RESPIRATORY DISORDER

PULMONARY VASCULAR DISORDERS AND RESPIRATORY FAILURE

Common Nursing Diagnosis for Patients with Pulmonary Vascular Disorders and Respiratory Failure
• Impaired gas exchange related to decreased ventilation or perfusion
• Ineffective airway clearance related to excessive secretions
• Ineffective breathing patter related to anxiety or pain
• Activity intolerance related to imbalance between oxygen supply and demand

PULMONARY VASCULAR DISORDERS

• As blood moves through the lung, blood oxygen levels are raised, and carbon dioxide is removed. These
processes depend on the matching ventilation (gas exchange) and perfusion (blood flow).

PULMONARY EMBOLISM
• Pulmonary Embolism is the obstruction of the pulmonary artery or one of its branches by a thrombus (or
thrombi) that originates somewhere in the venous system or in the right side of the heart. PE is a common
disorder and often is associated with trauma, surgery, pregnancy, heart failure, age older than 50 years,
hypercoagulable states, and prolonged immobility.

SIGNS AND SYMPTOMS

• Dyspnea
• Chest pain
• Other symptoms include anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and
syncope.
• The most frequent sign is tachypnea (very rapid respiratory rate).

PATHOLOGY
• When a thrombus completely or partially obstructs a pulmonary artery or its branches, the alveolar dead space
is increased.
• The area, although continuing to be ventilated, receives little or no blood flow.
• Therefore, gas exchange is impaired or absent in this area. In addition, various substances are released from
the clot and surrounding area that cause regional blood vessels and bronchioles to constrict.
• This results in an increase in pulmonary vascular resistance.
• This reaction compounds the ventilation–perfusion imbalance.
• The hemodynamic consequences are increased pulmonary vascular resistance due to the regional
vasoconstriction and reduced size of the pulmonary vascular bed.
• This results in an increase in pulmonary arterial pressure and, in turn, an increase in right ventricular work to
maintain pulmonary blood flow.
NURSING INTERVENTIONS
MEDICAL MANAGEMENT
• Emergency management is of primary concern. After emergency measures have been initiated and the
patient is stabilized, the treatment goal is to dissolve (lyse) the existing emboli and prevent new ones from
forming.
• The immediate objective is to stabilize the cardiopulmonary system. These consist of the following actions
• Nasal oxygen administration, intravenous infusion lines are established
• A perfusion scan, hemodynamic measurements, and arterial blood gas determinations are performed. Spiral
(helical) CT or pulmonary angiography may be performed along with ECG, ABG, blood chemistries and
complete blood count
• Hypotension is treated by a slow infusion of dobutamine (Dobutrex), which has a dilating effect on the
pulmonary vessels and bronchi, or dopamine (Intropin).

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 • Treatment may include a variety of modalities: general measures to improve respiratory and vascular status,
anticoagulation therapy, thrombolytic therapy, and surgical intervention.
• Measures are initiated to improve respiratory and vascular status. Oxygen therapy is administered to correct
the hypoxemia, relieve the pulmonary vascular vasoconstriction, and reduce the pulmonary hypertension.
• Use of anti-embolism stockings or intermittent pneumatic leg compression devices reduces venous stasis.
• Surgical embolectomy is rarely performed but may be indicated in a massive PE This invasive procedure
involves removal of the actual clot and must be performed by a cardiovascular surgical team with the patient
on cardiopulmonary bypass

NURSING MANAGEMENT
• Assessing and minimizing the risk of pulmonary embolism
• Preventing thrombus formation- The nurse encourages ambulation and active and passive leg exercises to
prevent venous stasis in patients prescribed bed rest. The nurse instructs the patient to move the legs in a
“pumping” exercise so that the leg muscles can help increase venous flow.
• Managing pain specifically Chest pain, if present, is usually pleuritic rather than cardiac in origin. A semi-
Fowler’s position provides a more comfortable position for breathing
• Managing oxygen therapy where in the nurse assesses the patient frequently for signs of hypoxemia and
monitors the pulse oximetry values to evaluate the effectiveness of the oxygen therapy.
• Relieving anxiety by verbalization of questions and fears
• Monitoring for complications of cardiogenic shock or right ventricular failure
• If the patient has undergone surgical embolectomy, the nurse measures the patient’s pulmonary arterial
pressure and urinary output.
• The nurse also assesses the insertion site of the arterial catheter for hematoma formation and infection. It is
important to maintain the blood pressure at a level that supports perfusion of vital organs.

