WK5. Altered Ventilatory Function PDF

BACHELOR OF SCIENCE IN NURSING: NCMB 418 - CARE OF THE CLIENT WITH LIFE- THREATENING CONDITIONS, ACUTELY ILL / MULTI- ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION (ACUTE AND CHRONIC) COURSE MODULE COURSE UNIT WEEK 1...

BACHELOR OF SCIENCE IN NURSING: NCMB 418 - CARE OF THE CLIENT WITH LIFE- THREATENING CONDITIONS, ACUTELY ILL / MULTI- ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION (ACUTE AND CHRONIC) COURSE MODULE COURSE UNIT WEEK 1 5 5 Nursing Care of Clients with Altered Ventilatory Function Comprehend the course and unit objectives ✓ Peruse through the study guide prior to class attendance ✓ Analyze the required learning resources; refer to unit terminologies for jargons ✓ Proactively participate in classroom discussions ✓ Participate in weekly discussion board (Canvas) ✓ Answer and submit course unit tasks on time At the end of this unit, the students are expected to: 1. Discuss the pathophysiologic responses of clients with altered ventilatory functions. 2. Analyze the health status/competence of clients with altered ventilatory functions. 3. Formulate a plan of care based on client’s priorities to address the needs/ problems. 4. Institute appropriate corrective actions to prevent or minimize harm arising from adverse effects. 5. Apply safe and quality interventions to address the client’s identified needs/ problems. 6. Offer client health education using selected planning models as appropriate for clients. 7. Document nursing care and services rendered and processes outcomes of the findings/ result of the client data.  8. Ensure completeness, integrity, safety, accessibility, and security of information. 9. Adhere to protocols of confidentiality in safekeeping and releasing of records and other information. 10. Evaluate the client’s health status / competence and/or expected outcomes of nurse-client working relationship. Schumacher, L., & Chernecky, C. C. (2010). Saunders nursing survival guide: critical care & emergency nursing. St. Louis, Mo.: Elsevier Saunders. Crouch, R., Charters, A., Dawood, M., & Bennett, P. (2017). Oxford handbook of emergency nursing. Oxford, United Kingdom: Oxford University Press. Baid, H., Creed, F., & Hargreaves, J. (2016). Oxford handbook of critical care nursing. Oxford, United Kingdom: Oxford University Press. Respiratory emergencies may range from “shortness of breath,” or dyspnea, to complete respiratory arrest, or apnea. These conditions can result from a large number of causes, but most typically they involve the lungs. Pulmonary Embolism (Pulmonary Embolus) This is a thrombotic or non-thrombotic embolus that lodges in the pulmonary artery system. It can damage part of the lung due to restricted blood flow, decrease oxygen levels in the blood, and affect other organs as well. Large or multiple blood clots can be fatal. The blockage can be life-threatening Risk Factors 1. Injury or damage leading to blood clot formation 2. Inactivity for prolonged periods 3. Medical conditions or treatment procedures that cause blood to clot easily (e.g. surgery, DVT, etc.) Clinical Manifestations 1. Virchow’s triad: venous stasis, coagulation problems, vessel wall injury 2. Chest pain 3. Tachycardia, tachypnea 4. Anxiety, restlessness 5. Clammy or bluish skin Diagnostics 1. CXR – to rule out other disorders with the same presenting manifestations 2. ABG analysis 3. D-dimer test – detects clot fragments from clot lysis 4. ECG 5. V/Q scan / Pulmonary angiography / spiral CT scan Treatment: 1. Oxygenation (ET and mechanical ventilation) 2. Heparin therapy 3. Surgery – umbrella filter, pulmonary embolectomy 4. Prevention of development of DVT Acute Respiratory Distress Syndrome (ARDS) / Lung Injury This is a syndrome with inflammation and increased permeability of the alveolocapillary membrane that occurs as a result of an injury to the lungs. This condition is fatal when left undiagnosed or treated for 48hrs. Risk Factors 1. Critically ill patients 2. Age (60y/o and above) 3. Malignancy (cancers) 4. Cigarette smoking, COPD Causes: Aspiration pneumonia or systemic illness (e.g. burns, sepsis, drug overdose) Clinical Manifestations: Signs and symptoms are often exhibited within 24-48 hours after initial insult to the lungs 1. Restlessness, 2. Hyperventilation, tachycardia, SOB 