ETIOLOGY

SIGNS AND
SYMPTOMS

PATHOPHYSIOLOGY

DIAGNOSTIC /
LABORATORY
TESTS

NURSING
INTERVENTIONS

MEDICATION



ACTIVITY/
EXERCISE

HEALTH
TEACHINGS











































Acute respiratory failure

Obstruction
When something gets lodged in your throat, you may have trouble getting enough oxygen into your
lungs.
Injuries
Injuries that impair or compromise your respiratory system can adversely affect the amount of oxygen
in your blood. For instance, if you have an injury to the spinal cord or brain can immediately affect your
breathing. The brain tells the lungs to breathe. If they cannot relay messages due to injury or damage,
the lungs do not continue to function properly.
Injury to the ribs or chest can also hamper the breathing process. These injuries can impair your ability
to inhale enough oxygen into your lungs.
Acute Respiratory Distress Syndrome (ARDS)
ARDS is a serious condition described as low oxygen in the blood. ARDS affects you if you already
have an underlying health problem such as pneumonia. It can occur while you are in the hospital being
treated for that problem.
Drug or Alcohol Abuse
If you overdose on drugs or drink too much alcohol, you can impair brain function. Your brain may not
tell your lungs to breathe or exhale.
Chemical Inhalation


Inhaling toxic chemicals, smoke, or fumes can also cause acute respiratory failure. These chemicals
may injure or damage the tissues of your lungs, including the air sacs and capillaries.
Stroke
A stroke occurs when your brain experiences tissue death or damage on one or both sides of the brain.
Often, it affects only one side. Although stroke does present some warning signs such as slurred
speech or confusion, it typically occurs quickly. If you have a stroke, you may lose your ability to
breathe properly.


Who Is at Risk for Acute Respiratory Failure?
You may be at risk for acute respiratory failure if you:
smoke (tobacco products) or drink (alcohol) excessively
have a family history of respiratory disease or conditions
become injured in the spine, brain, or chest
have chronic (long-term) respiratory problems, such as cancer of the lungs and chronic obstructive pulmonary disease (COPD)
Part 5 of 8: Symptoms
What Are the Symptoms of Acute Respiratory Failure?
The symptoms vary according to how healthy you are. But most people acute failure of the lungs with low oxygen levels will experience:


inability to breathe
bluish coloration in your skin, fingertips, or lips
passing out


Etiology
Respiratory causes include:
Acute exacerbation of asthma
Pulmonary embolism: can occur as a result of hypercoagulable states, such as those induced by pregnancy, oral contraceptive pill use, inherited protein
deficiencies (e.g., protein C, protein S, antithrombin III, factor V Leiden deficiencies), and autoimmune conditions (e.g., antiphospholipid antibody syndrome, SLE)
Pulmonary edema
Acute respiratory distress syndrome
Pneumonia
Acute epiglottitis
Cardiogenic pulmonary edema
Pulmonary trauma
Inhalation injury (with toxic fumes or gases including chlorine, smoke, carbon monoxide, hydrogen sulfide)
Upper/lower airway obstruction (e.g., foreign bodies, retropharyngeal abscess, epiglottitis, and swelling as a result of acute allergy or anaphylaxis)
Pneumothorax
Chronic lung disease (e.g., chronic obstructive pulmonary disease, cystic fibrosis, pulmonary fibrosis, chronic interstitial lung disease)
Bronchiectasis
Alveolar abnormalities (e.g., emphysema, Goodpasture syndrome, Wegener granulomatosis)
Chest wall abnormalities (e.g., kyphoscoliosis)
Malignancy


Decompensated congestive cardiac failure
Collagen vascular disease.
Nonrespiratory causes include:



diagnostic test

Diagnostic Tests
1st Tests To Order
Test Result
pulse oximetry SpO2 <80%
arterial blood gases pH <7.38; PaO2 <60 mmHg (or <50 mmHg in
chronic lung disease) on room air; PaCO2
>50 mmHg on room air
Other Tests to Consider
Test Result
CBC elevated white blood cell count
screening for hypercoagulable states variable


Other Tests to Consider
Test Result
serum bicarbonate (HCO3) may be elevated
ECG variable
CXR diffuse or patchy infiltrates; pneumothorax;
pulmonary effusion; hyperinflation;
asymmetric opacification of lung fields;
asymmetric lucency of lung fields
pulmonary function tests PEFR <35% to 50% of predicted; FEV <35%
to 50% of predicted; FVC <50% to 70% of
predicted; FEV1 <50% of predicted; NIF
above -25 cm H2O
chest CT pulmonary embolism; chronic lung disease;
infection; parenchymal disease;
bronchiectasis
ventilation/perfusion lung scan pulmonary embolism
Emerging Tests
Test Result
transcutaneous CO2 monitoring reduced PaCO2


