NUR 445: Module 2 (Exam 1) Respiratory
MODULE 2: RESPIRATORY DISORDERS & MANAGEMENT OF CARE
Priority Assessments Critical Cues Priority Actions & Interventions
_@ Virchow’s Triad: Diagnosis: Actions:
Obstruction of 1+ e Pulmonary e elevate HOB (facilitates
branches of the prom———— -G angiography oxygenation)
pulmonary artery o olaonan e chest X-ray e administer IV fluids
1. Sikte ool et e (CTscan e Anticoagulants (heparin,
2. Polycythemia vera
3. Abrupt discontinuation of anticoal plasma D-DIMER warfarin, factor Xa)
Venous stasis * Prolonged bedrest/immobility
[Prescence of a e Thrombolytics
o thrombus], ABG e Inotropic agents to
* Pregnancy increase cardiac
e
* Any postoperative patient °
contractiity
Norepinephrine and
EE——— gl vasopressin (maintain BP)
* Atherosclerosis e Bleeding precautions
Risk Factors: [electric razors, avoid
e post-operative (long bone football]
surgeries with onset SOB) e Prepare for intubation +
resuscitation d/t massive
Manifestations: PE
e sudden onset of dyspnea e Massive PE - call a rapid
e pleuritic chest pain or notify HCP
e tachypnea
e accessory muscle use
e tachypnea
e crackles
e cough
e hemoptysis
Labs/DX: e Bronchodilators, inhaled
Impaired gas exchange « Ay enncin rcor e e Decreased pH steroids [reduce
and oxygenation because %};mmmmmm - e PaCO2 increased inflammation], diuretics,
of a V/Q mismatch, a g Py bt e May see affect sedation [anxiety], ABX
shunt, or impaired S Ll on RBCs e Oxygen (with humidity)
diffusion. Manifestations: e Chest X-ray e Elevate HOB; sit them up
Crackles, rhonchi, or diminished e CTScan (aids in WOB)
lung sounds e Position pt with the GOOD
Table 27.7 Clinical Manifestations of Respiratory Failure
LUNG DOWN!!I! (ensures
Early Intermediate Late
© Dyspnea o Confusion e Cyanosis
lung maintains adequate
« Restlessness e Lethargy (due to e Coma blood flow)
o Anxiety increased CO,)
« Fatigue ® Pink skin coloration (due e Chest PT and suctioning +
to increased CO,)
* Increased blood
ambulation
pressure (from baseline)
® Tachycardia o |V fluids
e Nutritional support
e Be prepared for
ventilatory support
®ES
, NUR 445: Module 2 (Exam 1) Respiratory
ute Respirato DX/Labs: Primary: mechanical ventilation for
istress Syndr z;::t’:“" :‘:::‘s':ic:' e Hypoxemia + hypoxemia
(ARDS) Parcreaths hypocapnia
acute onset of less than 7 | eneumonia (intectious or aspiration) ~ Burns e High WBC Nursing:
days, refractory Riomsse e ® Respiratory ~* Positioning: PRONE
hypoxemia, and bilateral L::::::Z::"ke T ooy b alkalosis oy
infiltrates ruling out Drug/aicohol overdose e v
cardiac pulmonary edema | Manifestations: e o
as the cause. e Hypoxemia —
e Hyperventilation T
e Tachycardia s
e Tachypnea - >
Meds Depend on Cause:
e Infection 2 ABX
e Inflammation 2
corticosteroids
e Mechanical 2
neuromuscular blocking
agents for comfort
e Diuretics, fluids (watch
and monitor closely)
e Hydration
_ Manifestations: DX: Treatment (ABCs):
Two types: blunt and e Decreased oxygenation e Chest X-ray 1. Airway: Is it patent? Is
penetrating and ventilation e US = toruleout there obstruction? =
e Tachypneic a cardiac intubation
Blunt = object hitting the [compensation] tamponade 2. Breathing: Does the pt
chest [steering wheel, seat ® Respiratory alkalosis d/t [blood in demonstrate ability to
belt, airbag] hyperventilation pericardium] breathe w/o compromise
e Acidosis will develop ad e ChestCT in gas exchange? = oxygen
Penetrating = sharp CO2 is not exchanged e Lactate level = then.int.ubation and
objects [knives, bullets, e One side: chest risk and increased ventilation [pneumothorax
objects from MVA] breath sounds, or e HctandHgb= or hemo = CHEST TUBE
tracheal deviation is decreased d/t INSERTION]
Flail chest: present ONE SIDED) bleeding 3. Circ.ulation: Does the
3 or more adjacent ribs * FEarly: hypoxemia > L paTent ha;vekgdeqluat?e_ IV
that have been fractured agitation and anxiety, Compllcatlons: IF:)IU 'Sdes and skin co 0.;-- =
[hallmark sign = decreased LOC Tensmn pneumothorax = d/lilblresc;lf;c'ta:lfin [:j itis
paradoxical chest wall e Subcutaneous air or blood collects in X 00d 10Ss _ eén doa
emphysema = airin pleural space [tracheal ood transfusion]
movqmflent] tissues under skin deviation toward
unaffected sign is Other Actions:
HALLMARK] * Oxygen
e EMEGRENCY e Intubation prep
e Llarge-Bore IV e Elevate HOB
[14/16 G] into
