RESPONSE TO ALTERED VENTILATORY FUNCTION

1. Pulmonary Embolism Key Features of Pulmonary Embolism

2. Pulmonary Hypertension  Symptoms
3. Pneumothorax
4. Hemothorax 1. Dyspnea, sudden onset
2. Pleuritic chest pain
Pulmonary Embolism 3. Apprehension, restlessness
4. Feeling of impending doom
 A pulmonary embolism (PE) occurs when a clot (thrombotic embolus) 5. Cough
or other matter (nonthrombotic embolus) lodges in the pulmonary 6. Hemoptysis
arterial system, disrupting the blood flow to a region of the lungs.
 Signs
Anatomy
1. Tachypnea
2. Crackles
3. Pleuritic friction rub
4. Tachycardia
5. S3 or S4 heart sound
6. Diaphoresis
7. Fever, low-grade
8. Petechiae, over chest and axillae
9. Decreased arterial O2 saturation

Etiology
The following are major risk factors for DVT leading to Pulmonary Embolism

1. Prolonged immobilization
Pulmonary Circulation 2. Central Venous catheters
3. Surgery (Orthopedic surgery)
4. Obesity
5. Advancing age
6. Hypercoagulability
7. History of thromboembolism
8. Cancer diagnosis

Virchow’s Triad
Virchow’s Triad gives us three main factors that can lead to blood clot
formation within a vein.

 Remember: “SHE”
Stasis of Venous Circulation
• Blood cannot just hang out and become static within a vessel
(Immobilization, varicose veins, traveling for long hours w/o
moving extremities, pregnancy/obesity)

Hypercoagulability
• Increase or high coagulation process in the body
Pathophysiology (Cancer, Severe illness (sepsis), Dehydration, Usage of
Estrogen (birth control), Heparin Induced Thrombocytopenia
Large emboli obstruct pulmonary blood flow (HIT), Postpartum Period)
Decreased systemic oxygenation
Endothelial damage to the vein
• This endothelial is a layer of cells that lines the inside of the vein.
Pulmonary tissue hypoxia
• This damage stimulates platelets and the coagulation process
Potential death What are some conditions that cause damage the endothelial lining?
 IV drug usage (venipuncture)
 Indwelling devices (central line catheter, IV line, or heart valves
etc.)
 Medications that are damaging to the vein
 Trauma or injury to the vessel (surgery)

Signs and Symptoms of DVT

 Redness
 Swelling
 Very warm
 Pain
 Homan’s Sign: NOT reliable for detecting a DVT because of false
positives
• Extend the patient’s leg and manually dorsiflex the
patient’s foot (bend it up towards the shin).
 • If it causes the patient pain, it considered a Positive
Homan’s Sign.
Collaborative Management of Pulmonary Embolism Common Nursing Diagnoses and Collaborative Problems
Assessment
 History  The primary collaborative problem for clients in PE is Hypoxemia
• Ask any client with sudden onset of breathing difficulty about the
 The following are priority nursing diagnoses
risk factors for PE, especially history of DVT, recent surgery, or
prolonged immobilization
1. Impaired Gas Exchange related to disrupted pulmonary
perfusion and increased n dead space
 Physical Assessment/Clinical Manifestations
2. Decrease Cardiac Output related to acute pulmonary
• Respiratory manifestations
hypertension
• Cardiac manifestations
3. Acute confusion related to hypoxemia
• Low grade fever
4. Anxiety related to hypoxemia and life-threatening illness
• Petechiae
5. Risk for Injury (Bleeding) related to anticoagulant therapy
• General Malaise
Planning and Implementation
 Laboratory Assessment
 When a client has a sudden onset of dyspnea and Pleuritic chest
• Arterial Blood Gas shows Respiratory Alkalosis (↓ PaCO2)
pain, take the vital signs and notify the physician.
• As blood is shunted without picking up oxygen from the
lungs, PaCO2 level start to rise, indicating Respiratory
 Reassure the client and assist him or her to a position of comfort
Acidosis.
with the head of the bed elevated.
• Later metabolic acidosis results from accumulation of lactic
acid due to tissue hypoxia  Prepare for oxygen therapy and blood gas analysis while continuing
to monitor and asses for other manifestations.
D-dimer (also called fibrin degradation fragment)
 This is a blood test that assesses for fibrin degradation fragment Planning: Expected Outcomes
(d-dimer), it’s a fibrin degradation product.
 Used to diagnose blood clots or Disseminated Intravascular  The client with PE is expected to have adequate tissue perfusion in all
Coagulation (DIC). major organs
 This is a protein fragment that hangs out in the blood when a clot
breaks down. So this means a clot has formed and has started to  Indicators of adequate perfusion
break down.
• ABGs within normal limits
Normal d-dimer • Pulse Oximetry above 95%
 D-dimer can be reported in fibrinogen equivalent units (FEU) or d- • Cognitive status not compromised
dimer units (DDU). • Absence of pallor or cyanosis
 Normal level: <500 ng/mL FEU or <250 ng/mL DDU