3. Hypoxemia 4. Severe: hypotension, cyanosis, decreased UO Diagnostic: Chest x-ray = reveals “white out” lungs Treatment Goal: improving and maintaining oxygenation and prevent respiratory and metabolic complications 1. Fluid management to maintain tissue perfusion 2. Corticosteroid therapy to decrease permeability of the alveolocapillary membrane 3. Nutrition – enteral feeding 4. Supplemental oxygen: Mechanical Ventilation – a form of artificial ventilation that takes over all or part of the work performed by the respiratory muscles and organs ✓ Modes, Settings, Alarms Acute Respiratory Failure It is a change in respiratory gas exchange such that normal cellular function is jeopardized. ARF is defined as’pO2 of less than 50 mmHg and a pCO2 of greater than 50 mmHg and a pH of less than 7.30. Actual pO2 and pCO2 that define ARF vary, depending on the different factors that influence patient’s normal arterial blood gasses. For example, if pO2 level of a 75 – year old man is 55 mmHg, ARF will not be diagnosed until the pO2 have decreased to 50 mmHg or less. This is a condition in which the blood doesn't have enough oxygen or has too much carbon dioxide, sometimes one can have both problems. Respiratory failure is divided into type I and type II. Type I respiratory failure involves low oxygen, and normal or low carbon dioxide levels. Type II respiratory failure involves low oxygen, with high carbon dioxide. Table 1. Types of Acute Respiratory Failure Type I (Hypoxemic) Type II (Hypercapnic) Lung failure, respiratory insufficiency Pump failure, ventilatory failure Failure of lungs and heart to provide adequate Failure of lungs to eliminate adequate CO2 oxygen PaCO2 < 60mmHg with normal or decreased PaCO2 > 50mmHg PaO2 Alveolar hypoventilation Increase dead space Associated with acute diseases of the lungs Drug overdose, neuromuscular disease, chest (pulmonary edema, ARDS, pneumonia) wall deformity, COPD Causes of Acute respiratory failure in adults Impaired ventilation o Spinal cord injury above C5 o Phrenic nerve damage o Neuromuscular blockade o Guillain barre syndrome o CNS depression o Respiratory muscle fatigue Impaired gas exchange o Pulmonary edema o ARDS o Aspiration pneumonia Airway obstruction o Aspiration of foreign body o Thoracic tumors o Asthma o Bronchitis o Pneumonia Ventilation – perfusion abnormalities o Pulmonary embolism o Emphysema Chronic obstructive pulmonary disease (COPD) It is an umbrella term to describe various diseases (e.g. chronic bronchitis, emphysema, chronic asthma). Also described as a slowly progressive and irreversible disease, although some patients may show a degree of reversibility with bronchodilator treatment. This usually occurs in people over 50y of age and smoking is a major factor in its development Assessment: - Patient’s history: - Mild = a ‘smoker’s cough’ is the only abnormal sign. - Moderate = breathlessness and/ or wheeze on moderate exertion, cough, and generalized reduction in breath sounds. - Severe = breathlessness at rest, cyanosis, prominent wheeze and/ or cough, and lung overinflation ❖ Consider and record the following, too: ✓ current treatment— inhalers, nebulizers, antibiotics, steroids, O2, and theophyllines; ✓ exercise tolerance; ✓ previous admissions, especially intensive care or treatment with NIV; the reason for ED attendance— it is important to identify whether the exacerbation has been accompanied by an increase in the amount or type of sputum produced; a recent fall or chest injury may be the cause of the symptoms. In the ED, assess for the following: ▪ cough; sputum— color and amount; ▪ cyanosis; ▪ tachypnea; wheeze; ▪ accessory muscle usage; lip pursing on expiration; ▪ chest expansion (which is often poor); ▪ fever; ▪ dehydration; ▪ confusion or reduction in conscious level; ▪ pain Consider whether the patient is septic, and treat any signs of sepsis, severe sepsis, or septic shock immediately. Diagnostics and Laboratory Continuous monitoring— HR, RR, and SpO2. CXR. ECG. ABG analysis as soon as possible. FBC, U&E, and theophylline level (if the patient is taking theophylline). Sputum for C&S if purulent. Blood cultures if the patient is pyrexial. Nursing interventions Reassurance. Nurse the patient in an upright position. O2 therapy to keep saturations in the range of 88– 92% Nebulizers (may need to be