Emerging Tests
Test Result
cardiothoracic ultrasound evidence of effusion, pneumothorax,
consolidation, or abscess





Patho







MEDICATION
http://emedicine.medscape.com/article/167981-medication#9



nursing intervention


Outcome/Short Term
Client Centered Goals
Planning/Interventions
Implementation
Rationale for
interventions
Evaluation
Client will have exhibited
signs of adequate
perfusion.





Client ABGs will be within
normal baseline limits for
client.

Client will exhibit signs of
effective breathing
pattern.

Client will have adequate
tissue perfusion.




Monitor pulse oximetry
for oxygen saturation
and notify for < 90%





Monitor ABGs for
changes and trends.


Maintain HOB elevation
at least 30 degrees.

Monitor ECG changes in
cardiac rhythm,
dysrhythmias, or
conduction defects.
Oximetry readings of 90
correlate with PaO
2
of
60. Levels below this do
not allow for adequate
perfusion to tissues and
vital organs. Oximtery
uses light waves to
identify the differences
between the saturation
and reduced hemoglobin
of the tissues and may
be inaccurate in low flow
states.
Provides information on
acid/base status and
oxygenation.
Must consider both
oxygenation and
ventilation.


Elevating HOB decreases
risk of aspiration and
facilitates lung
expansion.
Hypoxia can result in life-
threatening
dysrhythmias that
require emergent
treatments.
Pulse oximetery readings
are > 90%






ABGs remain in normal
limits for client.

Client will exhibit
decreased difficulty
breathing.

Client will not exhibit
dysrhythmias.



Pulmonary embolism
Etiology

- Prolonged immobilization
- Central venous catheters
- Abdominal, pelvic or thoracic surgery
- Obesity
- Advancing age
- Hyper-coagulability
- History of thrombo-embolism
- Cancer diagnosis
- Venous stasis
- Thrombophlebitis
- Pregnancy and use of contraceptive.
Risk factors
Heart disease. High blood pressure and cardiovascular disease make clot formation more likely.
Cancer. Certain cancers especially pancreatic, ovarian and lung cancers, and many cancers with metastasis can increase levels of substances that help
blood clot, and chemotherapy further increases the risk. Women with a history of breast cancer who are taking tamoxifen or raloxifene also are at higher risk of
blood clots.
Prolonged immobility
Blood clots are more likely to form in your legs during periods of inactivity, such as:


Bed rest. Being confined to bed for an extended period after surgery, a heart attack, leg fracture or any serious illness makes you far more vulnerable to blood
clots. When the lower extremities are horizontal for long periods of time, the flow of venous blood slows and blood pools in the legs.
Long journeys. Sitting in a cramped position during lengthy plane or car trips slows blood flow, which contributes to the formation of clots in your legs.

Smoking. For reasons that aren't well understood, tobacco use predisposes some people to blood clot formation, especially when combined with other risk
factors.
Being overweight. Excess weight increases the risk of blood clots particularly in women who smoke or have high blood pressure.
Supplemental estrogen. The estrogen in birth control pills and in hormone replacement therapy can increase clotting factors in your blood, especially if you
smoke or are overweight.
Pregnancy. The weight of the baby pressing on veins in the pelvis can slow blood return from the legs. Clots are more likely to form when blood slows or
pools.
Common signs and symptoms include:
Shortness of breath. This symptom typically appears suddenly and always gets worse with exertion.
Chest pain. You may feel like you're having a heart attack. The pain may become worse when you breathe deeply (pleurisy), cough, eat, bend or stoop. The
pain will get worse with exertion but won't go away when you rest.
Cough. The cough may produce bloody or blood-streaked sputum.
Other signs and symptoms that can occur with pulmonary embolism include:
Leg pain or swelling, or both, usually in the calf
Clammy or discolored skin (cyanosis)
Excessive sweating
Rapid or irregular heartbeat
Lightheadedness or dizziness





