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MEDICAL SURGICAL NURSING II
VNRS B85
NURSING CARE OF CLIENTS WITH GAS EXCHANGE DISORDERS
INTRODUCTION:
Normal function of the lower respiratory system depends on several organ systems: the
central nervous system, which stimulates and controls breathing; chemoreceptor in the
brain, aortic arch, and carotid bodies, which monitor the pH and oxygen content of the
blood; the heart and circulatory system, which provide foe blood supply and gas
exchange; the musculoskeletal system, which provides an intact thoracic cavity capable
of expanding and contracting; and the lungs and bronchial tree, which allow air
movement and gas exchange. Impaired function of any of these systems affects
ventilation and respiration. As a result, tissues may become hypoxic, with inadequate
oxygen to support metabolic activity.
LEARNING OUTCOMES:
Upon completion of this unit, the student will be able to:
A.
Theory
1. Relate the pathophysiology and manifestations of obstructive, pulmonary
vascular, and critical respiratory disorders to their effects on ventilation
and respiration (gas exchange).
2. Compare and contrast the etiology, risk factors, and vulnerable
populations for disorders affecting ventilation and gas exchange within the
lungs.
3.
Describe interdisciplinary care and the nursing role in health promotion
and caring for clients with disorders that affect the ability to ventilate the
lungs and exchange gases with the environment.
4.
Discuss interdisciplinary interventions to provide airway and ventilatory
support for the client with respiratory failure, and nursing responsibilities
in caring for clients requiring airway and ventilatory support.
5.
Describe the nursing implications for medications used to promote
ventilation and gas exchange.
ASSIGNMENT:
LeMone-Burke Chapter 39
CHAPTER 39
LECTURE OUTLINE
NURSING CARE OF CLIENTS WITH GAS EXCHANGE DISORDERS
Asthma
•Chronic inflammatory disorder of the airways
•Generally brief, but acute asthma may be fatal
•Persistent inflammation of the airways
–Triggers
•Allergens
•Respiratory tract infection
•Exercise
Asthma
•Inhaled irritants
•Emotional upsets
•Second hand smoke
•Some medications
•The acute or early response of asthma produces bronchoconstriction, edema, and mucus
production.
Asthma
•Pathophysiology
–Inflammatory mediators are released
–Activation of inflammatory cells
–Bronchoconstriction
–Airway edema
–Impaired mucociliary clearance
–Work of breathing increases
–Trapping of air impairs gas exchange
Asthma
•Manifestations
–Chest tightness
–Cough, dyspnea, and wheezing
–Tachycardia, tachypnea, prolonged expiration
–Fatigue, anxiety, apprehension
–Respiratory failure
•Breath sounds may “improve” right before failure
Asthma
•Status Asthmaticus
–Sever, prolonged asthma
–Does not respond to routine treatment
•Cough-variant Asthma
–Persistent cough without wheezing or dyspnea
–Significant airway inflammation
Cystic Fibrosis
•Autosomal Recessive Disorder
–Lack of CFTR protein
–Abnormal electrolyte transfer
•Affects Epithelial Cells
–Respiratory
–Gastrointestinal
–Reproductive tracts
•Abnormal Exocrine Gland Secretions
Cystic Fibrosis
•Pathophysiology
–Respiratory
•Excess mucus production
•Impaired ability to clear secretions
•Progressive COPD
•Pulmonary hypertension
•Right ventricular hypertrophy
•Cor pulmonale
Cystic Fibrosis
–Gastrointestinal
•Pancreatic enzyme deficiency
•Impaired digestion
•Elevation of sodium/chloride in sweat
–Reproductive/endocrine
•Diabetes mellitus
•Liver failure
•Males usually sterile
•Women have difficulty conceiving
Cystic Fibrosis
•Manifestations
–Respiratory
•History of chronic lung disease
•Recurrent pneumonia
•Exercise intolerance
•Chronic cough
•Clubbing of fingers and toes
•Barrel chest
•Hyperresonant percussion tone
•Basilar crackles
Cystic Fibrosis
–Gastrointestinal
•Abdominal pain
•Steatorrhea
–Endocrine
•Small stature
Pulmonary Embolism (Thromboembolism)
•Obstruction of blood flow in part of pulmonary vascular system by embolus
•A medical emergency
–Fifty percent of deaths occur within 1st 2 hours following embolization
•Effects
•Large pulmonary artery occlusion
–May cause sudden death
•Significant portion of smaller vessels
–Lung tissue infarction
•Obstruction of small segment of pulmonary circulation
–May cause no permanent injury
–
Pulmonary Embolism (Thromboembolism)
