RESPIRATORY DISORDERS

ACTIVITY Ponce, Carlos Joshua L. BSN III-C

1. Pulmonary Embolism
A. Formulate at least three 1 nursing diagnoses related to patients with pulmonary embolism.
(Note: Must have both oxygenation and perfusion nursing diagnosis)

• Impaired Gas Exchanged related to decreased bronchial airflow associated with bronchocon-
striction as evidenced by tachypnea and irritability

• Ineffective tissue perfusion related to obstruction of pulmonary arterial blood flow as evidenced
by weak peripheral pulses and edema

• Ineffective breathing pattern related to chest pain as evidenced by restlessness and dyspnea
B. What are your goals of care related to your nursing diagnoses?

• Patient demonstrate adequate gas exchange as evidenced by relaxed breathing and comfort.
• Patient demonstrate improved tissue perfusion as evidenced by present and strong peripheral
pulses, absence of edema and chest pain.

• Patient demonstrate effective breathing pattern as evidenced by relaxed breathing and absence of
dyspnea.
C. List at least five appropriate nursing care (intervention/implementations) for patients with PE.
(Should be related to nursing diagnosis)

• Monitor for any changes in vital signs

• Monitor oxygen saturation as indicated for baseline.
• Position the client in High Fowler’s position to allow chest expansion, good lung excursion and fa-
cilitates movement and the drainage of secretions.

• Encourage deep breathing and coughing exercises to keep airway opens by clearing secretions.
• Administer oxygen as indicated as to provide adequate oxygenation thus decreases breathing,
relieves dyspnea and promotes comfort.

• Administer nitroglycerin as prescribed to relax arteries thus facilitating blood flow more easily.
• Maintain client on bed rest thus decreasing oxygen demands.
D. How do you know if the interventions you have listed above were effective?
The interventions are effective if the patient demonstrates the following:

• Strong peripheral pulses

• Absence of edema
• Absence of dyspnea
• Absence of chest pain
• Oxygen saturation of 96% to 99%
 RESPIRATORY DISORDERS

2. ARDS
A. What’s the hallmark symptom of ARDS? Explain why this occurs?

• The hallmark symptom of acute respiratory distress is severe shortness of breath where it oc-
curs because when fluid builds up in the tiny elastic air sacs (alveoli) into the lungs the fluid
keeps lung from filling enough air which means the body is deprived in oxygen so shortness of
breath happens because the body cannot compensate the oxygen that it needs.
B. Formulate at least four nursing diagnoses related to patients with ARDS.

• Impaired gas exchange related to ventilation perfusion imbalance possibly evidenced by confu-
sion and extreme tiredness

• Ineffective airway clearance related to abnormal breath sounds

• Anxiety related to cultural perceptions and cultural beliefs
• Ineffective breathing pattern related to abnormal respiratory rate, rhythm and depth
C. What are your goals related to these nursing diagnoses in your patient?

• Provide adequate fluid management

• Provide nutritional support
• Patient will demonstrate increased air exchange
• Reduce anxiety level
• Monitor arterial blood gas values, pulse symmetry and pulmonary function testing
• Establish patent airway and ventilation
D. Explain the hemodynamic monitoring values you anticipate in a patient with ARDS. This is a per-
son with fully infiltrated lungs who is on a mechanical ventilator and is not improving.

• The heart rate of the patient is higher than normal because the heart pumps faster to com-
pensate the oxygen that is gone in the body.

• The respiratory rate of the patient is within normal range.

• The oxygen saturation of the patient is lower than normal range because it is 60 to 90%.

Hint: Think of whether you would expect it to be high, low, or normal, look up the ranges, and en-
ter the numbers. Think about WHY the numbers are off. What is happening to this person?
) Heart Rate?
) Respiratory Rate?
) Oxygen Saturation?
 RESPIRATORY DISORDERS

