Acute Respiratory Failure PDF

Care Of Patients With Respiratory Disorders ACUTE RESPIRATORY FAILURE a. Aspiration of Foreign Body b. Thoracic Tumors c. Asthma I. DESCRIPTION d. Bronc...

Care Of Patients With Respiratory Disorders ACUTE RESPIRATORY FAILURE a. Aspiration of Foreign Body b. Thoracic Tumors c. Asthma I. DESCRIPTION d. Bronchitis 1. Respiratory Failure is a sudden and life threatening e. Pneumonia detoriation of gas exchange function of the lungs. D. Ventilation-Perfusion Abnormalities 2. It indicates failure of the lungs to provide adequate oxygenation or ventilation for the blood. 1. Conditions disrupting alveolar ventilation or capillary perfusion lead to an imbalance in ventilation and 3. Occurs when insufficient oxygen is transported to perfusion. This decreases the efficiency of the the blood or inadequate carbon dioxide is removed respiratory gas exchange process. from the lungs and the client’s compensatory mechanisms fail. a. Pulmonary Embolism b. Emphysema 4. Causes include a mechanical abnormality of the lungs or chest wall, a defect in the respiratory III. PATHOPHYSIOLOGY control center in the brain, or an impairment in the 1. Many abnormalities can lead to ARF. function of the respiratory muscles. 2. Regardless of the specific underlying cause, the 5. Manifestations of respiratory failure are related to the pathophysiology of ARF can be organized into 4 main extent and rapidity of change in PaO2 and PaCo2. components: II. TYPES OF RESPIRATORY FAILURE a. impaired ventilation 1. Acute Respiratory Failure b. impaired gas exchange c. airway obstruction a. Decrease in arterial oxygen tension (PaO2) to less d. ventilation-perfusion abnormalities than 60 mmHg (Hypoxemia), increase in arterial carbon dioxide tension (PaCO2) to greater than 50 IV. ASSESSMENT FINDINGS mmHg (Hypercapnia) with an arterial pH of less than 7.35. A. Clinical Manifestations b. in Acute Respiratory Failure, the ventilation or 1. Early signs are those associated with impaired perfusion mechanisms in the lung are impaired. oxygenation. Vague signs and symptoms make it difficult to determine what the patient is experiencing. 2. Chronic Respiratory Failure a. Hypoxemia (Pao2 50 mm Hg) - Conditions that disrupt the muscles of respiration or their neurologic control can impair ventilation and 2. The severity of ARF can be further increased when lead to ARF. anxiety and fear of impending death develop, a - Inadequate alveolar ventilation causes retention of common consequence of severe dyspnea and CO2 and hypoxemia. hypoxemia. a. Spinal Cord Injury (C4 or higher) a. Hypertension b. Phrenic Nerve Damage b. Irritability c. Neuromuscular Blockade c. Somnolence (late) d. Guillain-Barre Syndrome d. Cyanosis (late) e. CNS depression e. Loss of consciousness (late) f. Drug Overdoses (Narcotics/Sedatives) f. Pallor or cyanosis of skin g. Intracranial intracranial pressure g. Use of accessory muscles of respiration h. Anesthetic Agents h. Abnormal breath sounds (crackles, wheezes) i. i. Respiratory Muscle Fatigue Manifestations of primary disease B. Impaired Gas Exchange B. Diagnostic Evaluation 1. Conditions that damage the alveolar-capillary membrane impair gas exchange. 1. Chest X-rays 2. Another cause of impaired gas exchange occurs when a. Chest x-rays are obtained as part of fluid leaks from the intravascular space into the routinescreening procedures, when respiratory pulmonary interstitial space. disease is suspected. a. Pulmonary Edema b. Evaluate the status of respiratory abnormalities (eg, b. ARDS pneumothorax, pleural effusion, tumors) c. Aspiration Pneumonia c. Confirm proper invasive tube placement (ie, endotracheal, tracheostomy, or chest tubes, and pulmonary artery catheters) C. Airway Obstruction 1. Conditions that obstruct airways increase resistance d. Following traumatic chest injury. to air-flow into the lungs, causing alveolar hypoventilation and decreased gas exchange. 2. Computed Tomography (CT scan) and Magnetic 3. Anti-cholinergic (blocks the action of Resonance Imaging (MRI) acetylcholine from causing involuntary muscle movement in the lungs, GIT, urinary tract & other areas a. allow for the three-dimensional examination of of the body) Spiriva, combivent, trovent the chest in situations where two-dimensional chest 4. Antibiotics x-rays are insufficient. 