the ribs to allow
®ES
MODULE 2: RESPIRATORY DISORDERS & MANAGEMENT OF CARE
Priority Assessments Critical Cues Priority Actions & Interventions
_@ Virchow’s Triad: Diagnosis: Actions:
Obstruction of 1+ e Pulmonary e elevate HOB (facilitates
branches of the prom———— -G angiography oxygenation)
pulmonary artery o olaonan e chest X-ray e administer IV fluids
1. Sikte ool et e (CTscan e Anticoagulants (heparin,
2. Polycythemia vera
3. Abrupt discontinuation of anticoal plasma D-DIMER warfarin, factor Xa)
Venous stasis * Prolonged bedrest/immobility
[Prescence of a e Thrombolytics
o thrombus], ABG e Inotropic agents to
* Pregnancy increase cardiac
e
* Any postoperative patient °
contractiity
Norepinephrine and
EE——— gl vasopressin (maintain BP)
* Atherosclerosis e Bleeding precautions
Risk Factors: [electric razors, avoid
e post-operative (long bone football]
surgeries with onset SOB) e Prepare for intubation +
resuscitation d/t massive
Manifestations: PE
e sudden onset of dyspnea e Massive PE - call a rapid
e pleuritic chest pain or notify HCP
e tachypnea
e accessory muscle use
e tachypnea
e crackles
e cough
e hemoptysis
Labs/DX: e Bronchodilators, inhaled
Impaired gas exchange « Ay enncin rcor e e Decreased pH steroids [reduce
and oxygenation because %};mmmmmm - e PaCO2 increased inflammation], diuretics,
of a V/Q mismatch, a g Py bt e May see affect sedation [anxiety], ABX
shunt, or impaired S Ll on RBCs e Oxygen (with humidity)
diffusion. Manifestations: e Chest X-ray e Elevate HOB; sit them up
Crackles, rhonchi, or diminished e CTScan (aids in WOB)
lung sounds e Position pt with the GOOD
Table 27.7 Clinical Manifestations of Respiratory Failure
LUNG DOWN!!I! (ensures
Early Intermediate Late
© Dyspnea o Confusion e Cyanosis
lung maintains adequate
« Restlessness e Lethargy (due to e Coma blood flow)
o Anxiety increased CO,)
« Fatigue ® Pink skin coloration (due e Chest PT and suctioning +
to increased CO,)
* Increased blood
ambulation
pressure (from baseline)
® Tachycardia o |V fluids
e Nutritional support
e Be prepared for
ventilatory support
®ES
, NUR 445: Module 2 (Exam 1) Respiratory
ute Respirato DX/Labs: Primary: mechanical ventilation for
istress Syndr z;::t’:“" :‘:::‘s':ic:' e Hypoxemia + hypoxemia
(ARDS) Parcreaths hypocapnia
acute onset of less than 7 | eneumonia (intectious or aspiration) ~ Burns e High WBC Nursing:
days, refractory Riomsse e ® Respiratory ~* Positioning: PRONE
hypoxemia, and bilateral L::::::Z::"ke T ooy b alkalosis oy
infiltrates ruling out Drug/aicohol overdose e v
cardiac pulmonary edema | Manifestations: e o
as the cause. e Hypoxemia —
e Hyperventilation T
e Tachycardia s
e Tachypnea - >
Meds Depend on Cause:
e Infection 2 ABX
e Inflammation 2
corticosteroids
e Mechanical 2
neuromuscular blocking
agents for comfort
e Diuretics, fluids (watch
and monitor closely)
e Hydration
_ Manifestations: DX: Treatment (ABCs):
Two types: blunt and e Decreased oxygenation e Chest X-ray 1. Airway: Is it patent? Is
penetrating and ventilation e US = toruleout there obstruction? =
e Tachypneic a cardiac intubation
Blunt = object hitting the [compensation] tamponade 2. Breathing: Does the pt
chest [steering wheel, seat ® Respiratory alkalosis d/t [blood in demonstrate ability to
belt, airbag] hyperventilation pericardium] breathe w/o compromise
e Acidosis will develop ad e ChestCT in gas exchange? = oxygen
Penetrating = sharp CO2 is not exchanged e Lactate level = then.int.ubation and
objects [knives, bullets, e One side: chest risk and increased ventilation [pneumothorax
objects from MVA] breath sounds, or e HctandHgb= or hemo = CHEST TUBE
tracheal deviation is decreased d/t INSERTION]
Flail chest: present ONE SIDED) bleeding 3. Circ.ulation: Does the
3 or more adjacent ribs * FEarly: hypoxemia > L paTent ha;vekgdeqluat?e_ IV
that have been fractured agitation and anxiety, Compllcatlons: IF:)IU 'Sdes and skin co 0.;-- =
[hallmark sign = decreased LOC Tensmn pneumothorax = d/lilblresc;lf;c'ta:lfin [:j itis
paradoxical chest wall e Subcutaneous air or blood collects in X 00d 10Ss _ eén doa
emphysema = airin pleural space [tracheal ood transfusion]
movqmflent] tissues under skin deviation toward
unaffected sign is Other Actions:
HALLMARK] * Oxygen
e EMEGRENCY e Intubation prep
e Llarge-Bore IV e Elevate HOB
[14/16 G] into
the ribs to allow
®ES