3. Chest Trauma
Situation: A 41 year old man was in car accident. Instead of waiting for an ambulance, by
standers pulled the man from his seatbelt and transported him to the hospital. You are working with
the trauma team as a nurse. No other information related to the accident is available to you at this
time.
Upon arrival to the ER, what do you do first?
Assess the ABCDE of the patient which are:
 Airway with c-spine protection, Is the patient responds to his normal voice? Is the patient
speaking in full sentences? If not check if there is airway obstruction through the technique
of head tilt and lift the chin up this way you can easily check the airway. With the proper
equipment, suction of the airways to remove obstructions, for example, blood or vomit, is
recommended. If possible, foreign bodies causing airway obstruction should be removed. In
the event of a complete airway obstruction, treatment should be given according to current
guidelines. If the victim becomes unconscious, call for help and start cardiopulmonary re-
suscitation according to guidelines. Importantly, high-flow oxygen should be provided to all
critically ill persons as soon as possible.
 Breathing and ventilation, is the breathing labored? Are symmetrical, breath sounds present
bilaterally? If breathing is insufficient, assisted ventilation must be performed by giving res-
cue breaths with or without a barrier device.
 Circulation with hemorrhage control, if there is bleeding apply pressure to it to stop the
bleeding. Are pulses present and symmetric? How does the patient’s skin appear? (cold
clammy, warm well-perfused). The capillary refill time and pulse rate can be assessed. In-
spection of the skin gives clues to circulatory problems. Color changes, sweating, and a de-
creased level of consciousness are signs of decreased perfusion. And as soon as possible
monitor the blood pressure. For possible hypotension occurs.
 Disability, what is their GCS scale? Are they moving all extremities? A decreased level of
consciousness due to low blood glucose can be corrected quickly with oral or infused glu-
cose.
 Exposure/Environmental Control, completely expose the patient to allow a thorough physical
examination to be performed. Body temperature can be estimated by feeling the skin or us-
ing a thermometer when available. Is rectal tone present? Is there any gross blood per rec-
tum? Signs of trauma, bleeding, skin reactions (rashes), needle marks, etc. must be ob-
served. Bearing the dignity of the patient in mind

The patient is connected to the ER Monitor, two IVs are in place (that you got with 1-stick –
cause you’re that good) and oxygen was placed on him via nasal cannula per protocol. Suddenly, the
alarm sounds. His heart is racing and his oxygen saturation is quickly dropping.
What action should you take?
 Position the patient in an upright position, monitor patient’s heart rate, record pulse, pro-
vide supplemental oxygen if needed, monitor fluid intake, including IVs if necessary, moni-
tor blood pressure and alert the health care provider. Also check if the patient is allergic in
the medicines that are provided or there is any heart failure to the patient.
 RESPIRATORY DISORDERS

3. Chest Trauma (continuation…)

You are not able to palpate the patients’ pulse and unable to obtain blood pressure. He is
cyanotic and limp. What Steps do you take? The monitor shows an organized cardiac rhythm.

What is happening? (which arrhythmia is occurring?) What critical steps must be taken?
 The patient is suffering from atrial fibrillation in the type of arrhythmia that is occurring in
the patient is paroxysmal atrial fibrillation because it occurs when a rapid erratic heart be-
gins the suddenly stops on its own. The critical step to be taken is to initiate report to the
higher health care provider per facility policy and start CPR.

A second nurse starts CPR with 30 chest compressions and grab a bag valve mask off the
crash card to start giving 2 breath. You notice that it is very difficult to ventilate the patient. His
chest rise is unequal. Chest wall is rising on the right and not the left.

You suspect pneumothorax. What other assessment information do you expect to find?
• Decreased breath sounds on auscultation
• Hyperresonance on percussion on affected side
• Tracheal deviation
• Sub-Q emphysema on affected side
• Pleuritic pain
• Tachypnea

What emergent procedure is needed?

• CRX for diagnosis
• Chest tube placement
• Chemical pleurodesis through test tube
 RESPIRATORY DISORDERS

3. Chest Trauma (Continuation…)

After the physician implements the initial emergent procedure, the patient stirs and starts to
cough. Upon evaluation, you document improved oxygen saturation, blood pressure is improving,
pulse pressure is appropriate, trachea is midline, symmetrical chest rise.

What do you anticipated that needs to be put in place to manage thoracic pressure until the child’s
pleura and lung can heal and the air leak is resolved?
• Digital chest drainage system devices are to be used because it attains faster recovery and
higher life quality and more accurate.

4. Pulmonary Edema
Case: A 63 y/o male presents with sudden onset shortness of breath, and is coughing up pink,
frothy sputum. A chest radiograph reveals pulmonary edema and an enlarged heart, which is
interpreted as congestive heart failure.
A. Create a simple schematic diagram to show pathophysiology, nursing diagnoses and
intervention needed by a patient with pulmonary edema.

(...please proceed to the next page.)