Nursing Interventions
 Radiographic Assessment
• Chest X-ray may show evidence of PE, if its is large  Nonsurgical Management
• Lung infiltration may be present around the embolism site
• Spiral CT Scan are often used to diagnose PE 1. Oxygen Therapy
• Transesophageal echocardiography 2. Monitoring
• Doppler ultrasound 3. Anticoagulant Therapy
• Impedance plethysmography (IPG) is used to document PE
and DVT  Surgical Management

Transesophageal echocardiography

1. OXYGEN THERAPY ( nonsurgical)

 Low Flow Oxygen Therapy

 Nasal Cannula
 Delivers 2-5 L/min
 21-50% FiO2

Low Flow Oxygen Therapy

 Simple Face Mask

 Delivers 6-10 l/min
 40-60% FiO2

 Partial Rebreather Mask

 Delivers 6-11 L/min
 60%-75% FiO2

 Non Rebreather Mask

 Delivers 12-15 L/min
 80%-95% FiO2
High Flow Oxygen Delivery Systems

 Venturi Mask

• Delivers the most accurate oxygen concentration Types of Mechanical Ventilation

 Modern mechanical ventilators use positive pressure to push air

into your lungs. Positive pressure ventilation can be invasive or
noninvasive.

1. Invasive mechanical ventilation: The tube can go through

your mouth (intubation) or neck (tracheostomy).

2. Noninvasive ventilation: This uses a face mask connected to

a ventilator.

• Forms of noninvasive ventilation include devices you might

use at home, like CPAP or BiLevel positive airway pressure
(often known under the trade name BiPAP)

 Intubation is a process where a

healthcare provider inserts a tube
through a person’s mouth or nose,
then down into their trachea
(airway/windpipe). The tube keeps
the trachea open so that air can
get through

 Sterile Technique is used

Non-invasive Positive-Pressure Ventilation

Transtracheal Oxygen Therapy
 CPAP – Continuous Nasal
 Tracheotomy – is a surgical incision Positive airway Pressure
into the trachea for the purpose of
establishing airway  BiPAP – Bi-Level Positive
airway Pressure
 Tracheostomy – is the stoma, or
opening, that results from
tracheotomy.

Mechanical Ventilation

 Mechanical ventilation is a form of life

support. A mechanical ventilator is a machine
that takes over the work of breathing when a
person is not able to breathe enough on their
own.

 The mechanical ventilator is also called a

ventilator, respirator, or breathing machine.

