● Pulmonary embolism: clot that travels to the lungs
○ Risk factors
■ Prolonged immobility
■ Central venous catheter
... [Show More] surgery
■ Obesity
■ Advancing age
■ Conditions that increase blood clotting (DIC)
■ Distort of thromboembolism
■ Smoking
■ Pregnancy
■ Hormonal birth control (estrogen therapy)
■ Heart failure
■ Stroke
■ Cancer
■ Trauma
■ Afib
○ S/s:
■ Dyspnea - SUDDEN ONSET
■ Pleuritic chest pain (sharp, stabbing type pain on inspiration)
■ Crackles
■ Wheezes
■ Apprehension
■ Anxiety
● Give O2
■ Restlessness
■ Impending doom
■ Cough (productive or dry)
■ Tachypnea
■ Pleural friction rub
■ S3 or s4 heart sound
■ Diaphoresis
■ Low grade fever
■ Petechiae (fat embolism , does not impede blood flow, causes actual damage to the blood vessels) over chest and a axillae
■ If really big you can see EKG changes
■ hemoptysis - bloody sputum
■ Decreased Sao2
■ Sudden dyspnea and chest pain= immediately notify rapid response team
○ Labs:
■ Hyperventilation (caused from pain and hypoxia) = respiratory alkalosis (low paco2 <35, high PH >7.45) = blood shunting from right side to left
○ Dx:
side without picking up O2 from the = respiratory acidosis (high paco2
>45, low PH <7.35)= build up of lactic acid = metabolic acidosis (low HCO3 <22, low PH <7.35)
■ D-dimer rises (positive)
■ Pulmonary angiography = gold standard
● Only if stable
● Inject dye, use imaging
■ CT
■ Chest X-ray
■ Doppler ultrasound
○ Nursing intervention:
■ Call rapid
■ O2 - use pulse ox
● Nasal cannula
● Mask
● Mechanical ventilation
■ Tele
■ IV access
■ Monitor VS. lung sounds and cardiac/ respiratory status Q1-2hrs
● Assess for and document increasing dyspnea, dysrhythmias, JVD, pedal or sacral edema, crackles, cyanosis
■ CTPA, pulmonary angiography
■ Bleeding precautions
● Monitor and record amount of bleeding
● Asses Q2 hours
■ Measure abdominal girth Q8 Hours
■ Monitor labs daily
● Monitor CBC to watch for blood loss
○ Blood loss= RBC, plasma
○ Monitor platelet count = decreased platelet count = HIIT
■ Drug therapy
■ Make sure antidote is on the floor
● Anticoagulants - keep clots from getting bigger
○ Unfractionated heparin
■ Check PTT (normal 20-30) before administering (range between 1.5-2.5 times the control) (therapeutic 46-70) (>75 = complication)
■ 5-10 days (for 24 hours)
■ Protamine sulfate = antidote
○ Then transferred to oral warfarin
■ Monitor INR (2.0-3.0)
■ Vitamin K = antidote
○ Heparin 5-10 days, most patients started on warfarin on day 1-2, both are continued together until the INR reaches 2-3, heparin will be continued for 24 hours after INR is >2
●
○ Heparin induced thrombocytopenia
■ Body creates antibodies to the heparin = increased thrombin - prothrombin = increased clotting
■ Risk factors include:
● Duration of heparin use longer than 1 week
● Exposure to unfractionated heparin
● Post surgical prothrombin prophylaxis
● Being female
■ S/s:
● DVT
● PE
● Thrombocytopenia (hallmark sign) = platelets <150,000
● Can through thrombus
■ Treatment:
● Argatroban and lepirudin (direct thrombin inhibitors)
● Inferior vena cava filtration - bedside procedure
○ Filter that catches things before it gets to the lungs
● Mechanical ventilation for respiratory acidosis + pao2 <60 = respiratory failure
●
● TPA
○ Antidote = clotting factors, frozen plasma, aminocaproic acid
● Mechanical ventilation
○ Mode:
■ A/C : assistive control ventilation
● Most restrictive - vent takes control of breathing completely
● Complications:
○ Hyperventilation
○ Respiratory alkalosis ( paco2 <35, ph >7.45)
● Resting mode: to try to allow patient to breath on their own, if not working then the vent takes over and breathing pattern is established
■ SIMV: synchronized intermittent mandatory ventilation
● Can be used as a main ventilator or as a weaning method
● Allows for spontaneous breathing at patients own rate
■ CPAP: continuous positive airway pressure
○ Rate
○ Fractionated inspired O2 (FiO2)
○ Tidal volume (Vt)
○ Positive end expirations pressure (PEEP)
■ Keep alveoli open longer
■ Complications:
● Pneumothorax
● Decreased pre load
○ Mechanical ventilator care
■ Lung assessment
■ Frequent VS
■ Pulmonary hygiene
■ Monitor ABG
■ ETT cuff/ pilot balloon
■ NPO
■ Skin care
■ I&O / Foley catheter
■ VTE prophylaxis
○ Pneumonia
■ Remove water from circuits
■ HOB up 30 degrees
■ Turn Q2hrs
■ Suction
■ Oral care
■ Lip moisturizer
■ Percussion
○ High pressure alarms
■ Blocked airway
■ Biting tube
■ Kinks
■ Coughing
■ Tension pneumothorax
■ Pulmonary edema
■ Psychomotor agitation
■ Pain
○ Low pressure alarms
■ Not getting enough air in or out
■ Air leak in the cuff
■ Disconnect tubing
■ Patient not breathing
● Acute respiratory distress syndrome (ARDS): stiffness= things in alveoli= refractory hypoxemia
○ Causes respiratory tissue to become inflamed which becomes stiff and then allows debri and other things into the alveoli - things that should not be in pockets
■ Gas exchange happens in the alveoli
■ Acute in onset, results from lung injury
○ Subtle changes in early stages (s/s)
■ Refractory hypoxemia : when a pt is given O2 and they remain hypoxemia
- 100% O2 and still hypoxia = ARDS
■ Decreased PAO2 (80-100)
■ Hyperpnea
● Increased work effect
● Noisy respiration
■ Hypoxia
■ Cyanosis
■ Pallor
■ Intercostal and substernal retractions
■ Diaphoresis
■ Clear lung sounds early - abnormal lung sounds are not heart on auscultation because the edema occurs first in the interstitial spaces not in the airways
● Late signs = crackles
● Dysrhythmias
○ Common causes:
■ Shock
■ Trauma
■ Pancreatitis
■ Fat/ amniotic fluid emboli
■ Sepsis
■ Aspiration - especially stomach contents
■ Pneumonia
■ Inhaling toxic fumes
■ Drug ingestion (heroine, opioids, aspirin)
■ Hemolytic disorders
■ Cardiopulmonary bypass
■ Multiple blood transfusions
● Usually within 6 hours of transfusion
■ Water aspiration from submersion
● Especially fresh water
■ COVID
■ Nervous system injury
■ Fat embolism
■ Amniotic fluid emboli
○ Requires immediate intervention
○ Difficult to diagnose
■ ABG
● Low PAO2
● Sputum cultures
● Chest X-ray
○ Will show ground glass appearance “whited out”
● Hemodynamic monitoring is ****** waiting for an answer!
○ PAP and PCWP
○ May lead to complications
■ SIRS
■ Multi organ failure
■ Respiratory failure - respiratory acidosis (ph 7.28, Co2 55) and a PAO2 of
<60, respiratory rate goes up, oxygen saturation goes down [Show Less]