Diagnostic test
Blood tests
Your doctor may order a blood test for the clot-dissolving substance D dimer in your blood. High levels may suggest an increased likelihood of blood clots,
although D dimer levels may be elevated by other factors, including recent surgery.
In addition, blood tests may be done to determine whether you have an inherited clotting disorder.
Chest X-ray
This noninvasive test shows images of your heart and lungs on film. Although X-rays can't diagnose pulmonary embolism and may even appear normal when
pulmonary embolism exists, they can rule out conditions that mimic the disease.
Ultrasound
A noninvasive "sonar" test known as duplex ultrasonography (sometimes called duplex scan or compression ultrasonography) uses high-frequency sound waves
to check for blood clots in your thigh veins. In this test, your doctor uses a wand-shaped device called a transducer to direct the sound waves to the veins being
tested. These waves are then reflected back to the transducer and translated into a moving image by a computer. The absence of the presence of clots reduces
the likelihood of DVT. If clots are present, treatment likely will be started immediately.
CT scan
Regular CT scans take X-rays from many different angles and then combine them to form images showing 2-D "slices" of your internal structures. In a spiral
(helical) CT scan, the scanner rotates around your body in a spiral like the stripe on a candy cane to create 3-D images. This type of CT can detect
abnormalities in the arteries in your lungs with much greater precision, and it's also much faster than are conventional CT scans. In some cases, contrast material
is given intravenously during the CT scan to outline the pulmonary arteries.


V/Q lung scan
This test uses small amounts of radioactive material to study airflow (ventilation) and blood flow (perfusion) in your lungs. For the first part of the test, you inhale a
small amount of radioactive material while a camera that's able to detect radioactive substances takes pictures of the movement of air in your lungs. Then a small
amount of radioactive material is injected into a vein in your arm, and pictures are taken as the blood flows into the blood vessels of your lungs. Comparing the
results of the two studies helps provide a diagnosis.
Pulmonary angiogram
This test provides a clear picture of the blood flow in the arteries of your lungs. It's the most accurate way to diagnose pulmonary embolism, but because it requires
a high degree of skill to administer and carries potentially serious risks, it's usually performed when other tests fail to provide a definitive diagnosis.
In a pulmonary angiogram, a flexible tube (catheter) is inserted into a large vein usually in your groin and threaded through your heart into the pulmonary
arteries. A special dye is then injected into the catheter, and X-rays are taken as the dye travels along the arteries in your lungs.
A risk of this procedure is a temporary change in your heart rhythm. In addition, the dye may cause kidney damage in people with decreased kidney function.
MRI
MRI scans use radio waves and a powerful magnetic field to produce detailed images of internal structures. Because MRI is expensive, it's usually reserved for
pregnant women and people whose kidneys may be harmed by dyes used in other tests.


Medication
Medications


Blood thinners (anticoagulants). These drugs prevent new clots from forming, but it may take a few days before these medicines begin to work. Risks
include bleeding gums and easy bruising.
Clot dissolvers (thrombolytics). While clots usually dissolve on their own, there are medications that can dissolve clots quickly. Because these clot-busting
drugs can cause sudden and severe bleeding, they usually are reserved for life-threatening situations.
Surgical and other procedures
Clot removal. If you have a very large clot in your lung, your doctor may suggest removing it via a thin, flexible tube (catheter) threaded through your blood
vessels.
Vein filter. A catheter can also be used to position a filter in the main vein called the inferior vena cava that leads from your legs to the right side of your
heart. This filter can block clots from being carried into your lungs. This procedure is typically reserved for people who can't take anticoagulant drugs or when
anticoagulant drugs don't work well enough or fast enough. The catheter with a filter in the tip is usually inserted in a vein in your neck.


Nursing intervention
Bed rest with active and passive range of motion.
- Keep the patient with fowler position to enhance ventilation.
- Assist with turning, coughing, and deep breathing to mobilize secretions and clear airway.
- Assess respiratory status to detect respiratory distress.
- Assess cardiovascular status. An irregular pulse may signal arrhythmia caused by hypoxemia. If cause of PE by thrombophlebitis, temperature may be elevated.
- Administer O2 to enhance oxygenation.
- Establish an IV line for fluids and drugs.
- Monitor and record intake and output to detect fluid volume overload and renal perfusion.
- ABGs monitoring to evaluate the need for mechanical ventilation.
- Monitor laboratory studies because patient on heparin and need to evaluate electrolyte, CBC and Hct.