5. Respiratory Stimulant (increase the action of respiratory system; stimulates respiration, can improve b. If possible, use of relaxation or music tapes, ear ventilation-perfusion ) ex. Doxapram HCL (Dopram or plugs or headsets, and the presence of a family Stimulex) Increase in tidal volume and RR. member or friend should be considered. VI. NURSING DIAGNOSIS 1. Impaired Gas Exchange c. In addition, short-acting anxiolytics should be used for patients who need them. 2. Ineffective Airway Clearance 3. Impaired Spontaneous Ventilation 4. Ineffective Breathing Pattern 3. Pulmonary Angiograms 5. Impaired Tissue Perfusion 6. Risk/Decreased cardiac output a. Pulmonary angiograms are one of the most 7. Anxiety / Fear sensitive tools for diagnosis of pulmonary emboli. VII. MANAGEMENT b. A catheter is advanced into the pulmonary Medical Management and Nursing Management of the artery and contrast material is injected during patient in ARF revolves around four primary areas: rapid filming. 1. improving oxygenation and ventilation 4. Computed Tomography of the Pulmonary Arteries 2. treating the underlying disease state (CTPA) 3. reducing anxiety 4. preventing and managing complications. a. less invasive but very specific method of diagnosing a Pulmonary Embolism (PE). A. Medical Management b. only requires a peripheral line through which to 1. Airway Management inject the contrast material. Similar to the pulmonary angiogram, defects may be readily seen in a. The practice of evaluating, planning, and using a the pulmonary artery and the study can be done very wide array of medical procedures and devices for the quickly. purpose of maintaining or restoring a safe, effective pathway for oxygenation and ventilation. These 5. Ventilation/Perfusion (V/Q) Lung scan procedures are indicated in patients with airway a. is a nuclear medicine diagnostic tool that requires obstruction, respiratory failure. medical isotopes to be inhaled or injected in order b. Use of artificial airways (Intubation, to view the lungs and pulmonary arteries respectively. Tracheostomy) b. Used to identify areas of lungs not receiving air 2. Mechanical Ventilation flow (ventilation) or blood flow (perfusion). Is a method to mechanically assist or replaces spontaneous breathing and indicated when alveolar c. Nursing considerations: Assess for allergies to ventilation is inadequate to maintain blood O2 and CO2 dye, iodine or seafood. Monitor the client for level. reaction to the radionuclide. Encouraged increase fluid intake to clear dye from the body, if there is no Different Modes of Mechanical Ventilation: fluid restriction. 1.Assist Control Mode Ventilation (ACMV) 6. Pulmonary Function Test 2.Synchronized Intermittent Mandatory Ventilation (SIMV) a. Tests used to evaluate lung mechanics, gas 3.Continuous Positive Airway Pressure (CPAP) exchange, and acid–base disturbance through 4.Positive-End Expiratory Pressure (PEEP) spirometric measurements, lung volumes, and arterial 5.Pressure Support ventilation (PSV) blood gas levels. 6.Pressure Control Ventilation (PCV) b. Evaluating the ability for a patient to be weaned 7.Non-invasive Ventilation (NIV) from a ventilator. c. Assesses the progression of lung disease and the c. Ventilator Settings effectiveness of treatment. 1. Rate (f). Number of ventilator-delivered breaths per d. Spirometry – inhalation and exhalation minute. measurements. Usually measured twice, both before 2. Tidal V olume (Vt) Amount of gas delivered each and after giving a bronchodilator. ventilator breath: usually 7-8 ml/kg body weight 3. Oxygen Concentration (FIO2)Percentage of O2 7. Arterial Blood Gas Analysis delivered with ventilator breaths: can be set between 21% (room air) and 100% a. Assess ventilation and acid-base balance 4. Pressure Limit. Maximal pressure within airways that b. Radial Artery is the most common site for will terminate a ventilator breath withdrawal of blood specimen c. Allen’s test is done to assess for adequacy of d. Ventilator Weaning. collateral circulation (Ulnar Artery) of the hand. The process of removing ventilator support and re- establishing spontaneous, independent respirations. V. PHARMACOLOGIC MANAGEMENT Begins only after the underlying process causing 1. Bronchodilators. Theophylline