continuous). Steroids. IV theophylline (for patients who do not respond to nebulizers). Assessment for NIV. Mouth care. IV fluids if the patient is dehydrated. Analgesia. AVPU and GCS scores. Management: 1. Non- invasive ventilation (NIV) - Increasingly used in ED resuscitation rooms (evidence suggests that using NIV in patients with COPD reduces mortality and the need for invasive ventilation)  - NIV should be considered in patients who meet the following criteria: respiratory acidosis (pH 6kPa) that persists despite maximal medical therapy; not moribund, GCS score >8 able to protect the airway; cooperative and conscious; few co- morbidities; hemodynamically stable; no excess respiratory secretions; potential for recovery to a quality of life acceptable to the patient. Ideally, patients should have an anesthetic assessment prior to the commencement of NIV, in order to determine their suitability and outline what the ceiling treatment should be. A ‘do not attempt resuscitation’ (DNAR) order may be completed at this time if the patient is not suitable for invasive ventilation. 2. Intensive care - Patients with exacerbations of COPD should not be automatically excluded from invasive ventilation if all other treatments are failing. The following will have to be considered: quality of life (ideally involving the family in the discussion); O2 requirements when stable; co-morbidities; forced expiratory volume in 1s (FEV1); body mass index (BMI). Pneumonia Pneumonia is an inflammation of the lung, which is characterized by exudation into the alveoli. It can be classified anatomically as lobar or by etiology. It is most commonly caused by bacteria. The terms ‘pneumonia’ and ‘chest infection’ are often used interchangeably. Causes: Pneumonia can be caused by any of over 100 microorganisms. Therefore, the treatment should be started before the causative organism has been identified. Common microorganisms that can cause Pneumonia Streptococcus pneumoniae (90% of cases) Haemophilus influenzae Staphylococcus aureus Legionella species Types of Pneumonia: Community acquired – not hospitalized or residing in a long-term care facility for ≥ 14 days prior to onset of symptoms. Hospital acquired – more than 48 h between admission and onset of symptoms. Ventilator associated – more than 48–72 h between intubation and onset of symptoms. Aspiration – micro-aspiration of bacteria colonizing the upper respiratory tract, macro- aspiration of gastric contents, indirect transmission from staff, inhaled aerosols. Atypical Assessment findings: The clinical findings are often referred to as consolidation. Expansion is reduced on the affected side. There is percussion dullness over the area of consolidation. Breath sounds are bronchial; adventitious crackles. Tachypnea and central cyanosis. Fever, sweats, and rigors. Cough and sputum. Diagnostics and Laboratory: Sputum microscopy, culture, and sensitivity. CXR. ABG (if SpO2 is 93% IV fluids (if the patient is dehydrated) Medications: IV antibiotics, analgesia, antipyretic Bronchoalveloar lavage may be used for patients who are immunocompromised, those who do not respond to antimicrobial therapy, or those from whom a sputum sample cannot be obtained. Nursing Management Positioning (upright) Ensure timely antimicrobial therapy. Monitor hemodynamics, fluid and electrolytes and imbalances Adherence to infection prevention and control. Ventilator-associated pneumonia care bundle Ventilator-associated pneumonia Ventilator-associated pneumonia (VAP) develops 48 h or later after commencement of mechanical ventilation via endotracheal tube or tracheostomy. It develops as a result of colonization of the lower respiratory tract and lung tissue by pathogens. Intubation compromises the integrity of the oropharynx and trachea, allowing oral and gastric secretions to enter the airways. VAP is the most frequent post-admission infection in critical care patients, and significantly increases the number of mechanical ventilation days, the length of critical care stay, and the length of hospital stay overall. - Risk factors: immunocompromised, the elderly, and those with chronic illnesses (e.g. lung disease, malnutrition, obesity). - Diagnosis is difficult due to the number of differential diagnoses that present with the same signs and symptoms (e.g. sepsis, ARDS, cardiac