PULMONARY ARTERIAL PRESSURE

• The mean pulmonary artery pressure exceeds 25 mm Hg with a pulmonary capillary wedge pressure of less
than 15 mmHg

TYPES:
1. Idiopathic (or primary) pulmonary arterial hypertension
2. Secondary or pulmonary arterial hypertension due to a known cause

SIGNS AND SYMPTOMS

• Dyspnea occurs at first with exertion and eventually at rest.
• Substernal chest pain also is common.
• Other signs and symptoms include weakness, fatigue, syncope, occasional hemoptysis, and signs of right-sided
heart failure
• Anorexia and abdominal pain in the right upper quadrant

PATHOLOGY
• If the pulmonary vascular bed is destroyed or obstructed, the increased blood flow then increases the pulmonary
artery pressure.
• As the pulmonary arterial pressure increases, the pulmonary vascular resistance also increases.
• Both pulmonary artery constriction (as in hypoxemia or hypercapnia) and a reduction of the pulmonary vascular
bed (which occurs with pulmonary emboli) result in increased pulmonary vascular resistance and pressure

NURSING INTERVENTIONS
MEDICAL MANAGEMENT
• The goal of treatment is to manage the underlying condition related to pulmonary hypertension of known
cause.
• Thoracentesis is performed to remove fluid, to obtain a specimen for analysis, and to relieve dyspnea and
respiratory compromise
• Anticoagulation should be considered for patients with pulmonary hypertension and patients with an
indwelling catheter for administration of medications.
• Most patients with pulmonary hypertension do not have hypoxemia at rest but require supplemental oxygen
with exercise.

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 • Diuretics and oxygen should be added as needed
• Different classes of medications are used to treat pulmonary hypertension; these include calcium channel
blockers, phosphodiesterase-5 inhibitors, endothelin antagonists, and prostanoids. The choice of therapeutic
agents is based on the severity of the disease.

NURSING MANAGEMENT
• The major nursing goal is to identify patients at high risk for pulmonary arterial hypertension,
• The nurse must be alert for signs and symptoms, administer oxygen therapy appropriately and instruct the
patient and family about the use of home oxygen therapy In patients treated with prostanoids, education
about the need for central venous access, subcutaneous infusion, proper administration and dosing of the
medication, pain at the injection site, and potential severe side effects is extremely important
• Emotional and psychosocial aspects of this disease must be addressed

COR PULMONALE
• Pulmonary Heart Disease (Cor Pulmonale) is a condition in which the right ventricle of the heart enlarges (with
or without right-sided heart failure) as a result of diseases that affect the structure or function of the lung or its
vasculature.

SIGNS AND SYMPTOMS

• Symptoms of cor pulmonale are usually related to the underlying lung disease, such as COPD.
• With right ventricular Failure – increasing edema of the feet and legs, distended neck veins, an enlarged palpable
liver, pleural effusion, ascites, and heart murmurs. Headache, confusion, and somnolence may occur as a result
of increased levels of carbon dioxide (hypercapnia)
• Patients often complain of increasing shortness of breath, wheezing, cough, and fatigue

PATHOLOGY
• Cor pulmonale results from pulmonary hypertension, which causes the right side of the heart to enlarge because
of the increased work required to pump blood against high resistance (Hypoxemia and hypercapnia cause
pulmonary arterial vasoconstriction and possibly reduction of the pulmonary vascular bed) through the
pulmonary vascular system.

NURSING INTERVENTIONS
MEDICAL MANAGEMENT
• Supplemental oxygen is administered to improve gas exchange and to reduce pulmonary arterial pressure
and pulmonary vascular resistance
• Chest physical therapy and bronchial hygiene maneuvers as indicated to remove accumulated secretions
and the administration of bronchodilators further improve ventilation.
• Bed rest, sodium restriction, and diuretic therapy also are instituted judiciously to reduce peripheral edema
and the circulatory load on the right side of the heart.
• ECG monitoring may be indicated because of the high incidence of dysrhythmias in patients with cor
pulmonale.
• Additional measures depend on the patient’s condition.
• The prognosis depends on whether the pulmonary hypertension is reversible

NURSING MANAGEMENT
• The nurse assesses the patient’s respiratory and cardiac status and administers medications as prescribed.
If required the nurse assists with the intubation procedure and maintains mechanical ventilation
• During the patient’s hospital stay, the nurse instructs the patient about the importance of close self-monitoring
(fluid retention, weight gain, edema) and adherence to the therapeutic regimen, especially the 24-hour use
of oxygen

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 ACUTE RESPIRATORY FAILURE and acute respiratory distress syndrome
• Acute Respiratory Failure or ARF, a term sometimes used synonymously with acute respiratory distress syndrome
or ARDS, is far broader and comprises respiratory failure resulting from many other conditions: for example,
chronic obstructive pulmonary disease (COPD).

ACUTE RESPIRATORY FAILURE

• A sudden and life-threatening deterioration of the gas exchange function of the lung and indicates failure of
the lungs to provide adequate oxygenation or ventilation for the blood. Acute respiratory failure is defined as
a decrease in arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial
carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35.

SIGNS AND SYMPTOMS

EARLY SIGNS:
• Restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure.

LATENT SIGNS:
• confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and finally respiratory arrest

PATHOPHYSIOLOGY
• ARF results from impaired gas exchange. Conditions associated with alveolar hypoventilation (deficient
movement of air into and out of the alveoli), (ventilation-perfusion) mismatch, and intrapulmonary (right-to-left)
shunting can cause ARF if left untreated. Too little ventilation with normal blood flow or too little blood flow with
normal ventilation may cause the imbalance, resulting in decreased PaO2 levels and, thus, hypoxemia. The
hypoxemia and hypercapnia characteristic of ARF stimulate strong compensatory responses by all body
systems, including the respiratory system, cardiovascular system, and CNS.