IV, salbutamol respiratory failure is corrected or stabilized. Use of 2. Beta-adrenergic agonists. (relax muscles of the T-piece airways, therefore widening the airway for easier breathing) Albuterol, Terbutaline 3. Ventilator Alarms 4. Prevent and Manage Complications a. Low Pressure a. Pulmonary aspiration: Ensure proper inflation of endotracheal (ET) tube cuff at all times to Causes: System disconnects or leaks prevent ventilator-associated pneumonia (VAP). - Reconnect pt to ventilator - Evaluate cuff and reinflate if needed. (If rupture, b. Gastrointestinal (GI) bleeding: Protect gastric tube must be replaced) mucosa in ventilator patients by using peptic ulcer - Check ET tube placement (Auscultate lung fields disease prophylaxis and/or tube feedings. and assess for equal, bilateral breath sounds) c. Barotrauma: Avoid unnecessary increases in b. High Pressure airway pressures (eg, patient/ventilator dyssynchrony, excesive coughing) and assess for Causes: Resistance within system such as a kink or signs and symptoms of pneumothorax, water in the tubing. Biting ET tube, copious pneumomediastinum, and other barotrauma secretions, or plugged ET tube. complications. - Suction if secretions is suspected. - Insert bite block as needed. d. Volutrauma: Prevent alveolar damage from - Reposition head and neck, or reposition tube. 5. excessive tidal volumes. Sedation may be required to prevent patient from fighting against ventilator, but only after you exclude 5. Ventilator Management physical or mechanical causes. a. When ventilator alarms, always check patient c. High Respiratory Rate first. Causes: Anxiety or pain, secretions in ET Tube or b. Pt not in distress: Check ventilator to determine airway, or Hypoxia. source of problem. - Suction patient. - Look for source of anxiety (e.g. Pain, environmental c. Pt in distress: stimuli, inability to communicate, restlessness). - Evaluate oxygenation. 1. Disconnect ventilator tubing from ET tube and manually ventilate patient d. Low Exhaled Volume 2. Notify RT (respiratory therapist) and HCP (healthcare provider). Assist with reintubation as Causes: Tubing disconnect or inadequate seal. needed. - Evaluate/reinflate cuff. (if ruptured, ET tube must be replaced) 3. Manually ventilate patient while RT assesses - Evaluate connections; tighten or replace as needed. ventilator. Check ET tube placement, reconnect to ventilator. B. Nursing Management 1. Improve oxygenation and ventilation a. Provide supplemental O2 to maintain Pao2 greater than 60 mm Hg. b. Improve ventilation with the administration of bronchodilators and other airway management modalities (suctioning, positioning, mobilization) as indicated. c. Intubate and initiate mechanical ventilation if non-invasive methods fail to correct hypoxemia and hypercapnia or if cardiovascular instability develops. 2. Treat the underlying disease state a. Correction of the underlying cause of the ARF should be done as soon as possible. b. Specific management approaches depend on the disease state. 3. Reduce anxiety a. Maintain a calm, supportive environment to avoid unnecessary escalation of anxiety. b. Give brief explanations of activities and approaches being done to relieve ARF. c. Vigilance and presence of healthcare providers during anxious periods is crucial to avoid panic by patients and visiting family members.  ACUTE BIOLOGIC CRISIS 2. INITIAL ASSESSMENT - It’s a condition that may result to patient mortality if left - Initial Impression unattended in a brief period of time - Mental status - ABCs - A condition that warrants immediate attention for - Assign priority (Stable, Unstable) reversal of disease process and prevention of further - Treatment & transport decisions morbidity and mortality. FOCUSED HISTORY & PHYSICAL EXAM: MEDICAL CRITICAL CARE NURSING - Sequence depends on patient’s condition - Components: - Nursing specialty that deals specifically with human responses to life-threatening problems. 