Acute respiratory distress syndrome














CVA
A stroke occurs when the blood supply to your brain is interrupted or reduced. This deprives your brain of oxygen and nutrients, which can cause your brain cells
to die.
A stroke may be caused by a blocked artery (ischemic stroke) or a leaking or burst blood vessel (hemorrhagic stroke). Some people may experience a temporary
disruption of blood flow through their brain (transient ischemic attack, or TIA).
Ischemic stroke
About 85 percent of strokes are ischemic strokes. Ischemic strokes occur when the arteries to your brain become narrowed or blocked, causing severely reduced
blood flow (ischemia). The most common ischemic strokes include:
Thrombotic stroke. A thrombotic stroke occurs when a blood clot (thrombus) forms in one of the arteries that supply blood to your brain. A clot may be caused
by fatty deposits (plaque) that build up in arteries and cause reduced blood flow (atherosclerosis) or other artery conditions.
Embolic stroke. An embolic stroke occurs when a blood clot or other debris forms away from your brain commonly in your heart and is swept through
your bloodstream to lodge in narrower brain arteries. This type of blood clot is called an embolus.
Hemorrhagic stroke
Hemorrhagic stroke occurs when a blood vessel in your brain leaks or ruptures. Brain hemorrhages can result from many conditions that affect your blood vessels,
including uncontrolled high blood pressure (hypertension) and weak spots in your blood vessel walls (aneurysms).
A less common cause of hemorrhage is the rupture of an abnormal tangle of thin-walled blood vessels (arteriovenous malformation) present at birth. Types of
hemorrhagic stroke include:
Intracerebral hemorrhage. In an intracerebral hemorrhage, a blood vessel in the brain bursts and spills into the surrounding brain tissue, damaging brain
cells. Brain cells beyond the leak are deprived of blood and damaged.
High blood pressure, trauma, vascular malformations, use of blood-thinning medications and other conditions may cause intracerebral hemorrhage.


Subarachnoid hemorrhage. In a subarachnoid hemorrhage, an artery on or near the surface of your brain bursts and spills into the space between the
surface of your brain and your skull. This bleeding is often signaled by a sudden, severe headache.
A subarachnoid hemorrhage is commonly caused by the bursting of a small sack-shaped or berry-shaped outpouching on an artery (aneurysm) in the brain.
After the hemorrhage, the blood vessels in your brain may widen and narrow erratically (vasospasm), causing brain cell damage by further limiting blood flow.
Transient ischemic attack (TIA)
A transient ischemic attack (TIA) also called a ministroke is a brief period of symptoms similar to those you'd have in a stroke. A temporary decrease in blood
supply to part of your brain causes TIAs, which often last less than five minutes.
Like an ischemic stroke, a TIA occurs when a clot or debris blocks blood flow to part of your brain. A TIA doesn't leave lasting symptoms because the blockage is
temporary.
Seek emergency care even if your symptoms seem to clear up. If you've had a TIA, it means there's likely a partially blocked or narrowed artery leading to your
brain, or a clot source in the heart, putting you at a greater risk of a full-blown stroke that could cause permanent damage later.
It's not possible to tell if you're having a stroke or a TIA based only on your symptoms. Up to half of people whose symptoms appear to go away actually have had
a stroke causing brain damage.
Lifestyle risk factors
Being overweight or obese
Physical inactivity
Heavy or binge drinking
Use of illicit drugs such as cocaine and methamphetamines
Potentially treatable risk factors
High blood pressure risk of stroke begins to increase at blood pressure readings higher than 120/80 millimeters of mercury (mm Hg). Your doctor will help
you decide on a target blood pressure based on your age, whether you have diabetes and other factors.
Cigarette smoking or exposure to secondhand smoke.
High cholesterol a total cholesterol level above 200 milligrams per deciliter (5.2 millimoles per liter).


Diabetes.
Obstructive sleep apnea a sleep disorder in which the oxygen level intermittently drops during the night.
Cardiovascular disease, including heart failure, heart defects, heart infection or abnormal heart rhythm.
Other risk factors
Personal or family history of stroke, heart attack or transient ischemic attack.
Being age 55 or older.
Race African-Americans have higher risk of stroke than do people of other races.
Gender Men have a higher risk of stroke than women. Women are usually older when they have strokes, and they are more likely to die of strokes than are
men. Also, they may have some risk from some birth control pills or hormone therapies that include estrogen, as well as from pregnancy and childbirth.
Symptoms
Trouble with walking. You may stumble or experience sudden dizziness, loss of balance or loss of coordination.
Trouble with speaking and understanding. You may experience confusion. You may slur your words or have difficulty understanding speech.
Paralysis or numbness of the face, arm or leg. You may develop sudden numbness, weakness or paralysis in your face, arm or leg, especially on one side
of your body. Try to raise both your arms over your head at the same time. If one arm begins to fall, you may be having a stroke. Similarly, one side of your
mouth may droop when you try to smile.
Trouble with seeing in one or both eyes. You may suddenly have blurred or blackened vision in one or both eyes, or you may see double.
Headache. A sudden, severe headache, which may be accompanied by vomiting, dizziness or altered consciousness, may indicate you're having a stroke.
When to see a doctor
Seek immediate medical attention if you notice any signs or symptoms of a stroke, even if they seem to fluctuate or disappear.
Think "FAST" and do the following:


