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PATHOPHYSIOLOGY OF ACUTE RESPIRATORY FAILURE SECONDARY TO COPD in Acute Exacerbation and Community Acquired Pneumonia Predisposing Factors Age-

71 y/o smoking Hereditary- Asthma 41 y/o I Precipitating Factors - History of Cigarette (starts at 17 y/o and stop at pack per day) -Occupational Exposure -Low immune system

Allergens enter the upper respiratory tract

Stimulation and activation of B-lymphocytes Medication: Hydrocortisone B-lymphocytes produces Immunoglobulin E(IgE) (solu cortet) 100mg IV q6 IgE and antibodies attached to mast cells and basophils in the bronchial walls

mast cell degranulation

mast cell releases chemical mediators of inflammation------->

Histamine

bradykinin

prostaglandins

Slow Reacting Substances of

Increase blood flow to the area of insult

increase mucus production

Anaphylaxis Chemical Mediators induced capillary dilation


Contraction of

edema of the airway

attraction of WBC to the area

Fluid shifting from the Deposition vasculature and to the collagen alveoli below the
basement membrane

S/Sx: -Crackles -Rales -Productve cough (whitish Sputum in minimal amount)

the bronchial smooth muscle


Airway Constriction or Bronchoconstri ction

that encircles the airway

(Bronchospasm)

of

Hyperinflation of alveoli

Medicatio n: Salbutamo l+ Ipratropiu m Nebq6


Narrowi ng of the airway

Decreased
S/Sx: weakne ss -cough

Increase d work of breathin elevation g

Fatigue on the muscle of ventilation

Increase d Resistan ce to airflow

Diagnostic Exam: -Chest X-Ray Impression: Pulmonary emphysema bilateral, atherosclero sis, thrombus aorta Bronchiectas is, both bases

Ventilation-Perfusion V/Q Mismatch shunt Inadequate exchange of Oxygen and Carbon dioxide
Diagnostic Exam: ABG- O2: 99% Increased PaCO2 Decreased PaO2 Increased HCO3 RESPIRATORY ACIDOSIS WITH S/Sx: -Tachycardia (110bpm) -Paleness
BP: 130/80mmHG

Hypoxemia

ACUTE RESPIRATORY FAILURE

Capillary Refill: 5 seconds -Fatigue -Altered Sleep Pattern -drowsiness

Recovery

Complications: Tissue Hypoxia, subsequent organ damage, Chronic respiratory failure,

Tension Pneumothorax, Lobal atelectasis, Pulmonary Edema

DEATH Nursing Problem: ___________

CUES
Subjective:

Objective: Confusion Somnolence Restlessness Irritability Inability to move secretions Hypercapnia

NURSING DIAGNOS IS Impaired Gas Exchange related to altered oxygen supply.

RATION ALE
Normally there is a balance between ventilation and perfusion; however, certain conditions can offset this balance, resulting in impaired gas exchange. Altered blood flow from a pulmonary embolus, or decreased cardiac output or shock can cause ventilation without perfusion. Conditions that cause changes or collapse of the alveoli (e.g., atelectasis, pneumonia , pulmonary edema, and adult respiratory distress syndrome [ARDS]) impair ventilation.

PLAN
Patient maintains optimal gas exchange as evidenced by normal arterial blood gases (ABGs) and alert responsive mentation or no further reduction in mental status.

INTERVENTIO N
1.Assessed respirations: note quality, rate, pattern, depth, and breathing effort.

RATIONALE
Both rapid, shallow breathing patterns and hypoventilation affect gas exchange. Collapse of alveoli increases physiological shunting.

EVALUATI ON

2. Assessed for
signs and symptoms of atelectasis: diminished chest excursion, limited diaphragm excursion, bronchial or tubular breath sounds, rales, tracheal shift to affected side. 3.Assessed skin color for development of cyanosis. 4.Monitored vital signs.

For cyanosis to be present, 5 g of hemoglobin must desaturate. With initial hypoxia and hypercapnia, blood pressure (BP), heart rate, and respiratory rate all rise. As the hypoxia and/or hypercapnia becomes more severe, BP may drop, heart rate tends to continue to be rapid with arrhythmias, and respiratory failure may ensue with the patient unable to maintain the rapid respiratory rate. Restlessness is an early sign of hypoxia. Chronic hypoxemia may result in cognitive changes such as memory changes. Increasing PaCO2 and decreasing PaO2 are signs of respiratory

5.Assessed for changes in orientation and behavior.

6.Monitored ABGs and noted changes.

Nursing Problem: ___________

CUES

NURSIN RATIONA G LE DIAGN OSIS


Ineffectiv e Brea thin g Patt ern Respiratory failure can be seen with a change in respiratory rate, change in normal abdominal and thoracic patterns for inspiration and expiration, change in depth of ventilation (Vt), and respiratory alternans. Breathing pattern changes may occur in a multitude of cases from hypoxia, heart failure, diaphragma tic paralysis, airway obstruction, infection, neuromusc ular impairment , trauma or surgery resulting in musculoske letal impairment and/or pain, cognitive impairment and anxiety, metabolic abnormaliti es (e.g., diabetic ketoacidosi s [DKA], uremia, or

PLAN

INTERVENTION

RATIONALE

EVALUATI ON

-Dyspnea Tachypnea -Fremitus -Cyanosis -Cough -Nasal flaring Respirator y depth changes -Altered chest excursion -Use of accessory muscles -Pursed-lip breathing or prolonged expiratory phase -Increased anteropost erior chest diameter

Patients breathing pattern is maintaine d as evidenced by eupnea, normal skin color, and regular respirator y rate/patte rn.

1. Assess respiratory
rate and depth by listening to lung sounds.

2.Assess for dyspnea at rest versus activity and note changes.

3.Note muscles used for breathing

4.Monitor for changes in orientation, increased restlessness, anxiety, and air hunger. 5.Ensure that oxygen delivery system is applied to the patient.

Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties. Dyspnea that occurs with activity may indicate activity intolerance. The accessory muscles of inspiration are not usually involved in quiet breathing. These include the scalenes (attach to the first two ribs) and the sternocleidomasto id (elevates the sternum). Restlessness is an early sign of hypoxia.

The appropriate amount of oxygen is continuously delivered so that the patient does not desaturate.

6.

Nursing Problem: ___________ CUES NURSIN RATIONA G LE DIAGNO SIS

PLAN

INTERVENTION

RATIONALE

EVALUATI ON

Nursing Problem: ___________

CUES

NURSIN G DIAGNO SIS

RATIONA LE

PLAN

INTERVENTION

RATIONALE

EVALUATI ON

Nursing Problem: ___________

CUES

NURSIN G DIAGNO SIS

RATIONA LE

PLAN

INTERVENTION

RATIONALE

EVALUATI ON

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