•Manifestations
•Depend upon size and location
•Small emboli may be asymptomatic
•Common manifestations
–Dyspnea
–Pleuritic chest pain
–Anxiety
–Sense of impending doom
–Cough
–Diaphoresis
–Hemoptysis
Pulmonary Embolism (Thromboembolism)
•Manifestations of fat emboli
•Sudden onset dyspnea
•Tachypnea
•Tachycardia
•Confusion
•Delirium
•Decreased level of consciousness
•Petechiae
Acute Respiratory Failure
•Consequence of severe respiratory dysfunction
•Defined by arterial blood gas values
–An arterial oxygen level of less than 50 to 60 mmHg
–Arterial carbon dioxide level of greater that 50 mmHg
•In COPD
–Acute drop in blood oxygen levels
–Increased carbon dioxide levels
•Failure of oxygenation: hypoxemia without a rise in carbon dioxide levels
•Hypoventilation: hypoxemia with hypercapnia
•
Acute Respiratory Failure
•Manifestations
•Dyspnea
•Restlessness, apprehension
•Impaired judgment
•Motor impairment
•Tachycardia
•Hypertension
•Cyanosis
•Dysrhythmias
•Hypotension
•Decreased cardiac output
Acute Respiratory Distress Syndrome
•Characterized by noncardiac pulmonary edema and refractory hypoxemia
•Mortality due to multiple organ system dysfunction
•Pathophysiology
•Acute lung injury
•Unregulated systemic inflammatory response
Acute Respiratory Distress Syndrome
•Tissue hypoxia
•Metabolic acidosis
•Manifestations
•Develop 24-48 hours after the initial insult
•Dyspnea, tachypnea, and anxiety
•Progressive respiratory distress
•Cyanosis does not improve with oxygen administration
Asthma
•Incidence
–Prevalence of asthma currently relatively stable
–Hospitalizations and deaths due to asthma decreasing
–
•Risk Factors
–Allergies
–Family history
–Air pollution
–Occupational exposures
–Respiratory viruses
–Exercise in cold air
–Emotional stress
Chronic Obstructive Pulmonary Disease
•Risk Factors
–Cigarette smoking
–Air pollution
–Occupational exposures
–Airway infection
–Familial and genetic factors
Atelectasis
•Etiology
–Obstruction of the bronchus
–Pneumothorax
–Pleural effusion
–Tumor
–Loss of pulmonary surfactant
–
•Risk Factors
–COPD
–Smokers undergoing surgery
–Prolonged bedrest
–Mechanical ventilation
Pulmonary Embolism
•Etiology
–Thromboemboli
•Venous system
•Right side of the heart
–Tumors
–Fat or bone marrow
–Amniotic fluid
–Intravenous injection of air or other foreign substances
Pulmonary Embolism
•Risk Factors
–Status of venous flow
–Vessel wall damage
–Altered blood coagulation
–Prolonged immobility
–Trauma
–Surgery
–Myocardial infarction
–Obesity
–Advanced age
–Oral contraceptive use
–Estrogen therapy
Asthma
•Interdisciplinary Care
–Control of symptoms
–Prevention of acute attacks
–Restoring airway patency
–Restoring alveolar ventilation
•Treatments
–Peak expiratory flow rate (PEFR)
–Prevention
Asthma
•Nursing Diagnoses
–Ineffective airway clearance
–Ineffective breathing pattern
–Anxiety
–Ineffective therapeutic regimen management
Chronic Obstructive Pulmonary Disease
•Interdisciplinary Care
–Symptom relief
–Minimization of obstruction
–Slowing development of disability
–
•Diagnosis
–Pulmonary function tests
–Ventilation-perfusion scanning
–Serum alpha 1-antitrypsin levels
–ABGs
–Pulse oximetry
–Capnogram
–CBC with WBC differential
–Chest x-ray
Chronic Obstructive Pulmonary Disease
•Treatments
–Smoking cessation.
–Avoidance of airway irritants and allergens
–Pulmonary hygiene measures
–Adequate hydration
–Regular aerobic exercise if applicable
–Breathing exercises
–Long-term oxygen therapy
Chronic Obstructive Pulmonary Disease
•Nursing Diagnoses
–Ineffective airway clearance
–Imbalanced nutrition: Less than body requirements
–Compromised family coping
–Decisional conflict: Smoking
Cystic Fibrosis
•Interdisciplinary Care
–Preventing or treating respiratory complications
–Maintaining adequate nutrition
•Diagnosis
–Analysis of chloride concentrations in the sweat
–ABGs and oxygen saturation levels
–Pulmonary function testing
–Alveolar-capillary diffusion
Cystic Fibrosis
•Treatments
–Chest physiotherapy with percussion and postural drainage
–Oxygen therapy
–Liberal fluid intake
–High protein, high fat, high calorie diet
Cystic Fibrosis
•Surgery
–Organ transplantation
•Single lung
•Double lung
•Heart lung
•Nursing Diagnoses
–Ineffective airway clearance
–Anticipatory guidance
Atelectasis
•Interdisciplinary Care
–Prevention
–Reversing underlying cause
–Bronchoscopy
–Antibiotic therapy