failure, lung atelectasis); radiological changes = consolidation and new or progressive infiltrates) - Clinical signs include; ▪ pyrexia > 38°C ▪ raised or reduced white blood cell (WBC) count ▪ new-onset purulent sputum  ▪ increased respiratory secretions/suctioning requirements ▪ worsening gas exchange. Management: A. Care Bundle approach for the prevention of ventilator-associated pneumonia - demonstrated to be an effective preventive strategy. - 6 elements for the prevention (should be reviewed daily): 1. Elevation of the head of the bed to 30–45° (unless contraindicated) 2. Sedation level assessment – unless the patient is awake and comfortable, sedation is reduced or held for assessment at least daily (unless contraindicated). 3. Oral hygiene – clean with chlorhexidine gluconate (≥ 1–2% gel or liquid) q6h; teeth are brushed q12h with standard toothpaste. 4. Subglottic aspiration – a tracheal tube (endotracheal or tracheostomy) that has a subglottic secretion drainage port is used if the patient is expected to be intubated for > 72 h. Secretions are aspirated via the subglottic secretion port 1- to 2-hourly. 5. Tube cuff pressure – cuff pressure is measured q4h, and maintained in the range 20–30 cmH2O (or 2 cmH2O above peak inspiratory pressure). 6. Stress ulcer prophylaxis – stress ulcer prophylaxis is prescribed only for high-risk patients, according to locally developed guidelines. B. Scoring the severity of pneumonia - validated CURB- 65 score to assess severity, risk of death, and risk of ICU admission - Scoring can also guide subsequent treatment and the decision about the need for hospital admission CURB-65 Scoring Interpretation: 0 or 1 – relatively mild symptoms with good social support and no other significant health problems can usually be discharged home. 2 – more severe symptoms; at higher risk; for admission ≥3 – associated with a 17% risk of death. Pneumonia and Sepsis The elderly is particularly vulnerable to developing sepsis from pneumonia, and general assessment of the breathless patient should identify any signs of sepsis COVID-19 COVID-19 affects different people in different ways. Most infected people will develop mild to moderate illness and recover without hospitalization; zoonotic (passed between animals and people)  1. Severe Acute Respiratory Syndrome-2 (SARS-COV-2) = COVID-19 - new (novel) strain of coronavirus - not previously identified in humans 2. Middle East Respiratory Syndrome (MERS-CoV) = 2012 3. Severe Acute Respiratory Syndrome (SARS-CoV) = 2003 Origin of Covid-19: ▪ bats or pangolins ▪ transmitted to humans directly or through an intermediate host ▪ source location: large live animal market in Wuhan, Hubei Province ▪ human – to – human spread Epidemiology of Disease Transmission: Source: WHO, 2021 ***Incubation period – 2-14 days; symptoms usually begin around 5th day VARIANTS OF CONCERNS: WHO as of August 13, 2021 ▪ Increase in transmissibility or detrimental change in COVID-19 epidemiology; OR ▪ Increase in virulence or change in clinical disease presentation; OR ▪ Decrease in effectiveness of public health and social measures or available diagnostics, vaccines, therapeutics. Clinical Manifestations: 1. Most common symptoms: Fever (83% - 99%), dry cough (59% - 92%), shortness of breath (31% - 40%) 2. Less common symptoms: aches and pains sore throat diarrhea conjunctivitis headache loss of taste or smell (anosmia or ageusia) a rash on skin, or discoloration of fingers or toes 3. Serious symptoms: difficulty breathing or shortness of breath, chest pain or pressure, loss of speech or movement Diagnostics: C-Xray, CT scan, ECG Laboratory tests: CBC with differential, metabolic profile, inflammatory markers (CRP, D-dimer, ferritin) Prevention: Keep at least a 1-meter distance from others, even from family members. Wear a medical mask to protect others, including if/when seeking for medical care. Clean hands frequently. Use soap and water, or an alcohol-based hand rub. When possibly exposed, stay in a separate room from other family members, and if not possible, wear a medical mask. Keep the room well-ventilated; choose open, well-ventilated spaces over closed ones. Open a window if indoors If sharing a room with another person, place beds at least 1 meter apart. Stay home if you feel unwell and call COVID hotlines; monitor