1. History of present illness 2. Assessment of complaints, signs, symptoms - A Critical Care Nurse is a licensed professional nurse (OPQRST) 3. SAMPLE history who is responsible for ensuring that acutely and critically ill patients and their families receive optimal care. 4. Rapid Assessment 5. Baseline VS 6. Emergency medical care CRITICALLY ILL PATIENT A. HISTORY OF PRESENT ILLNESS - Are those patients who are at high risk for actual or potential life-threatening health problem - Why was EMS called? - Elaboration of chief complaint - The more critically ill patient is, the more likely the - Chief Complaint patient is at high risk What patient states in his/her own words is primary problem THE FOCUS OF CRITICALLY CARE NURSING - Onset Goal of Critical Care Nursing - Provocation - To provide comfort and facilitate healing of patients - Quality whose lives under threat from illness or trauma, whether - Radiation sudden or chronic, accidental or surgical. - Severity - Time - Critical illness influences all body systems and has a profound impact on the people it affects OPQRST EMS ACRONYMS ASSESMENT ONSET – What was the patient doing when the signs and symptoms first occurred? Was the onset sudden or 1. FOCUSED HISTORY / PE gradual? - Taken 8-14 minutes that addressed the patients PROVOCATION or PALLIATION – Is there anything presenting health issue. that makes the symptom better or worse? - Explore and characterize the patient’s main health QUALITY – description of what the patient is feeling. concern. For example, the pain can be described as dull, sharp, crushing, aching, tearing, throbbing, etc. - No need to go into each item of critical backgrounds history in great detail, but should briefly touch on each REGION and RADIATION – where is the pain located item or at least consider them. and does it move to another part of the body? SEVERITY – How severe is the symptom based on a Goals of assessing medical patients scale of 1 to 10? TIME – when did the signs and symptoms first occur? - Differentiate between critical and non- critical conditions. B. MEDICAL PATIENT ASSESSMENT OPQRST– Important for qualifying patient conditions - Gather focused history and choose appropriate assessment 1. Pain 2. Respiratory difficulties FOCUSED HISTORY / PE: MEDICAL 3. Altered mental Status 4. Allergic reaction 1. SCENESIZE-UP 5. Poisoning / overdose 2. INITIALASSESSMENT 6. Environmental emergencies 3. FOCUSED HISTORY & PHYSICAL EXAM 7. Obstetric conditions 4. RAPIDASSESSMENT 5. VITAL SIGNS (VS) 8. Behavioral emergencies /psychiatric 6. ONGOING ASSESSMENT emergencies 1. SCENE SIZE-UP C. SAMPLE HISTORY - BSI (Body Substance Isolation) precautions 1. Signs & Symptoms - Evaluating scene safety 2. AllergieS - Determining the Mechanism of Injury / nature of 3. Medications injury 4. Past Medical History - Determining the total number of patients 5. Last oral intake 6. Events leading up to episode D. RAPID ASSESSMENT VENOUS BLEEDING - Conscious patients – history first Blood flow steadily and is usually dark red. - Critical / unstable patients – history & assessment - Generally easier to control than arterial simultaneously bleeding but still requires prompt attention. - Unresponsive patients – assessment first, then history CAPILLARY BLEEDING Head to toe order Involves slow, oozing blood from small capillaries TRAUMA - Common in minor cuts and abrasions; usually DCAPBTLS – Deformities, Contusions, Abrasions, stops on its own or with minimal intervention Penetrations, Burns, Tenderness, Lacerations, INTERNAL HEMORRHAGE Swelling Internal hemorrhage refers to bleeding that MEDICAL occurs inside the body, where blood escapes from blood vessels into internal spaces or - Function cavities. Unlike the external hemorrhage, - Guarding internal bleeding is not immediately visible, - Masses making it more difficult to diagnose and manage. - Pain It can be life-threatening if not promptly - Tenderness recognized and treated. E. VITAL SIGNS CAUSE OF INTERNAL HEMORRHAGE - Baseline 1. TRAUMA - Trending with multiple sets 2. MEDICAL CONDITION 3. MEDICATIONS - Changes in condition Response to treatment 4. BLOOD DISORDERS TRAUMA Blunt force injuries (e.g., car accidents, falls) can cause F. EMERGENCY MEDICAL CARE internal bleeding in organs such as the liver, spleen, or - When assessment is complete, plan, or initiate care brain - Care should be focused on signs & symptoms Penetrating injuries (e.g., stab wounds, gunshot wounds) can damage internal blood vessels and organs. EMERGENCY MEDICAL CARE MEDICAL CONDITIONS - Unresponsive medical patient Gastrointestinal (GI) Bleeding: Conditions like - Pay attention to environment