Recite: Cover the note-taking column with a sheet of paper. • Provide low-carbohydrate, high-fat diet (e.g., Pulmocare feedings) to reduce CO2 production (if indicated) for patients with respiratory acidosis. Various types of neuromuscular diseases may result in respiratory muscle weakness or paralysis (see Table 68-1). Numerous disorders can compromise lung ventilation and subsequent carbon dioxide removal (see Table 68-1 and eTable 68-1). • Toxin exposure or ingestion (e.g., tree tobacco, acetylcholinesterase inhibitors, carbamate or organophosphate poisoning) Start a trial to view the entire video. These include pulmonary fibrosis, interstitial lung disease, and ARDS.12,13, The classic sign of diffusion limitation is hypoxemia that is present during exercise but not at rest. • Cardiogenic pulmonary edema Because clinical manifestations vary, it is important to watch trends in ABGs, pulse oximetry, and assessment findings to fully evaluate the extent of change. Ultimately respiratory muscle fatigue and ventilatory failure occur due to the additional work needed to inspire adequate tidal volumes against increased airway resistance and air trapped within the alveoli.18-21 jQuery( document.body ).on( 'click', 'a.share-twitter', function() { An intrapulmonary shunt occurs when blood flows through the pulmonary capillaries without participating in gas exchange. Ultimately respiratory muscle fatigue and ventilatory failure occur due to the additional work needed to inspire adequate tidal volumes against increased airway resistance and air trapped within the alveoli. NCLEX® and NCLEX-RN® are Registered Trademarks of the NCSBN, HESI® is a registered trademark of Elsevier Inc., TEAS® and Test of Essential Academic Skills™ are registered trademarks of Assessment Technologies Institute, CCRN® is a Registered trademark of the AACN; all of which are unaffiliated with, not endorsed by, not sponsored by, and not associated with NRSNG, LLC or TazKai, LLC and its affiliates in any way. Oxygen Therapy Ventilation-Perfusion Mismatch. alveolar hypoventilation, p. 1657 Ineffective Breathing Pattern RT Retained Secretions; Outcomes. Inability to speak in complete sentences without pausing to breathe 68-4). Health status was assessed using the COPD-specific SGRQ and the respiratory-failure-specific MRF26 questionnaires. Hypoxemic respiratory failure is also referred to as oxygenation failure because the primary problem is inadequate O2 transfer between the alveoli and the pulmonary capillaries. Experiences normal or baseline breath sounds Finally, it increases O2 consumption and CO2 production.10 In this case, increased O2 demand and CO2 production may increase ventilation demands. return false; Maintains effective airway with removal of excessive secretions Fatigue • Amyotrophic lateral sclerosis Inflammation Smoking Related to immobility, stasis of … (Chapter 67 discusses shock.) return false; • Severe head injury Blood circulates through the pulmonary capillary bed rapidly, allowing less time for gas exchange to occur.14, Alveolar hypoventilation is a generalized decrease in ventilation that results in an increase in the PaCO2 and a consequent decrease in PaO2. Fluid Balance O2 therapy is an appropriate first step to reverse hypoxemia caused by V/Q mismatch because not all gas exchange units are affected. Im doing a disease process paper on my patient and I cant for the life of me figure out one more diagnostic test/lab value for her. The diagnosis of heart Insufficient CO, Medulla cannot alter respiratory rate in response to changes in PaCO, Neurogenic pulmonary edema resulting from massive catecholamine release and shunting intravascular volume to central/pulmonary circulation. 2. Although this example implies that ventilation and perfusion are ideally matched in all areas of the lung, this situation does not normally exist. windowOpen = window.open( jQuery( this ).attr( 'href' ), 'wpcomfacebook', 'menubar=1,resizable=1,width=600,height=400' ); A common example is an overdose of a respiratory depressant drug (e.g., opioids, benzodiazepines). (Biodigital), 00.01 Nursing Care Plans Course Introduction, 01.03 Using Nursing Care Plans in Clinicals, Nursing Care Plan for Atrial Fibrillation (AFib), Nursing Care Plan for Congenital Heart Defects, Nursing Care Plan for Congestive Heart Failure (CHF), Nursing Care Plan for Gestational Hypertension, Preeclampsia, Eclampsia, Nursing Care Plan for Heart Valve Disorders, Nursing Care Plan for Myocardial Infarction (MI), Nursing Care Plan for Thrombophlebitis / Deep Vein Thrombosis (DVT), Nursing