PE (not to be confused with pulmonary edema) is a collection of matter (solids, liquids, or gaseous substances) that enters venous circulation

and lodges in the pulmonary artery

Large emboli obstruct pulmonary blood flow, leading to decreased systemic oxygenation, pulmonary tissue hypoxia, and potential death.

Pulmonary Embolism most common acute pulmonary disease (90%) among hospitalized clients. In most people a blood clot from a DVT breaks loose from one of the veins in the legs or pelvis.

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

Major factors
Prolonged

Additional factors

immobilization Surgery Obesity Advancing age Hypercoagulability Hx of thromboembolism

Smoking Pregnancy Estrogen therapy CHF Stroke Malignant neoplasms (esp lung or prostate) Major trauma

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) during the acute phase, give warfarin (Coumadin) orally when the heparin drip is discontinued Thrombolytics may be used to break an existing clot if the PE is massive or the client is hemodynamically unstable. Monitor partial thromboplastin time before therapy is started Frequently assess the client for bleeding and protect from situations that could lead to bleeding

Symptoms
Sudden onset of

Signs

dyspnea Pleuritic chest pain Apprehension, restlessness Feeling of impending doom Cough Hemoptysis

Tachypnea Crackles Pleural friction rub Tacycardia S3or S4 heart sound Diaphoresis Low grade fever Petechiae over chest & axillae SAO2

Respiratory Cardiovascular assessment ABGs. pulse ox Chest xray

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

Many times are normal May show some infiltration around site

ARDS is a form of acute respiratory failure characterized by hypoxia, decreased pulmonary compliance, dyspnea, noncardiac bilateral pulmonary edema, and the presence of pulmonary

The major site of injury in the lung is the alveolar capillary membrane

Chest injuries are responsible for about 25% for all civilian 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 and treatment of life-threatening conditions

Physical exam Chest x-ray CBC, clotting studies, type & cross match, UA, electrolytes & osmolality Oxygen saturation, ABGs & an ECG

 After chest-wall contusion, rib fractures

are the next most common injury to the chest wall Rib fractures most often result for direct blunt trauma to the chest Direct force applied to the ribs fractures them and drives the bone ends into the thorax Risk for injury such as pulmonary contusion or pneumothorax, which occurs most often if ribs one through four are fractured

The inward movement of the thorax during inspiration with outward movement during expiration ( usually involving one side of the chest) Blunt trauma results in hemothorax and rib fractures, causing a loose segment of the chest wall to become paradoxical to the expansion and contraction of the rest of the chest wall Gas exchange, the ability to cough, and secretion removal are impaired

Medical Management Providing ventilatory support Clearing secretions from the lungs Controlling pain The specifics for the above three areas depends on the degree of respiratory dysfunction

An accumulation of atmospheric air in the pleural space, resulting in intrathoracic pressure and 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)

Interventions are aimed at rapid removal of trapped atmospheric air, including insertion of large bore needle and chest tubes to ensure lung inflation

Results from an air leak into the lung or chest 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 limiting venous return

Because this process leads to decreased filling of the heart, cardiac output is reduced. If not promptly detected and treated this will be fatal

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

Interventions A large bore needle is inserted into the second intercostal space in the midclavicular line of the affected area as initial treatment for tension pneumothorax. After this, a chest tube is placed into the 4th intercostal space Monitor pulmonary function Monitor the clients vital signs Monitor for increase blood loss Assess the clients response to chest tubes

A common problem occurring after blunt chest trauma or penetrating injury. Simple hemothorax blood loss < 1500ml into the chest cavity Massive hemothorax blood loss > 1500ml. Bleeding - caused by injury to lung tissue, such as pulmonary contusions or lacerations, that can occur with rib and sternal fractures.

A chest tube is inserted into the pleural space to maintain the normal negative pressure and facilitate respiration. It is inserted when the pleural space is opened. It is also inserted as treatment for pneumothorax or hemothorax Drainage system; A water seal system assists in maintaining negative pressures (chest tube). The chest drainage uses a water seal mechanism that acts as a one-way valve to prevent air or liquid from moving back into the chest cavity

Check all connections are tight (to prevent accidental disconnections), insertion site to the chest drainage system (keep sterile dressing at bedside in case of accidental dislodging), suction control chamber to the suction unit (padded clamps at bedside to use if the drainage 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. Record amount of hourly drainage, assess drainage at least every 8 hours Assess drainage system for proper functioning Check suction control ( suction is on, if ordered)

Check the water seal chamber for unexpected bubbling 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.