for clues ulcers, diverticulosis, or varices can lead to - Rely on patient’s presentation and information from internal bleeding in the digestive tract. bystanders/family Ruptured Aneurysms: A burst blood vessel, - Consider ACLS intercept (clinical interventions for often in the brain or aorta, can lead to significant urgent emergencies) internal hemorrhage. - HEMORRHAGE (Internal & External and Ectopic Pregnancy: A pregnancy outside the Hypovolemic Shock) uterus, typically in a fallopian tube, can rupture and cause severe internal bleeding. WHAT IS HEMORRHAGE? Hemorrhagic Stroke: Bleeding within the brain - A loss of blood from a damage blood vessel due to a ruptured blood vessel - The bleeding can be internal or external - The blood loss can be minor or major. MEDICATIONS Anticoagulants and Antiplatelet ETIOLOGY OF HEMORRHAGE Agents: Medications like warfarin, and aspirin, can TRAUMA (Blunt or penetrating injury) increase the risk of internal bleeding. MEDICAL CONDITION (Hemophilia, liver disease, NSAIDS: Long term use can lead to gastrointestinal gastrointestinal ulcer, aneurysm) bleeding OBSTETRIC HEMORRHAGE (Postpartum BLOOD DISORDERS hemorrhage, placental abruption) Conditions like hemophilia or thrombocytopenia (low SURGICAL COMPLICATIONS (Intraoperative platelet count) can predispose a person to spontaneous bleeding, postoperative bleeding) internal bleeding STAGES OF HEMORRHAGE TYPES OF HEMORRHAGE Class 1: Volume loss up to 15% of total blood volume, 1. EXTERNALHEMORRHAGE approximately 750mL. Heart rate is minimally elevated 2. INTERNALHEMORRHAGE or normal. Typically, there is no change in blood pressure, pulse pressure, or respiratory rate. EXTERNAL HEMORRHAGE Class 2: Volume loss from 15% to 30% of total blood - External hemorrhage refers to bleeding that occurs volume from 750mL to 1500mL. Heart rate and outside the body, usually from a wound or injury where respiratory rate become elevated (100 BPM to 120 BPM, blood escapes through the skin, it can result from 20 RR to 24 RR). Pulse pressure begins to narrow, but trauma, surgical procedures, of medical conditions that systolic blood pressure may be unchanged to slightly cause blood vessels to rupture. decrease. Class 3: Volume loss from 30% to 40% of total blood TYPES OF EXTERNAL HEMORRHAGE volume, from 1500mL to 2000mL. A significant drop in 1. ARTERIALBLEEDING–spurting blood, pulsating flow, blood pressure and changes in mental status occurs. bright red color Heart rate and respiratory rate are significantly elevated 2. VENOUS BLEEDING – steady, slow flow, dark red (more than 120 BPM). Urine output declines. Capillary color refill is delayed. 3. CAPILLARY BLEEDING – slow, even flow Class 4: Volume loss over 40% of total blood volume. Hypotension with narrow pulse pressure (less than 25 ARTERIAL BLEEDING mmHg). Tachycardia becomes more pronounced (more than 120 bpm), and mental status becomes increasingly Characterized by bright red, spurting blood that is altered. Urine output is minimal or absent. Capillary refill typically synchronized with the heartbeat. is delayed. Often more severe and harder to control due to the higher pressure in arteries. CLINICAL ASSESSMENT INITIAL ASSESSMENT The patient is assessed for signs and symptoms of - Conduct a rapid assessment of the patient’s shock: airway, breathing, and circulation (ABCs). Cool, moist skin (resulting from poor peripheral - Look for signs of internal bleeding, such as perfusion), decreasing blood pressure, increasing heart hypotension, tachycardia, and altered mental status. rate, delayed capillary refill, decrease urine volume, dizziness or fainting and altered level of consciousness. STABILIZATION - Administer oxygen to support tissue oxygenation. SPECIFIC SYMPTOMS - Establish large-bore IV access for fluid resuscitation or blood transfusion. Abdominal Pain and Distension: May indicate bleeding - Start fluid resuscitation with isotonic crystalloids in the abdomen or pelvis (e.g., normal saline) and consider blood products if Flank or Back Pain: Could suggest retroperitoneal available. bleeding or a ruptured aortic aneurysm Blood in Stool or Vomit: Indicates gastrointestinal MONITORING bleeding - Continuously monitor vital signs, including blood Hematuria (blood in urine): Suggests bleeding in the pressure, heart