resp. - care of pt w pulmonary embolism

focus on nursing CARE

oxygen therapy

admin of O2 at concentration greater of room air

• boost % that pt is taking in

goal: increase O2 availability to lungs/tissue

• reduces effort of breathing

• reduces cardiac stress

low-flow

room air and supplemental oxygen

inconsistent or unknown O2 concentration

delivery options: traditional nasal cannula, mask (simple, partial rebreather, non-rebreather)

high-flow

total inspired air (meet or exceed demand)

precise O2 concentration

delivery options: venturi mask, high flow nasal cannula, mechanical ventilation

non-rebreather

one-way valves - only getting new air, exhale out old (think name)

O2 reservoir → bag

venturi mask

v for valve, open

not reservoir, but open gaps for room air

emergency use of oxygen

nurses can apply low flow w/o order

• nasal cannula, simple mask, partial rebreather, non-rebreather

high flow oxygen therapy

newer form

meets or exceeds inspiratory flow demand

must be heated and humidified for comfort (irritating to nasal passages)

no built-in monitoring capabilities → freq. assessment needed

oxygen toxicity - manifestations

from too much oxygen

headaches, substernal discomfort, dyspnea, alveolar atelectasis, paresthesia, restlessness, anxiety, fatigue, malaise, confusion, refractory hypoxemia

oxygen toxicity - assess

chest tightness, respiratory rate, breath sounds, O2 sat, numbness/tingling of extremities, activty lvl, general attitude, change in mentation

oxygen toxicity - intervention

monitor O2 flow, total therapy time

assess w change in therapy, initiated at correct dose

PEEP

positive end-expiratory pressure: maintains airway pressure above atmospheric airway pressure at end of expiration; may be used w either spontaneous or mechanical ventilation

CPAP

continuous positive airway pressure - maintains positive airway pressure throughout whole respiratory cycle; used w spontaneous ventilation

BiPAP

bilevel positive airway pressure

• similar to CPAP, noninvasive

• two lvl of pressure - w higher pressure during inhalation

• used for COPD, sleep apnea, pneumonia

use of PEEP/CPAP/BiPAP

helps prevent micro atelectasis

• maintains slight positive lung pressure

• maintain slightly expanded lung tissue

allows lower % of oxygen to be effective

positive and expiratory pressure

pt education - oxygen therapy

maintain therapy at prescribed settings

notify physician of

• frequent headaches, increased anxiety, blue tinge, drowsiness, new confusion, restlessness

• change in established breathing pattern - slow, shallow, difficult, irregular

safety

pt education - safety precautions

no open flames, combustible products

exercise care w electrical devices, use explosion-proof plugs

storage: cart or collar cylinder, avoid bumping them, post “no smoking”, keep in well ventilated area

therapy - examine

whole patient, monitor VS + color for cyanosis

respiratory retraction, nasal flaring

false or low oxygen saturation reading: cold extremities or fingers

• hypothermia or hypovolemia

false high: anemia, CO reading

incentive spirometer - use

exhale (breathe out) normally and then:

• mouthpiece in mouth + close lips tightly around

• inhale slowly and deeply through mouthpiece

• when you cannot inhale any longer, remove mouthpiece and hold breath for at least 5 seconds

• exhale normally

pulmonary embolism

an embolus that clogs an artery (or arteries) in pulmonary vascular system

pulmonary emboli - vascular problem

blood flow obstructed → poor lung perfusion of lung tissue

originate in venous system, in left heart if affecting brain

pulmonary emboli - respiratory response

air gets into lungs but enough oxygen can’t get into obstructed blood stream → SOB

pulmonary emboli - basic dx

chest X-ray: dilated pulmonary artery

spiral CT scan

EKG: sinus tachy, r heart strain

d-dimer: rules out blood clot

VQ scan - perfusion is issue

pulmonary emboli - gold standard

pulmonary angiogram (arteriogram)

• dye injected through cath treaded through vena cava into R side of heart

• allows for direct visual of obstruction, assessment of perfusion deficit

pulmonary emboli - risk factors [START EDITS]

Age 50+

Venous stasis

Prolonged immobility

Hypercoagulability

Previous history of thrombophlebitis

Damage to vessel walls

Orthopedic surgery

Hip>knee for PE

Certain disease states: heart disease, trauma, postoperative, diabetes mellitus, COPD

Other conditions: pregnancy, post-partum, supplemental estrogen, birth control pill, obesity, constrictive clothing

pulmonary emboli - consequences

death can result only 1 hour from onset

pulmonary emboli - priorities

early recognition of clinical pic, early treatment

pulmonary emboli - human response

non-specific, non-diagnostic

anxiety, fear

chest pain

cough - may have bloody sputum

crackles, rub near area of embolus

sudden dyspnea - when clot lodges

syncope, tachycardia, tachypnea, diaphoresis

pulmonary emboli - chest pain

Sudden, pleuritic; substernal

May become worse with deep breaths, coughing, eating, bending, or stooping

Worsens with exertion but won't recede with rest

prevent PE - NI

Identify presence of risk factors

Early ambulation

Reposition frequently

Active/passive leg exercises

AE hose/SCDs

Change IV sites according to best practices

Patient/family education

• Avoid prolonged sitting, legs and feet in dependent position, knees crossed, adequate hydration, wear AE hose/SCDs, etc.

Recognize PE clinical presentation

PE - emergency NI: independent

Vital Signs

Assess lung sounds

Assess respiratory rate/effort

Administer O2: Low flow systems

High Fowler’s position

EKG: Dysrhythmia, R-side failure

PE - emergency: with orders NI

Establish IV access

Labs: H&H, electrolytes, d-Dimer

Medications: Morphine, Sedation, Anti-anxiety

PE - emergency medical management

Protect airway

Manage pain/anxiety

Confirm diagnosis

Pharmacology: Thrombolytic, Anticoagulation (i.e. heparin, warfarin)

Surgery: Transvenous catheter embolectomy for major/massive PE, Implantation of umbrella filter (Greenfield or IVC filter)

Post PE - post-embolectomy or umbrella

Routine post-op care

• Assessment, activity/ROM, AE/SCDs, C/T/DB, skin/incision care, hydration, O2 prn

Post-PE: NI

Monitor labs: PT/INR/PTT, platelets

Monitor pulmonary parameters

Monitor respiratory effort

Evaluate all assessment data against previous data

• Intervene as appropriate

• Alert PCP

• Document

Patient/family education

PE: patient education

Anti-coagulant medication

Importance of

• Labs as ordered, Dosing as ordered

Safety: S/S of bleeding – joints, brain; OTCs, Alert of HCPs

Self care

Notify MD if/when…

Post-op

Activity

Incision care

Notify MD if/when…

Post-PE: patient education

Alert all future HCP of PE history

Stay active; get out of bed as soon as possible after illness

On long car or plane trips, take breaks/walk at least every 2 hours

Change positions often

Do leg exercises if you are on bed rest

Don’t cross your legs

Get immediate medical attention for….