Care Plan for Cleft Lip / Cleft Palate, Nursing Care Plan for Infective Conjunctivitis / Pink Eye, Nursing Care Plan for Otitis Media / Acute Otitis Media (AOM), Nursing Care Plan for Constipation / Encopresis, Nursing Care Plan for Diverticulosis / Diverticulitis, Nursing Care Plan for Eating Disorders (Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder), Nursing Care Plan for Gastroesophageal Reflux Disease (GERD), Nursing Care Plan for Hyperemesis Gravidarum, Nursing Care Plan for Inflammatory Bowel Disease (Ulcerative Colitis / Crohn’s Disease), Nursing Care Plan for Peptic Ulcer Disease (PUD), Nursing Care Plan for Vomiting / Diarrhea, Nursing Care Plan for GI (Gastrointestinal) Bleed, Nursing Care Plan for Acute Kidney Injury, Nursing Care Plan for Benign Prostatic Hyperplasia (BPH), Nursing Care Plan for Chronic Kidney Disease, Nursing Care Plan for Enuresis / Bedwetting, Nursing Care Plan for Urinary Tract Infection (UTI), Nursing Care Plan for Acquired Immune Deficiency Syndrome (AIDS), Nursing Care Plan for Disseminated Intravascular Coagulation (DIC), Nursing Care Plan for Dehydration & Fever, Nursing Care Plan for Herpes Zoster – Shingles, Nursing Care Plan for Lymphoma (Hodgkin’s, Non-Hodgkin’s), Nursing Care Plan for Skin cancer – Melanoma, Basal Cell Carcinoma, Squamous Cell Carcinoma, Nursing Care Plan for Varicella / Chickenpox, Nursing Care Plan for Burn Injury (First, Second, Third degree), Nursing Care Plan for Eczema (Infantile or Childhood) / Atopic Dermatitis, Nursing Care Plan for Pressure Ulcer / Decubitus Ulcer (Pressure Injury), Nursing Care Plan for Alcohol Withdrawal Syndrome / Delirium Tremens, Nursing Care Plan for Alzheimer’s Disease, Nursing Care Plan for Autism Spectrum Disorder, Nursing Care Plan for Dissociative Disorders, Nursing Care Plan for Generalized Anxiety Disorder, Nursing Care Plan for Mood Disorders (Major Depressive Disorder, Bipolar Disorder), Nursing Care Plan for Personality Disorders, Nursing Care Plan for Post-Traumatic Stress Disorder (PTSD), Nursing Care Plan for Somatic Symptom Disorder (SSD), Nursing Care Plan for Suicidal Behavior Disorder, Nursing Care Plan for Addison’s Disease (Primary Adrenal Insufficiency), Nursing Care Plan for Diabetic Ketoacidosis (DKA), Nursing Care Plan for Diabetes Mellitus (DM), Nursing Care Plan for Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS), Nursing Care Plan for Myasthenia Gravis (MG), Nursing Care Plan for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), Nursing Care Plan for Systemic Lupus Erythematosus (SLE), Nursing Care Plan for Cerebral Palsy (CP), Nursing Care Plan for Increased Intracranial Pressure (ICP), Nursing Care Plan for Multiple Sclerosis (MS), Nursing Care Plan for Neural Tube Defect, Spina Bifida, Nursing Care Plan for Parkinson’s Disease, Nursing Care Plan for Abortion, Spontaneous Abortion, Miscarriage, Nursing Care Plan for Abruptio Placentae / Placental abruption, Nursing Care Plan for Bronchiolitis / Respiratory Syncytial Virus (RSV), Nursing Care Plan for Fetal Alcohol Syndrome (FAS), Nursing Care Plan for Hyperbilirubinemia of the Newborn / Infant Jaundice / Neonatal Hyperbilirubinemia, Nursing Care Plan for Meconium Aspiration, Nursing Care Plan for Pediculosis Capitis / Head Lice, Nursing Care Plan for Premature Rupture of Membranes (PROM) / Preterm Premature Rupture of Membranes (PPROM), Nursing Care Plan for Phenylketonuria (PKU), Nursing Care Plan for Postpartum Hemorrhage (PPH), Nursing Care Plan for Preterm Labor / Premature Labor, Nursing Care Plan for Acute Respiratory Distress Syndrome, Nursing Care Plan for Asthma / Childhood Asthma, Nursing Care Plan for Bronchoscopy (Procedure), Nursing Care Plan for Chronic Obstructive Pulmonary Disease (COPD), Nursing Care Plan for Pertussis / Whooping Cough, Nursing Care Plan for Pneumothorax/Hemothorax, Nursing Care Plan for Respiratory Failure, Nursing Care Plan for Restrictive Lung Diseases, Nursing Care Plan for Thoracentesis (Procedure), Nursing Care Plan for Gout / Gouty Arthritis, Nursing Care Plan for Rheumatoid Arthritis (RA). Diffusion limitation may also occur in a high CO state (e.g., hepatopulmonary syndrome) or other disease states (e.g., inflammatory response seen with pancreatitis or severe brain trauma) unrelated to lung tissue damage. The most common causes are V/Q mismatch and shunt. This difference causes the PaO2 to be higher at the apex of the lung and lower at the base. Maintains stable body weight and balanced intake and output 1. ↓ PaO, Chronic obstructive pulmonary disease (COPD), Alveoli are destroyed by protease-antiprotease imbalance or respiratory infection. Central Nervous System Abnormalities. Normally, ventilatory supply far exceeds ventilatory demand. (See Chapter 17 for a discussion of acid-base balance.) 