115-NCLEX-RN Review Made Incredibly Easy, Fifth Edition (Incredibly Easy...

82 Respiratory system

Acute respiratory failure

In acute respiratory failure, the respiratory system cant adequately supply the body with the O2 it needs or adequately remove CO2. A client is considered to be in respiratory failure when PaO2 is less than or equal to 50 mm Hg or the partial pressure of arterial carbon dioxide (PaCO2) is greater than or equal to 50 mm Hg with a pH of less than or equal to 7.25.

Acute respiratory failure can be classified as ventilatory failure or oxygenation failure. Ventilatory failure is characterized by alve-olar hypoventilation. Oxygenation failure is characterized by V

./

.Q ratio mismatching

(blood flow to areas of the lung with reduced ventilation, or ventilation to lung tissue thats experiencing reduced blood flow) or physio-logic shunting (blood moving from the right side of the heart to the left without being oxygenated).

CAUSES Abdominal or thoracic surgery ARDS Anesthesia Atelectasis Brain tumors Chronic obstructive pulmonary disease (COPD) Drug overdose Encephalitis Flail chest Guillain-Barr syndrome Head trauma Hemothorax Meningitis Multiple sclerosis Muscular dystrophy Myasthenia gravis Pleural effusion Pneumonia Pneumothorax Poliomyelitis Polyneuritis Pulmonary edema Pulmonary embolism Stroke

disseminated intravascular coagulation, a complication of ARDS, monitor platelet count, fibrinogen level, PT, INR, and PTT. Monitor and record intake and output and central venous pressure (CVP) to determine fluid status and hemodynamic variables. Monitor mechanical ventilation (high PEEP leaves the client at risk for pneumo-thorax) to increase partial pressure of arterial oxygen (PaO2) without raising FIO2 , thereby reducing risk of O2 toxicity, and perform naso-pharyngeal or oropharyngeal suctioning as necessary to aid in removal of secretions. Maintain bed rest, with prone positioning, if possible, to promote oxygenation. Maintain fluid restrictions to reduce fluid volume overload. Reposition the client every 2 hours to stim-ulate postural drainage and mobilize secretions. Provide chest physiotherapy to promote drainage and keep airways clear. Keep the client in high Fowlers position to promote chest expansion. Administer total parenteral nutrition or enteral feedings, as appropriate, to prevent respiratory muscle impairment and maintain nutritional status. Administer medications, as prescribed, to optimize respiratory and hemodynamic status. Organize nursing care with rest periods to conserve energy and avoid overexertion and fatigue. Weigh the client daily to detect fluid reten-tion. Encourage the client to express feelings about fear of suffocation to reduce anxiety and, therefore, O2 demands.

Teaching topics Explanation of the disorder and treatment plan Recognizing the signs and symptoms of respiratory distress Performing coughing and deep-breathing exercises and incentive spirometry Drug therapy Nutritional therapy and fluid restrictions if appropriate Importance of adequate rest Avoiding exposure to chemical irritants and pollutants

PaO2 less than or equal to 50 mm Hg or PaCO2 greater

than or equal to 50 mm Hg with a pH of 7.25 or less signals respiratory

failure.

313419NCLEX-RN_Chap04.indd 82313419NCLEX-RN_Chap04.indd 82 4/8/2010 6:46:16 PM4/8/2010 6:46:16 PM

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