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 each attempted respiration.

Termed Sucking Wound

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 intubated patients

Tidal volume The volume of air moved in and out of the lungs with each normal breath Average prescribed is 710mL/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%

Volume cycled Most widely used ventilator Designed to deliver a preset tidal volume Independent of changes in airway resistance or lung compliance Safety valves that can be set to terminate inspiration when peak inspiratory pressures are excessive Pressures limits 10-20 cm H2O

Pressure cycled Terminates inspiration once a preset pressure is reached Patient then exhales passively Airway resistance or compliance effect tidal volume Only for stable patients w/normal lung compliance

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-induced paralysis, severe chest trauma Least utilized mode

Modes of Ventilation Assist-controlled ventilation (ACV)

Delivers a preset tidal volume upon pt inspiration or independently if preset limit is not reached.

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 each attempted respiration

Definition: Positive pressure exerted during expiration PEEP improves oxygenation by enhancing gas exchange and preventing atelectasis PEEP prevents alveoli from collapsing

Lungs are kept partially inflated so alveoli-

capillary gas exchange is facilitated throughout the ventilatory cycle

Definition: application of positive airway pressure throughout the entire respiratory cycle for spontaneously breathing clients CPAP keeps the alveoli open during inspiration and prevents alveolar collapse during expiration Results in functional residual capacity, improved gas exchange and improved oxygenation

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

Successful weaning is supplemented by intensive pulmonary care

O2 therapy ABG evaluation Pulse oximetry Bronchodilator therapy Chest physiotherapy Adequate nutrition, hydration and humidification Incentive spirometry

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

The body attempts to maintain homeostasis of hydrogen concentration within the extracellular fluid (ECF). Control of acid base balance and oxygenation is essential for optimal function of chemical reactions, enzymes, and tissue oxygenation.

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Normal Parameter
pH = 7.40 PaCO2 = 40 HCO3 = 24 PaO2 = 97

Acceptable Range
pH = 7.35 7.45 PaCO2 = 35 45 mmHg HCO3 = 22 26 mEq/L Pa O2 = 80 100 mmHg

SaO2 = 98%

SaO2 = 95 - 100%

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pH
7.35 7.45 < 7.35 >7.45

Description
Compensated Acidosis Uncompensated 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 (<7.35) PaCO2 is elevated (> 45mmHg) HCO3 is normal if uncompensated or elevated if compensated (REMEMBER: kidneys take a while to compensate)

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

CO2 retention from hypoventilation Impaired respiratory efforts due to airway obstruction, weakened resp. muscles or depressed resp. center Compensatory response is HCO3 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 (<35mmHg) HCO3 normal (uncompensated) HCO3 is decreased in compensated

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Hyperventilation due to hypoxia, high altitudes, anxiety, fear, pain, exercise, fever Stimulated resp. center due to septicemia, encephalitis, brain injury, salicylate poisoning Mechanical overventilation

Increased CO2 excretion from hyperventilation Compensatory response of HCO3 excretion by the kidney and 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 renal disease the kidneys lose the ability to reabsorb bicarbonate and secrete hydrogen ions. pH decreased (<7.35) PaCO2 normal or decreased if compensated HCO3 decreased (<22 mEq/L)

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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 excrete acid, a loss of base Compensatory response is CO2 excretion by the lungs and kidneys may attempt to excrete acid

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Occurs when a loss of acid (from prolonged vomiting or gastric suction) or a gain in bicarbonate (i.e. self ingestion of baking soda) 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 CO2 retention by the lungs and kidneys will increase HCO3 excretion

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Chronic vs Acute Compensated: The pH is inside the acceptable 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 the problem is respiratory in nature

If the arrows are in the same direction the problem is metabolic

pH Respiratory Acidosis Compensated Respiratory Acidosis Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis

PaCO2

HCO3

nl nl nl nl

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

First
Uncompensated Compensated

Last
Acidosis Alkalosis

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First, lets review normal values of an ABG

pH = 7.35 - 7.45

CO2 = 35 - 45 mmHg
HCO3 = 22 - 26 mEq/L

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OOPS! Almost done. One more gray area to cover. . . Sometimes we cannot identify a middle name for our ABG We refer to these imbalances as Combined and call them Respiratory and Metabolic

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