiety, tachycardia, increased respiratory

rate, cyanosis Respiratory rate & pattern Breath sounds Neurologic status Tidal volume, minute ventilation, forced vital

capacity


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November 27, 2013 39

The body attempts to maintain homeostasisof hydrogen concentration within the

extracellular fluid (ECF). Control of acid basebalance and oxygenation is essential foroptimal function of chemical reactions,enzymes, and tissue oxygenation.


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Normal Parameter Acceptable Range

pH = 7.40 pH = 7.35 7.45

PaCO2 = 40 PaCO2 = 35 45 mmHg

HCO3 = 24 HCO3 = 22 26 mEq/L

PaO2 = 97 Pa O2 = 80

100 mmHg

SaO2 = 98% SaO2 = 95 - 100%


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pH Description

7.35 7.45 Compensated

< 7.35 Acidosis Uncompensated

>7.45 Alkalosis

Uncompensated


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Excess in carbonic acid Occurs in hypoventilation---not blowing off CO2 Carbon dioxide and carbonic acid build up in the

blood pH is low ( 45mmHg) HCO3 is normal if uncompensated or elevated if

compensated (REMEMBER: kidneys take a while tocompensate)


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COPD Narcotics/Sedatives Chest wall abnormalities Obesity Pneumonia Atelectasis Respiratory Muscle

weakness Mechanical

underventilation

CO2 retention fromhypoventilation

Impaired respiratoryefforts due to airway

obstruction, weakenedresp. muscles or depressedresp. center

Compensatory response isHCO3 retention by the

kidney


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Carbonic acid deficit Occurs with hyperventilation, the increase

ventilation causes the PaCO2 level to

decrease pH is elevated (>7.45) PaCO2 is decreased (


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Hyperventilation due tohypoxia, high altitudes,anxiety, fear, pain,

exercise, fever Stimulated resp. center

due to septicemia,encephalitis, brain injury,salicylate poisoning

Mechanical overventilation

Increased CO2

excretion fromhyperventilation

Compensatoryresponse of HCO3

excretion by the kidneyand H+ ion retention


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Base bicarbonate deficit

Acids other than carbonic acid accumulate in the

body (ie. lactic acid accumulation in shock states).

Diarrhea can cause a loss of bicarbonate. In renaldisease the kidneys lose the ability to reabsorbbicarbonate and secrete hydrogen ions.

pH decreased (


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Diabetic Ketoacidosis

Lactic Acidosis Starvation

Severe diarrhea Renal Failure

Biliary fistulas Shock

Ingestion of acid

Gain of fixed acid,

inability to excreteacid, a loss of base

Compensatoryresponse is CO2

excretion by the lungsand kidneys may

attempt to excrete acid


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Occurs when a loss of acid (from prolongedvomiting or gastric suction) or a gain in

bicarbonate (i.e. self ingestion of bakingsoda) pH elevated (>7.45) PaCO2 normal or elevated if compensated HCO3 elevated (>26 mEq/L)


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Severe vomiting Excessive gastric

suctioning

Diuretic therapy Potassium deficit Excess NAHCO3 intake Excessive

mineralcorticoids

Loss of strong acid or

gain of base Compensatory

response is CO2retention by the lungs

and kidneys willincrease HCO3

excretion


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Chronic vs Acute

Compensated: The pH is inside theacceptable range Chronic

Uncompensated: The pH is outside the

acceptable range - Acute


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Respiratory Acidosis or Alkalosis

It is when the pH is abnormal due to a change in

PaCO2

Metabolic Acidosis or Alkalosis

It is when the pH is abnormal due to a change in

HCO3


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R - espitarory

O - opposite M etabolic

E - qual

If arrows are in the

opposite direction theproblem is respiratory

in nature

If the arrows are in thesame direction the

problem is metabolic


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pH PaCO2 HCO3

Respiratory Acidosis

Compensated

Respiratory Acidosis

Respiratory Alkalosis

Metabolic Acidosis

Metabolic Alkalosis

nl

nl

nl

nl


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Lets keep it simple Everyone has a name. Right? Well, so does every ABG! For example:

First Middle LastUncompensated Respiratory Acidosis

Compensated Metabolic Alkalosis


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First, lets review normal values of an ABG

pH = 7.35 - 7.45CO2 = 35 - 45 mmHg

HCO3 = 22 - 26 mEq/L


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OOPS! Almost done. One more gray area tocover. . .

Sometimes we cannot identify a middlename for our ABG We refer to these imbalances as Combined

and call them Respiratory and Metabolic

critical pt's

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