Risk Factors Pathophysiology
Age (65 years old)
• Position the client to semi-
fowler’s position.
• Turn patient every two hours.
• Administer morphine as pre-
scribed.
• Administer IV fluids as indicated.
• Administer oxygen as ordered.
• Monitor Vital signs every 15-30
mins.
• Monitor ABG levels.
• Monitor input and output.
• Provide adequate rest.
Impaired Gas Exchange due to ex-
cessive fluids as evidenced by
cough and pinky frothy sputum.
Pinky Frothy Sputum
Stimulation of cough
reflex
Paroxysmal nocturnal
dyspnea
Orthopnea
Mild Tachypnea Cyanotic
PULMONARY EDEMA
Signs/Symptoms Nsg. Diagnosis Nsg. Interventions Complications
Enlarged heart Congestive heart failure
Diminished function of left
ventricle
Decreased cardiac output
Blood back up into pulmo-
nary vein and capillaries Jugular vein distention
Capillary hydrostatic pres-
sure increases Respiratory failure
Respiratory acidosis
Fluids and solutes are
forced into the interstitial Cardiac arrest
spaces and alveoli
• Position client into orthopneic po-
Pulmonary interstitial con- sition
gestion • Administer oxygen as ordered.
• Administer morphine as pre-
scribed.
• Administer IV fluids as indicated.
PULMONARY EDEMA • Check for peripheral edema.
• Monitor Vital signs every 15-30
mins.
• Monitor ABG levels.
Arterial blood lacking • Monitor input and output.
oxygen • Provide adequate rest.
Ineffective tissue perfusion related
Hypoxia/Hypoxemia to decreased oxygen transport as
evidenced by dyspnea.
Arrythmias Hypertension Tachycardia Dyspnea on exertion
 RESPIRATORY DISORDERS

5. COPD/Asthma
Case: Mihret is a 25-year-old woman who comes to you complaining that when she was
cooking in her house this morning, she suddenly felt very tight in her chest and had difficulty
breathing. This is the first time this has happened. She went outside into the fresh air and her
breathing returned to normal within about 15 minutes. You asked her if she or any family members
smoke tobacco and she says ‘No’. You asked if there was smoke in the house from the cooking fire
and Mihret said ‘Yes, the house is always smoky when I am cooking’.
A. What condition do you suspect that Mihret has experienced?

• The situation tells that Mihret is just 25-years old, she is not a smoker and she does not
live with anyone who smokes. Next, the client suffered from sudden chest tightness and
difficulty breathing but eventually subside when she went outside in just within 15
minutes. Lastly, client verbalized that her house is smoky during cooking. Based from the
data presented, it is least possible that the client is experiencing COPD because usually,
signs and symptoms of COPD lasts for years and does not cured. She is also too young to
develop a COPD. Therefore, there is a great possibility that Mihret’s complaints shows a
bronchial asthma.
B. Make a pathophysiology (present in algorithm)
(...please proceed to the next page.)
C. Give 3 nursing diagnosis and justify

• Impaired gas exchange related to bronchial tubes spasm in response to inhaled irritants
as evidenced by patient’s complaint of difficulty of breathing.

JUSTIFICATION

According to the client, her house is smoky when she is cooking. The smoke may act as
an irritant that could damage the cilia causing swelling or inflammation. Bronchial smooth
muscle contracts and encircles the airway, causing further narrowing. Narrowed airways
don’t let as much air come in go or out from the lungs. This limits the amount of oxygen
that enters the blood and the amount of carbon dioxide that leaves the blood, causing sud-
den chest tightness and difficulty of breathing. The should establish improvement of gas
exchange to provide comfort and avoid complications for the patient.

• Activity intolerance due to ineffective breathing pattern secondary to bronchocon-

striction.

JUSTIFICATION

The contraction of bronchus muscles, causing the airway to narrow, restrict the amount
of air passing into and out of the lungs. This causes ineffective breathing pattern to the cli-
ent. Client may express intolerance to activity due to ineffective breathing pattern.

• Anxiety related to chest tightness secondary to bronchial asthma.

JUSTIFICATION

The client may express both worry and fear that could be a reaction to the stress that
may occur as the client suffers from chest tightness. The nurse then should provide
measures that relieves the anxiety of the client.
 ASTHMA

Predisposing factors: Precipitating Factor:

• Gender (woman) • Environmental factors
• Age (25 year old) • Atmospheric Pollutants
(smoke when cooking)
• Family History
• Allergens
• Race

Exposure to different pathogens

Release of Immunoglobulin E and

chemical mediators

Bronchoconstriction

Inflammatory process

Increase mucus production Increase airway resistance

Slowed mucus clearance Increase respiratory work

Increase water loss from mucus Muscle fatigue/exhaustion

Mucus becomes viscous Respiratory Alkalosis

Wheezing Cough production Difficulty of breathing