NURSING INTERVENTIONS
MEDICAL MANAGEMENT
• The objectives of treatment are to correct the underlying cause and to restore adequate gas exchange in the
lung. Intubation and mechanical ventilation may be required to maintain adequate ventilation and oxygenation
while the underlying cause is corrected.

NURSING MANAGEMENT
• Nursing management of patients with acute respiratory failure includes assisting with intubation and
maintaining mechanical ventilation
• The nurse assesses the patient’s respiratory status by monitoring the level of responsiveness, arterial blood
gases, pulse oximetry, and vital signs.
• The nurse assesses the entire respirator y system and implements strategies (e.g., turning schedule, mouth
care, skin care, range of motion of extremities) to prevent complications.
• The nurse also assesses the patient’s understanding of the management strategies that are use and initiates
some form of communication to enable the patient to express concerns and needs to the health care team
• The nurse addresses the problems that led to the acute respiratory failure.
• As the patient’s status improves the nurse assesses the patient’s knowledge of the underlying disorder and
provides teaching as appropriate to address the disorder.

RESPIRATORY DISTRESS SYNDROME

- A severe form of acute lung injury. This clinical syndrome is characterized by a sudden and progressive
pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia unresponsive to oxygen
supplementation regardless of the amount of PEEP, and the absence of an elevated left atrial pressure.

SIGNS AND SYMPTOMS

• Severe dyspnea that occurs 12-48 hours after the initiating event
• Arterial hypoxemia that doesn’t respond to supplemental oxygen
• Labored and unusually rapid breathing
• Low blood pressure
• Confusion and extreme
• tiredness

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 PATHOPHYSIOLOGY
• Fluid accumulates in the lungs’ interstitium, alveolar spaces, and small airways, as a result of loss of integrity of
the alveolar epithelial barrier causing the lungs to stiffen.
• This loss of integrity may result from direct injury to the alveolar epithelium by inhaled toxins or pulmonary
infection, or they may occur after primary injury to the pulmonary capillary endothelium by circulating toxins, as
in sepsis or pancreatitis, followed by secondary inflammatory injury to the alveolar epithelial barrier. This then
impairs ventilation and reduces oxygenation of pulmonary capillary

NURSING INTERVENTIONS
MEDICAL MANAGEMENT
• The primary focus in the management of ARDS includes identification and treatment of the underlying
condition.
• This supportive therapy almost always includes intubation and mechanical ventilation. In addition, circulatory
support, adequate fluid volume, and nutritional support are important
• This is then monitored by arterial blood gas analysis, pulse oximetry, and bedside pulmonary function testing.
• PEEP is a critical part of the treatment of ARDS. PEEP usually improves oxygenation, but it does not influence
the natural history of the syndrome. By using PEEP, a lower fraction of inspired oxygen (FiO2) may be
required. The goal is a PaO2 greater than 60 mm Hg or an oxygen saturation level of greater than 90% at
the lowest possible FiO2.
• Hypovolemia must be carefully treated without causing further overload. Inotropic or vasopressor agents may
be required.
• Pulmonary artery pressure catheters are used to monitor the patient’s fluid status and the severe and
progressive pulmonary hypertension sometimes observed in ARDS.
• Adequate nutritional support is vital in the treatment of
• ARDS. Patients with ARDS require 35 to 45 kcal/kg/day to meet caloric requirements

NURSING MANAGEMENT
• Close monitoring is required in the intensive care unit , due to the patient condition could quickly become life-
threatening
• Use and management of respiratory modalities such as oxygen administration, nebulizer therapy, chest
physiotherapy, endotracheal intubation or tracheostomy, mechanical ventilation, suctioning, bronchoscopy
• Positioning is important. The nurse turns the patient frequently to improve ventilation and perfusion in the
lungs and enhance secretion drainage. However, the nurse must closely monitor the patient for deterioration
in oxygenation with changes in position. Oxygenation in patients with ARDS is sometimes improved in the
prone position.
• Rest is essential to limit oxygen consumption and reduce oxygen needs.
• The patients may be anxious and “fight” the ventilator. Nursing assessment is important to identify problems
with ventilation that may be causing the anxiety reaction: tube blockage by kinking or retained secretions;
other acute respiratory problems; a sudden decrease in the oxygen level; the level of dyspnea; or ventilator
malfunction.
• Sedation may be required to decrease the patient’s oxygen consumption, allow the ventilator to provide full
support of ventilation, and decrease the patient’s anxiety.
• The nurse must reassure the patient that the paralysis is a result of the medication and is temporary if given
paralytics, it is important for the nurse to describe the purpose and effects of the paralytic agents to the
patient’s family.
• The nurse must anticipate the patient’s needs regarding pain and comfort. The nurse checks the patient’s
position to ensure it is comfortable and in normal alignment and talks to, and not about, the patient while in
the patient’s presence.

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