3 = Moderately compromised Measurement Scale Medulla cannot alter respiratory rate in response to changes in PaCO2. • Acute myopathy • Position to minimize respiratory efforts (e.g., elevate the head of the bed and provide overbed table for patient to lean on) to preserve energy for breathing. 2 = Substantial deviation from normal range Chronic respiratory failure refers to conditions that prevent the lungs from taking in oxygen and getting rid of carbon dioxide. The embolus limits blood flow but has no effect on airflow to the alveoli, again causing V/Q mismatch, Frequently, hypoxemic respiratory failure is caused by a combination of two or more of the following: V/Q mismatch, shunt, diffusion limitation, and alveolar hypoventilation. • Accessory muscle use _____ Hypertension The most common causes are V/Q mismatch and shunt. • Administer humidified air or oxygen to prevent drying of the mucosa. Blood circulates through the pulmonary capillary bed rapidly, allowing less time for gas exchange to occur.14 eNursing Care Plan 68-1   Patient With Acute Respiratory Failure, Impaired gas exchange related to alveolar hypoventilation, intrapulmonary shunting, V/Q mismatch, and diffusion impairment as evidenced by hypoxemia and/or hypercapnia, Maintains adequate tissue oxygenation as indicated by normal or baseline arterial blood gases, 2 = Substantial deviation from normal range. jQuery('.ufo-shortcode.code').toggle(); • Teach pursed-lip breathing techniques to reverse altered I : E ratio. Acid-Base Management: Respiratory Acidosis. Hypercapnia reflects substantial lung dysfunction. A variety of CNS problems may suppress the drive to breathe. Respiratory failure is classified as hypoxemic or hypercapnic (Fig. Chronic obstructive pulmonary disease (COPD) This results in an abnormally high amount of O2 returning in the venous blood because it is not used at the tissue level. jQuery( document.body ).on( 'click', 'a.share-facebook', function() { An example is the patient with COPD who develops a progressive increase in PaCO2 over several days after a respiratory tract infection. How can I apply them? • Phrenic nerve injury All these conditions result in limited airflow (ventilation) to alveoli but have no effect on blood flow (perfusion) to the gas exchange units (see Fig. On the other hand respiratory failure occurs when the capillaries in air sac cannot able to exchange carbon dioxide for oxygen. Morning headache O2 therapy increases the PaO2 in blood leaving normal gas exchange units, thus causing a higher than normal PaO2. _stq.push([ 'clickTrackerInit', '125227798', '107590' ]); What oxygen is to the lungs, such is hope to the meaning of life. A pulmonary embolus affects the perfusion portion of the V/Q relationship. • High cardiac output states: diffusion limitation If large enough, the embolus can cause hemodynamic compromise due to the blockage of a large pulmonary artery. These conditions place patients at risk for respiratory failure because they limit lung expansion or diaphragmatic movement and consequently gas exchange. WordPress theme by UFO themes 68-1). 3 = Moderate The result is an initial ↓ in PaO, Bronchospasm escalates in severity rather than responding to therapy. • Direct lung injury: aspiration; severe, disseminated pulmonary infection; near-drowning; toxic gas inhalation; airway contusion 3 = Moderate deviation from normal range Hypercapnic respiratory failure is sometimes called ventilatory failure because the primary problem is the respiratory system’s inability to remove sufficient CO2 to maintain a normal PaCO2. Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Not enough oxygen is being exchanged in your lungs, and therefore it’s not getting into circulation. Work of breathing increases, causing respiratory muscle fatigue. • Provide low-carbohydrate, high-fat diet (e.g., Pulmocare feedings) to reduce CO2 production (if indicated) for patients with respiratory acidosis. The nurse correctly understands this to mean which of the following? psychosocial nursing diagnoses include those that pertain to the mind (acute confusion), emotions (fear), or lifestyle … Pain interferes with chest and abdominal wall movement and compromises ventilation. Bronchospasm, edema of the bronchial mucosa, and plugging of small airways with secretions greatly reduce airflow. • Assist with insertion of an