NCM 106 Lecture Report: Acute Biologic Crisis/ Multi organ Failure Latombo, Krischel Jane M.

,BSN IV Impaired gas exchange Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane 1.Monitor respiratory rate, depth, and effort, including use of accessory muscles, nasal flaring, and abnormal breathing patterns. Increased respiratory rate, use of accessory muscles, nasal flaring, abdominal breathing, and a look of panic in the client's eyes may be seen with hypoxia. 2. Auscultate breath sounds q __ h(rs). Presence of crackles and wheezes may alert the nurse to an airway obstruction, which may lead to or exacerbate existing hypoxia. 3. Monitor client's behavior and mental status for onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. Changes in behavior and mental status can be early signs of impaired gas exchange 4. Monitor oxygen saturation continuously, using pulse oximeter. Note blood gas results as available. An oxygen saturation of <90% (normal: 95% to 100%) or a partial pressure of oxygen of <80 (normal: 80 to 100) indicates significant oxygenation problems.

5. Observe for cyanosis in skin; especially note color of tongue and oral mucous membranes. Central cyanosis of tongue and oral mucosa is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in extremities may or may not be serious (Carpenter, 1993). 6. If client is acutely dyspneic, coach the client to slow respiratory rate using touch on the shoulder, demonstrating slower respirations while making eye contact with the client, and communicating in a calm, supportive fashion., 2000). 7. Demonstrate and encourage the client to use pursed-lip breathing. Pursed-lip breathing results in increased use of intercostal muscles, decreased respiratory rate, increased tidal volume, and improved oxygen saturation levels 8. Position client with head of bed elevated, in a semi-Fowler's position as tolerated. Semi-Fowler's position allows increased lung expansion because the abdominal contents are not crowding the lungs. 9. If client has unilateral lung disease, alternate semi-Fowler's position with lateral position (with a 10- to 15degree elevation and "good lung down" for 60 to 90 minutes). 1011. If client is obese or has ascites, consider positioning client in reverse Trendelenburg position at 45 degrees for periods as tolerated.

12. Consider positioning the client prone with upper thorax and pelvis supported, allowing the abdomen to protrude. Monitor oxygen saturation, and turn back if desaturation occurs. Do not put in prone position if client has multisystem trauma. 13. If client is acutely dyspnic, consider having client lean forward over a bedside table, if tolerated. 14. Help client deep breathe and perform controlled coughing. Have client inhale deeply, hold breath for several seconds, and cough two to three times with mouth open while tightening the upper abdominal muscles as

tolerated. 15. Monitor the effects of sedation and analgesics on client's respiratory pattern; use judiciously.. 16. Schedule nursing care to provide rest and minimize fatigue. The hypoxic client has limited reserves; inappropriate activity can increase hypoxia. 17. Administer humidified oxygen through appropriate device (e.g., nasal cannula or face mask per physician's order); watch for onset of hypoventilation as evidenced by increased somnolence after initiating or increasing oxygen therapy. A client with chronic lung disease client may need a hypoxic drive to breathe and may hypoventilate during oxygen therapy. 18. Provide adequate fluids to liquefy secretions within the client's cardiac and renal reserve. If client is severely debilitated from chronic respiratory disease, consider use of a wheeled walker to help in ambulation. Decreased cardiac output Inadequate blood pumped by the heart to meet metabolic demands of the body . Intervention: Geriatric 1. Observe for atypical pain; the elderly often have jaw pain instead of chest pain or may have silent myocardial infarctions with symptoms of dyspnea or fatigue. The elderly have altered pain pathways and often do not experience the usual chest painof cardiac patients (Carnevali, Patrick, 1993). 2. Observe for syncope, dizziness, palpitations, or feelings of weakness associated with a irregular heart rhythm. Dysrhythmias are common in the elderly (Carnevali, Patrick, 1993). 3. Observe for side effects from cardiac medications. The elderly have difficulty with metabolism and excretion of medications due to decreased function of the liver and kidneys; therefore toxic side effects are more common.