rate, and oxygen saturation. urinary tract. - Monitor urine output as an indicator of renal Bruising: Especially around the navel (Cullen’s sign) or perfusion and overall circulatory status. flanks (Grey-Turner’s sign) may indicate internal abdominal bleeding. IMAGING AND DIAGNOSIS - Prepare the patient for imaging studies such as Headache, loss of Consciousness, or Neurological ultrasound, CT scan, or X-ray to identify the source Deficits: Can point to intracranial hemorrhage. and extent of bleeding The goal of emergency management are to control the - LABS: Obtain blood samples for haemoglobin, bleeding, maintain adequate circulating blood volume for haematocrit, coagulation profile, and blood type and tissue oxygenation, and prevent shock. crossmatch FIRST AID AND NURSING INTERVENTIONS FOR DEFINITIVE CARE EXTERNAL HEMORRHAGE - Internal haemorrhage often requires surgical intervention (e.g., laparotomy, thoracotomy) or APPLY – apply direct pressure interventional radiology (e.g., embolization) to USE – use a clean cloth or sterile dressing to apply firm control the source of bleeding pressure directly on the wound. - In the case of a hemorrhagic stroke, neurosurgical DO NOT REMOVE – if bleeding persists, do not remove intervention may be necessary the initial dressing; instead, add more layers and continue applying pressure POST-INTERVENTION CARE - After controlling the bleeding, monitor for signs of ELEVATION re-bleeding, organ dysfunction, and infection - Elevate the injured limb above the level of the heart to - Provide supportive care, including pain reduce blood flow to the area (unless a fracture is management and ongoing assessment of suspected, in which case immobilization is preferred) hemodynamic status PRESSURE POINTS - If direct pressure and elevation are not effective, apply HYPOVOLEMIC SHOCK pressure to the artery, supplying the affected area (e.g., FLUID REPLACEMENT IN HYPOVOLEMIC SHOCK the brachial artery for arm injuries or the femoral artery for leg injuries). TOURNIQUET USE - As a last resort, if bleeding cannot be controlled by other methods, apply a tourniquet above the site of the injury to constrict blood flow. - Note the time the tourniquet was applied and ensure it is not loosened until advanced medical care is available. HEMOSTATIC AGENTS - If available use hemostatic dressings or agents to promote clotting and control bleeding, especially in severe cases. WOUND CARE - Once bleeding is controlled, clean the wound with sterile saline or clean water. - Apply a sterile dressing or bandage to protect the wound and prevent infection. MONITOR FOR SHOCK - Watch for signs of shock, such as pale, cool, clammy skin, rapid pulse, shallow breathing or confusion. - Lay the patient flat and keep them warm. If possible, raise their legs slightly to improve blood flow to vital signs. TRANSPORT TO MEDICAL FACILITY - Ensure the patient is transported to a medical facility as soon as possible, especially if the bleeding is severe or cannot be controlled. DOCUMENTATION - Record the location, severity, and type of bleeding, interventions applied, and the patient’s response. - Communicate this information to emergency medical personnel or at the hospital. NURSING DIAGNOSIS - Fluid Volume Deficit - Decrease cardiac output - Ineffective tissue perfusion - Risk for shock FLUID VOLUME DEFICIT Related to: Excessive blood loss due to hemmorhage As evidenced by: Decreased blood pressure, increase heart rate, decreased urine output, altered mental status, and pallor Nursing Interventions: - Monitor vital signs frequently, especially blood pressure and heart rate - Assess for signs of shock (e.g., cold, clammy skin, confusion) - Administer IV fluids or blood products as ordered - Monitor intake and output closely, including urine output - Prepare for possible surgical intervention if bleeding is not controlled DECREASE CARDIAC OUTPUT Related to: Reduced blood volume secondary to hemorrhage As evidenced by: Hypotension, tachycardia, weak peripheral pulses, and decreased capillary refill Nursing Interventions: - Continuously monitor cardiac rhythm and vital signs - Administer oxygen as prescribed to enhance tissue oxygenation - Elevate the patient’s legs to improve venous return and support blood pressure - Prepare for possible