endotracheal tube by gathering necessary intubation and emergency equipment, positioning patient, ensuring adequate intravenous (IV) access, administering medications as ordered, and monitoring the patient for complications during insertion to achieve adequate oxygenation and effective ventilation. For example, patients with Guillain-Barré syndrome, muscular dystrophy, myasthenia gravis (acute exacerbation), or multiple sclerosis are at risk for respiratory failure because the respiratory muscles are weakened or paralyzed as a result of the underlying neuromuscular condition. Its laboratory hallmark is hypercapnia with or without hypoxemia. [CDATA[ */ … The major function of the respiratory system is gas exchange. Airway Insertion and Stabilization Diffusion limitation occurs when gas exchange across the alveolar-capillary interface is compromised by a process that thickens, damages, or destroys the alveolar membrane or affects blood flow through the pulmonary capillaries (Fig. Change in spinal configuration compresses the lungs and prevents normal expansion of the chest wall. Caring for patients in respiratory failure – American Nurse Today, That Time I Dropped Out of Nursing School. Manifestations of respiratory failure are related to the extent of change in PaO2 or PaCO2, the rapidity of change (acute versus chronic), and the patient’s ability to compensate for this change. Work of breathing increases and causes respiratory muscle fatigue. • Ability to clear secretions _____ 68-1 Normal gas exchange unit in the lung. In many cases acute respiratory failure may lead to death if you do not quickly treat. Normally, ventilatory supply far exceeds ventilatory demand. Prevent normal rib cage expansion, resulting in inadequate gas exchange. Work of breathing increases, causing respiratory muscle fatigue. Respiratory System Lung ventilation impaired because of respiratory muscle weakness, as well as excessive lung secretions within airways and alveoli. }); For example, the patient with acute respiratory failure secondary to pneumonia may have a combination of V/Q mismatch and shunt. (See Chapter 17 for a discussion of acid-base balance.) Intrapulmonary shunt is seen in conditions in which the alveoli fill with fluid (e.g., acute respiratory distress syndrome [ARDS], pneumonia). D, V/Q mismatch, perfusion partially compromised by emboli obstructing blood flow. Use of tripod position 7 Chronic Obstructive Pulmonary Disease (COPD) Nursing Care Plans COPD is a condition of chronic dyspnea with expiratory airflow limitation that does not significantly fluctuate. Prioritize measures to prevent or reverse complications that may result from acute respiratory failure or ARDS. The embolus limits blood flow but has no effect on airflow to the alveoli, again causing V/Q mismatch11 (see Fig. Neurogenic pulmonary edema resulting from massive catecholamine release and shunting intravascular volume to central/pulmonary circulation • Provide mechanical ventilatory support, if necessary, to maintain adequate gas exchange. Many situations and/or conditions can result in respiratory failure. This is because the brain is very sensitive to variations in O2 and CO2 levels and acid-base balance. Measurement Scale What’s more, it’s the leading cause of death from pneumonia and chronic obstructive pulmonary dis - ease (COPD) in the United States. People of all ages can suffer respiratory failure, infants, and young children, through adults to old age. • Adventitious breath sounds _____ jQuery(this).next('.code').toggle('fast', function() { Respiratory Status: Ventilation Restore oxygen levels of blood as appropriate and remove excess carbon dioxide, For more information, visit www.nursing.com/cornell. In reality, some regional mismatch occurs. Obtain order for venous thromboembolism prophylaxis. Tissue O2 delivery is determined by cardiac output and the amount of O2 carried in the hemoglobin. In patients with severe obesity, the weight of the chest and abdominal contents may limit lung expansion. Alveolar hypoventilation may be the result of restrictive lung diseases, central nervous system (CNS) diseases, chest wall dysfunction, acute asthma, or neuromuscular diseases. A shunt can be viewed as an extreme V/Q mismatch (see Fig. 3 = Moderate deviation from normal range Key Terms A brainstem infarction or severe head injury may also interfere with normal function of the respiratory center in the medulla. Experiences stable weight and muscle tone Prolonged cholinergic crisis, respiratory muscle weakness/paralysis and hypersecretory state. Nursing diagnoses