self for any symptoms for 14 days. Call a health care provider immediately if any of the danger signs are observed: difficulty breathing, loss of speech or mobility, confusion or chest pain. Stay positive by keeping in touch with loved ones by phone or online, and by exercising at home. Medical treatments WHO does not recommend self-medication with any medicines, including antibiotics, as a prevention or cure for COVID-19. Optimal supportive care includes oxygen for severely ill patients and those who are at risk for severe disease and more advanced respiratory support such as ventilation for patients who are critically ill. Dexamethasone is a corticosteroid that can help reduce the length of time on a ventilator and save lives of patients with severe and critical illness. Other medicines used in COVID-19: 1. Antiviral agents: a. Remdesivir b. Tocilizumab c. Bamlanivimab and Casirivimab and Imdevimab d. Baricitinib in combination with remdesivir Prevention: To prevent the spread of COVID-19: Maintain a safe distance from others, even if they don’t appear to be sick. Wear a mask in public, especially indoors or when physical distancing is not possible. Choose open, well-ventilated spaces over closed ones. Open a window if indoors. Coronaviruses – family of viruses causing illness from the common cold to severe critical illness COPD – chronic obstructive pulmonary disease is a condition involving constriction of the airways and difficulty or discomfort in breathing Embolism – a mass, such as an air bubble, detached blood clot or foreign body that travels in the bloodstream, lodges in a blood vessel and obstructs or occludes it. Respiratory failure – a syndrome in which the respiratory system fails in one or both of its gas exchange functions: oxygenation and carbon pCO2 – partial pressure of carbon dioxide usually from the arterial blood (35 – 45 mmHg) pO2 – partial pressure of oxygen usually from the arterial blood (80 – 100 mmHg) Pneumothorax – a collapsed lung that occurs when air enters into the pleural cavity, the space around lungs causing pain in the chest and difficulty in breathing Sars-Cov-2 – a new type of coronavirus that can affect people first detected in December 2019 in Wuhan City causing now a pandemic Pandemic – world wide Emergency Nurses Association. (2019). Sheehy’s Manual of Emergency Care, 7th ed. St. Louis: Elsevier Mosby. pp 504-593 Lentz, S., et. al. (2020, July 4). Initial emergency department mechanical ventilation strategies for COVID-19 hypoxemic respiratory failure and ARDS, The American Journal of Emergency Medicine. Retrieved from https://www.sciencedirect.com/science/article/pii/S0735675720305866 Read and summarize the research article by Lentz, et.al found in ScienceDirect.com. Explain its objectives, methods, and results, then reflect on its implication(s) in today’s nursing practice. Department of Health (Kagawaran ng Kalusugan). https://www.doh.gov.ph Emergency Nurses Association. (2019). Sheehy’s Manual of Emergency Care, 7th ed. St. Louis: Elsevier Mosby. Heart Disease and Stroke Statistics 2017 Update: A Report from the American Heart Association Statistics Committee  and Stroke Statistics Subcommittee. Circulation. 2017, January 25, Retrieved from http://circ.ahajournals.org/content/early/2017/01/25/CIR.0000000000000485. Hinkle, J. and Cheever, K. (2017). Brunner & Suddharth’s Textbook of Medical-Surgical Nursing, 14th ed. USA: Wolters Kluwer Institute for Quality and Efficiency in Health Care. (2018, January 25). Types of heart failure [chapter], InformedHealth.org. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK481485/ Lentz, S., et. al. (2020, July 4). Initial emergency department mechanical ventilation strategies for COVID-19 hypoxemic respiratory failure and ARDS, The American Journal of Emergency Medicine.Retrieved from https://www.sciencedirect.com/science/article/pii/S0735675720305866 Mayo Clinic. (2020). ARDS. Retrieved from https://www.mayoclinic.org/diseases- conditions/ards/symptoms-causes/syc-20355576 Philippine Statistics Office (PSA). (2019). Registered deaths in the Philippines, 2017 [report]. Retrieved from https://psa.gov.ph/vital-statistics/id/138794 Schumacher, L., & Chernecky, C. C. (2010). Saunders nursing survival guide: critical care & emergency nursing. St. Louis, Mo.: Elsevier Saunders.