•Diagnosis
–Chest x-ray
•Nursing Care
–Directed toward airway clearance
Bronchiectasis
•Interdisciplinary Care
–Maintaining optimal pulmonary function
–Preventing progression
•Diagnosis
–Based on history and physical
–Chest x-ray
–CT scan
•Treatments
–Chest physiotherapy
–Percussion
–Postural drainage
–Bronchoscopy
Bronchiectasis
•Surgery
–Resection of areas of localized lung tissue
•Nursing Diagnoses
–Ineffective airway clearance
–Ineffective breathing pattern
–Impaired gas exchange
–Imbalanced nutrition: Less than body requirements
–Self care deficit
Occupational Lung Disease
•Interdisciplinary Care
–Prevention
•Diagnosis
–Chest x-ray
–Pulmonary function studies
–Bronchoscopy
–Pulmonary function tests
–ABGs
–Lung scans
–Lung biopsy
Occupational Lung Disease
•Treatments
–No specific therapy
–Elimination of further exposure is vital
–
•Nursing Diagnoses
–Activity intolerance
–Impaired gas exchange
–Ineffective breathing pattern
–Anticipatory grieving
–Low self-esteem
–Caregiver role strain
Sarcoidosis
•Diagnosis
–WBC with diff
–ESR
–Chest x-ray
–Pulmonary function tests
–Biopsy of granulomatous lesions
•Nursing Care
–Directed by the involved organ systems and related manifestations
Pulmonary Embolism
•Interdisciplinary Care
–Prevention
•Early ambulation of medical and surgical clients
•External pneumatic compression of the legs
•Elevating the legs
•Active and passive exercising
Pulmonary Embolism
•Treatments
–Oxygen therapy
–Analgesics
–Pulmonary artery wedge pressure monitoring
–Cardiac output monitoring
–Cardiac rhythm monitoring
Pulmonary Embolism
•Diagnosis
–Plasma D-dimer levels
–Chest CT with contrast
–Lung scans
–Pulmonary angiography
–Chest x-ray
–Electrocardiogram
–ABGs
–Exhaled carbon dioxide levels
–Coagulation studies
–Surgery
–Umbrella like filter insertion
–
•Nursing Diagnoses
–Impaired gas exchange
–Decreased cardiac output
–Ineffective protection
–Anxiety
Pulmonary Hypertension
•Interdisciplinary Care
–Slowing the course of the disease
–Preventing thrombus formation
–Reducing pulmonary vasoconstriction
•Diagnosis
–CBC
–ABGs
–Oxygen saturation
–Chest x-ray
–Electrocardiogram
–Doppler ultrasonography
–Heart catheterization
Pulmonary Hypertension
•Treatment
–Oxygen therapy
–Phlebotomy for polycythemia
–Salt and water restriction
–Diuretic therapy
–Surgery
–Bilateral lung or heart-lung transplant
Pulmonary Hypertension
•Nursing Diagnoses
–Anticipatory grieving
–Hopelessness
–Decreased cardiac output
–Excess fluid volume
–Ineffective individual coping
Acute Respiratory Distress Syndrome
•Interdisciplinary Care
–Identifying and treating its underlying cause
–Providing aggressive respiratory support
•Diagnosis
–ABGs
–Chest x-ray
–Pulmonary function tests
–Pulmonary artery pressure monitoring
Acute Respiratory Distress Syndrome
•Medication
–No definitive drug therapy
–Inhaled nitric oxide
–Surfactant
–NSAIDs
–Corticosteroids
–
Acute Respiratory Distress Syndrome
•Treatments
–Endotracheal intubation
–Mechanical ventilation
–Prone positioning
–Careful fluid replacement
–Nutrition
–Treatment of infection
–Correction of underlying condition
•Nursing Diagnoses
–Decreased cardiac output
–Dysfunctional ventilatory weaning response
Asthma
•Long-term Control
–Anti-inflammatory agents
–Long-acting bronchodilators
–Leukotriene modifiers
•Quick Relief
–Short-acting adrenergic stimulants
–Anticholinergic drugs
–Methylxanthines
Asthma
•Administration Methods
–Metered-dose inhaler (MDI)
–Dry powder inhaler (DPI)
–Nebulizer
Chronic Obstructive
Pulmonary Disease
•Immunizations against pneumococcal pneumonia and influenza
•Broad-spectrum antibiotics
•Bronchodilators
•Corticosteroids
•Alpha 1-antitrypsin replacement therapy
Cystic Fibrosis
•Immunization against respiratory infections
•Bronchodilators
•Antibiotics
•Dornase alfa
Bronchiectasis
•Antibiotics
•Inhaled bronchodilators
•Oxygen
Occupational
Lung Disease
•Anti-inflammatories
•Immunizations
Sarcoidosis
•Corticosteroids
•Anti-inflammatory
•Immune-modifiers
Pulmonary Embolism
•Heparin
•Warfarin sodium
•Thrombolytic therapy
–Streptokinase
–Urokinase
–Tissue plasminogen activator
Pulmonary Hypertension
•Calcium channel blockers
•Short-acting direct vasodilators
•Oral anticoagulants
Nursing Implications
•Client and family education
•Effects on other bodily systems
•Peak and trough levels
•Therapeutic blood levels
•IV compatibility