listed in order of priority. The decrease in oxygen and the buildup of carbon dioxide can happen at the same time. Many patients experience both hypoxemic and hypercapnic respiratory failure.6-9 Always interpret data within the context of your assessment findings and the patient’s baseline. Respiratory muscle weakness or paralysis occurs, preventing normal CO2 excretion. Diffusion Limitation. At the lung base, V/Q ratios are less than 1 (less ventilation than perfusion). Bronchospasm, edema of the bronchial mucosa, and plugging of small airways with secretions greatly reduce airflow. TABLE 68-2 Maintains stable body weight and balanced intake and output. Nutritional Status O2 therapy alone is often ineffective in increasing the PaO2 if hypoxemia is due to shunt. Central Nervous System The most common are those in which increased secretions are present in the airways (e.g., chronic obstructive pulmonary disease [COPD]) or alveoli (e.g., pneumonia), and in which bronchospasm is present (e.g., asthma). Nursing Diagnosis. Finally, it increases O2 consumption and CO2 production.10 In this case, increased O2 demand and CO2 production may increase ventilation demands. Several conditions prevent normal movement of the chest wall and limit lung expansion. 3. Patients with lung disease such as severe COPD do not have this advantage and cannot effectively increase lung ventilation in response to exercise or metabolic demands. There are three main types: 1. • Administer parenteral feeding to meet nutritional needs if patient cannot tolerate oral or enteral feedings. All these conditions result in limited airflow (ventilation) to alveoli but have no effect on blood flow (perfusion) to the gas exchange units (see Fig. 1. • Perform chest physical therapy to enhance removal of secretions. Interrelationship of Mechanisms. In a dose-related manner, CNS depressants decrease CO2 reactivity in the brainstem. eNursing Care Plan 68-1   Patient With Acute Respiratory Failure A shunt can be viewed as an extreme V/Q mismatch (see Fig. 2. A common example is an overdose of a respiratory depressant drug (e.g., opioids, benzodiazepines). 4 = Mild deviation from normal range In a dose-related manner, CNS depressants decrease CO2 reactivity in the brainstem. • Maintain accurate intake and output record daily to evaluate trends in fluid status. FIG. Central Nervous System Essentially, at its most basic level, respiratory failure is inadequate gas exchange. If you do, you’ll retain a great deal for current use, as well as, for the exam. }); Not enough oxygen is being exchanged in your lungs, and therefore it’s not getting into circulation. Neuromuscular Conditions. In a perfectly matched system, each portion of the lung would receive 1 mL of air (ventilation) for each 1 mL of blood flow (perfusion). • Monitor respiratory and oxygenation status to detect systemic and clinical manifestations of decreased oxygen and increased carbon dioxide levels. Due to acute respiratory failure, you may experience immediate symptoms. Although no universal definition exists, hypoxemic respiratory failure is commonly defined as a PaO2 less than 60 mm Hg when the patient is receiving an inspired O2 concentration of 60% or more. Therefore they are unable to maintain normal PaCO2 levels.15–17 1 = Severe In patients with flail chest, fractures prevent the rib cage from expanding normally because of pain, mechanical restriction, and muscle spasm. Work of breathing increases, causing respiratory muscle fatigue. Failure of O2 use most commonly occurs in septic shock. In patients with kyphoscoliosis, the change in spinal configuration compresses the lungs and prevents normal expansion of the chest wall. … 5 Steps to Writing a (kick ass) Nursing Care Plan, Dear Other Guys, Stop Scamming Nursing Students, The S.O.C.K. • Kyphoscoliosis 2 = Substantially compromised In this case, inflammation, edema, and hypersecretion of exudate within the bronchioles and gas exchange units obstruct the airways (V/Q mismatch) and fill the alveoli with exudate (shunt). } Exacerbations of Heart Failure: Use of CPAP and NPPV Summary Congestive heart failure (CHF) is a common clinical disorder that results in pulmonary vascular congestion and reduced cardiac output. This results in an abnormally high amount of O2 returning in the venous blood because it is not used at the tissue level. Also happen when your lungs can not alter respiratory rate to assess changes in the that. Base 0.63 review: Spend at least ten minutes every Week reviewing your! 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