Face. Ask the person to smile. Does one side of the face droop?
Arms. Ask the person to raise both arms. Does one arm drift downward?
Speech. Ask the person to repeat a simple phrase. Is his or her speech slurred or strange?
Time. If you observe any of these signs, call 911 immediately.
Trouble with walking. You may stumble or experience sudden dizziness, loss of balance or loss of coordination.
Trouble with speaking and understanding. You may experience confusion. You may slur your words or have difficulty understanding speech.
Paralysis or numbness of the face, arm or leg. You may develop sudden numbness, weakness or paralysis in your face, arm or leg, especially on one side
of your body. Try to raise both your arms over your head at the same time. If one arm begins to fall, you may be having a stroke. Similarly, one side of your
mouth may droop when you try to smile.
Trouble with seeing in one or both eyes. You may suddenly have blurred or blackened vision in one or both eyes, or you may see double.
Headache. A sudden, severe headache, which may be accompanied by vomiting, dizziness or altered consciousness, may indicate you're having a stroke.
When to see a doctor
Seek immediate medical attention if you notice any signs or symptoms of a stroke, even if they seem to fluctuate or disappear.
Think "FAST" and do the following:
Face. Ask the person to smile. Does one side of the face droop?
Arms. Ask the person to raise both arms. Does one arm drift downward?
Speech. Ask the person to repeat a simple phrase. Is his or her speech slurred or strange?
Time. If you observe any of these signs, call 911 immediately.



Diagnostic tests
Physical examination. Your doctor will ask you or a family member what symptoms you've been having, when they started and what you were doing when
they began. Your doctor then will evaluate whether these symptoms are still present.
Your doctor will want to know what medications you take and whether you have experienced any head injuries. You'll be asked about your personal and family
history of heart disease, transient ischemic attack or stroke.
Your doctor will check your blood pressure and use a stethoscope to listen to your heart and to listen for a whooshing sound (bruit) over your neck (carotid)
arteries, which may indicate atherosclerosis. Your doctor may also use an ophthalmoscope to check for signs of tiny cholesterol crystals or clots in the blood
vessels at the back of your eyes.
Blood tests. You may have several blood tests, which tell your care team how fast your blood clots, whether your blood sugar is abnormally high or low,
whether critical blood chemicals are out of balance, or whether you may have an infection. Care providers will manage your blood's clotting time and levels of
sugar and key chemicals as part of your stroke care.
Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create a detailed image of your brain. A CT scan can show a hemorrhage,
tumors, strokes and other conditions. Doctors may inject a dye into your bloodstream to view your blood vessels in your neck and brain in greater detail
(computerized tomography angiography).
Magnetic resonance imaging (MRI). An MRI uses powerful radio waves and magnets to create a detailed view of your brain. An MRI can detect brain tissue
damaged by an ischemic stroke and brain hemorrhages. Your doctor may inject a dye into a blood vessel to view the arteries and veins and highlight blood flow
(magnetic resonance angiography, or magnetic resonance venography).
Carotid ultrasound. In this test, sound waves create detailed images of the inside of the carotid arteries in your neck. This test shows buildup of fatty deposits
(plaques) and blood flow in your carotid arteries.
Cerebral angiogram. In this test, your doctor inserts a thin, flexible tube (catheter) through a small incision, usually in your groin, and guides it through your
major arteries and into your carotid or vertebral artery. Then your doctor injects a dye into your blood vessels to make them visible under X-ray imaging. This
procedure gives a detailed view of arteries in your brain and neck.


Echocardiogram. An echocardiogram uses sound waves to create detailed images of your heart. An echocardiogram can find a source of clots in your heart
that may have traveled from your heart to your brain and caused your stroke.
Medication
Aspirin. Aspirin is an immediate treatment given in the emergency room to reduce the likelihood of having another stroke. Aspirin prevents blood clots from
forming.
Intravenous injection of tissue plasminogen activator (TPA). Some people can benefit from an injection of a recombinant tissue plasminogen activator
(TPA), also called alteplase. An injection of TPA is usually given through a vein in the arm. This potent clot-busting drug needs to be given within 4.5 hours
after stroke symptoms begin if it's given in the vein.