administration of inotropic agents if ordered INEFFECTIVE TISSUE PERFUSION Related to: Reduced oxygen-carrying capacity and blood flow secondary to hemorrhage As evidenced by: Cyanosis, delayed capillary refill, altered mental status, and cold extremities Nursing Interventions: - Monitor oxygen saturation and administer supplemental oxygen as needed - Assess peripheral pulses and skin color regularly - Position the patient to promote optimal blood flow to vital organs (e.g., Trendelenburg position if appropriate) - Prepare for possible blood transfusion to restore oxygen-carrying capacity RISK FOR SHOCK Related to: Severe blood loss leading to inadequate tissue perfusion Nursing Interventions: - Monitor for early signs of shock, such as increased heart rate, hypotension, restlessness, and decreased urine output - Ensure rapid IV access and prepare for administration of fluids, blood products, and medications as needed - Keep the patient warm to prevent hypothermia, which can worsen shock - Provide psychological support to the patient and family, explaining the situation and interventions. ARTERIAL BLOOD GAS _____________________________________________ _____________________ HEMODIALYSIS / KIDNEY TRANSPLANT  PERITONEAL DIALYSIS v Principles: Dialyzing solution is introduced via a catheter inserted in the peritoneal cavity The peritoneal membrane is used as a dialyzing membrane to remove toxic substances metabolic waste & excess fluid Patient can dialyze alone in any location Can be used in patients who are hemodynamically unstable The peritoneal membrane that covers the abdominal organs and lines the abdominal wall serves as the semipermeable membrane Once the cavity, uremic toxins such as urea and creatinine begin to be cleared from the blood through diffusion and osmosis. v Nursing Care: Preparing the patient: ü Consent (patient and the family) ü Obtain Baseline vital signs ü Explain the procedure ü Empty the bladder and bowel to prevent puncture ü Administer broad-spectrum antibiotic to prevent infection ü Administer heparin to prevent fibrin formation ü Warm the dialysate to dilate vessels of peritoneum. Note: Normal color of the drainage fluid is colorless. § Cloudy: infection, peritonitis. § Bloody: normal at first few exchanges § Yellowish: Punctured urinary bladder ü Regulate fluid volume & drainage ü Promote comfort ü Prevent complications o Leaks o Obstruction o Peritonitis ü Drain exit site infection ü Monitor urine/glucose levels ü Teach client of dialysis & care of peritoneal catheter  ACUTE RENAL FAILURE v Acute tubular necrosis (ATN) renal parenchymal failure, Acute tubule-interstitial Nephritis v Reversible condition characterized by: v Diagnostic and Laboratory Findings: A sudden reduction or cessation of renal Hyperkalemia function Hyperphosphatemia Retention of waste products Hypocalcemia Increased UN & creatinine Metabolic acidosis Azotemia v Causes of Acute Renal Failure Proteinuria Urinalysis (Cast, RBC, WBC) Pre-renal v Sign and Symptoms: ü Hypoperfusion of kidney ü Volume depletion Irritability ü Impaired cardiac efficiency Headache ü Vasodilation Anorexia Tingling of extremities Intra-renal Lethargy that can progress to stupor & coma ü Actual damage to kidney tissue Sudden dramatic drop in urinary output ü Prolonged renal ischemia Restlessness, twitching, convulsions ü Nephrotoxic agents Skin pallor, anemia & increased bleeding time ü Infectious process Ammonia odor breath & perspiration Post renal Generalized edema ü Obstruction to urine flow Hypertension which can progress to pulmonary edema ü Urinary tract obstruction & CHF ü Calculi (stones), tumors ü Benign prostatic hyperplasia v Management - (Correct underlying cause) ü Blood clots Pharmacologic management: Phases of Acute Renal Failure Volume expanders (Dopamine) to restore renal Onset perfusion in hypertensive client Loop diuretics Benign with initial insult and ends when oliguria ACE inhibitors for hypertension develops H2 blockers to prevent gastric ulcers Initial phase of injury 1-3 days Kayexalate to reduce potassium Sodium bicarbonate to treat acidosis Oliguric phase Nursing Management The oliguria period is accompanied by an increase in the serum concentration of substances usually Diet excreted by the kidney Ø Moderate protein restriction Urine output