 When a person needs to be on a ventilator, a healthcare provider will

insert an endotracheal tube (ET tube) through the patient’s nose or
mouth and into their windpipe (trachea). This tube is then connected
to the ventilator

“Iron Lungs” 1928 Modern Mechanical Ventilator Machine

Monitoring
 Assess the client continually for any changes in status
 Check every 1 to 2 hours:
• Vital signs
• Lung sounds
• Cardiac and respiratory status
 Document increasing dyspnea, dysrhythmia, distended neck veins and
pedal or sacral edema
 Assess for crackles and other abnormal sounds on auscultation of the
lungs along with cyanosis of the lips, conjunctiva, oral mucosa, and
nail beds.
Anticoagulation/ Fibrinolytic Therapy
 Anticoagulants: do NOT break up the clot but helps prevent new ones
from developing and from getting bigger.
1. Heparin: Indirect thrombin inhibitor
• Enhances the activity of antithrombin III, which will inhibit
thrombin and the conversion of fibrinogen to fibrin. (acts fast)
given IV or subq…weight-based
• Monitor aPTT (activated partial thromboplastin time): 1.5 to
2.5 times normal ranges
– >80 seconds risk for bleeding - dose decreased
– <60 seconds NOT therapeutic - risk for clots and may
need dosage increased
– Used in combination with Warfarin until INR is
therapeutic and then Heparin is discontinued.
 Antidote: protamine sulfate
2. Warfarin: Vitamin K antagonist
• Since it’s a Vitamin K antagonist, it will work to inhibit
clotting factors from using Vitamin K.
• Slow onset - takes 3-5 day for patient to become
therapeutic
• Taken orally
• Monitor PT/INR (Prothrombin time/International
Normalized Ratio
• therapeutic INR is 2-3 (less than 2 is not therapeutic)
and greater than 3 at risk for bleeding)
 Antidote: vitamin K
3. Alteplase (Activase) and Urokinase
• Activase is a clot-busting agent indicated in large PEs in the
setting of hemodynamic instability.
• The nurse knows this drug is the priority, although heparin
may be started initially.
• In addition to greatly increased risk for bleeding use can
induce allergic response and anaphylaxis and can occur
within an hour after starting the infusion
• If a reaction occurs, stop the infusion and prepare to give IV
antihistamine, corticosteroids, or adrenergic agonists.
Surgical Management
 Embolectomy — also sometimes called thrombectomy — is the
removal of a blood clot (thrombus) that's keeping blood from flowing
through a blood vessel normally.
1. Balloon embolectomy
 Typically this is done by inserting a catheter with
an inflatable balloon attached to its tip into an
artery, passing the catheter tip beyond the clot,
inflating the balloon, and removing the clot by
withdrawing the catheter.
2. Aspiration embolectomy
 Catheter embolectomy is also used for aspiration
embolectomy, where the thrombus is removed
by suction rather than pushing with a balloon.
3. Surgical embolectomy
 Surgical embolectomy is the simple surgical
removal of a clot following incision into a vessel
by open surgery on the artery
Preventions (Health Teachings)
 Application and regular usage of pneumatic compression devices like
(SCDs) Sequential Compression Device per MD order. These devices
wrap around the legs and inflate and deflate to help move blood flow
(similar to walking).
• They must fit properly.
• They’re NOT to be applied to the extremity that has an active DVT
(can lead to dislodgement).
• Make sure the patient is wearing them while sitting or in bed.
Take them off when the patient is walking. Make sure they’re
plugged in, actually inflating and deflating (ask the patient).
• Also, make sure they are changed and cleaned regularly.
 Patient needs to be ambulating daily and out of the bed with all meals,
if possible.
 Teach patient to perform exercises by flexing and extending feet and
legs every hour while awake.
 Compression stockings per MD order: provides a specific amount of
compression to help decrease risk of blood clot development.
 Prophylactic medications: after surgery (post-op), especially joint
replacement surgery like the hip… Example: Enoxaparin (subq injection)
 If patient has a DVT:
“DEEP CLOT”
 Don’t rub or massage affected extremity (can dislodge clot)
 Elevate the affected extremity above heart level (promotes blood
return and decreases swelling)
 Ensure bed rest
 Pharmacological Measures
 Compresses (warm/moist) helps pain and circulation
 Leg circumference measurement (calf)…measure about 10 cm or 4
inches below tibial tuberosity…watch out for a 3 cm circumference or
more measurement when compared to the non-affected calf.
 Observe for signs and symptoms for PE
 Tight compression stockings per MD order - helps promote blood flow
and decreases swelling.