Home Care Interventions 1. Begin discharge planning as soon as possible with case manager or social worker to assess home support systems and the need for community or home health services. These may be to assist with home care, assistance with meal perparations, housekeeping, personal care, transportation to doctor visits, or emotional support. Clients often need help upon discharge. The existing social support network needs to be assessed and assistance provided as needed to meet client needs and to keep the support persons from being overwhelmed 2. Assess or refer to case manager or social worker to evaluate client ability to pay for prescriptions. The cost of drugs may be a factor to fill prescriptions and adhere to a treatment plan (Campbell, 1998). 3. Continue to monitor client for exacerbation of heart failure when discharged home. Transition to home can create increased stress and physiological instability related to diagnosis. 4. Assess client for understanding and compliance with medical regimen, includingmedications, activity level, and diet. 5. Instruct family and client about the disease process, complications of disease process, information on medications, need for weighing daily, and when it is appropriate to call doctor.

Early recognition of symptoms facilitates early problem solving and prompt treatment Ineffective Tissue perfusion (specify type): cerebral, renal, cardiopulmonary, GI, peripheral Decrease in oxygen resulting in failure to nourish tissues at the capillary level

Peripheral perfusion 1. Check dorsalis pedis and posterior tibial pulses bilaterally. If unable to find them, use a Doppler stethoscope and notify physician if pulses not present. 2. Note skin color and feel temperature of the skin. Skin pallor or mottling, cool or cold skin temperature, or an absent pulse can signalarterial obstruction, which is an emergency that requires immediate intervention. 3. Check capillary refill. Nail beds usually return to a pinkish color within 3 seconds after nail bed compression (Dykes, 1993). 4. Note skin texture and the presence of hair, ulcers, or gangrenous areas on the legs or feet. Thin, shiny, dry skin with hair loss; brittle nails; and gangrene or ulcerations on toes and anterior surfaces of feet are seen in clients with arterial insufficiency. 5. Note presence of edema in extremities and rate it on a four-point scale. Measure circumference of ankles and calf at the same time each day in the early morning (Cahall, Spence, 1995). 6. Assess for pain in extremities, noting severity, quality, timing, and exacerbating and alleviating factors. Differentiate venous from arterial disease. In clients with venous insufficiency the pain lessens with elevation of the legs and exercise. In clients with arterial insufficiency the pain increases with elevation of the legs and exercise Arterial insufficiency 1. Monitor peripheral pulses. If new onset of loss of pulses with bluish, purple, or black areas and extreme pain, notify physician immediately. These are symptoms of arterial obstruction that can result in loss of a limb if not immediately reversed. 2. Do not elevate legs above the level of the heart. With arterial insufficiency, leg elevation decreases arterial blood supply to the legs. 3. For early arterial insufficiency, encourage exercise such as walking or riding an exercise bicycle from 30 to 60 minutes per day. Exercise enhances the development of collateral circulation, strengthens muscles, and provides a sense of wellbeing 4. Keep client warm, and have client wear socks and shoes or sheepskin-lined slippers when mobile. Do not apply heat. Clients with arterial insufficiency complain of being constantly cold; therefore keepextremities warm to maintain vasodilation and blood supply. Heat application can easily damage ischemic tissues (Creamer-Bauer, 1992). 5. Pay meticulous attention to foot care. Refer to podiatrist if client has a foot or nail abnormality. Ischemic feet are very vulnerable to injury; meticulous foot care can prevent further injury.

Venous insufficiency 1. Elevate edematous legs as ordered and ensure that there is no pressure under the knee. Elevation increases venous return and helps decrease edema. Pressure under the knee decreases venous circulation. 2. Apply support hose as ordered. Wearing support hose helps to decrease edema. Studies have demonstrated that thigh-high compression stockings can effectively decrease the incidence of deep vein thrombosis

3. Encourage client to walk with support hose on and perform toe up and point flex exercises. Exercise helps increase venous return, build up collateral circulation, and strengthen the calf muscle pumps 4. If client is overweight, encourage weight loss to decrease venous disease. Obesity is a risk factor for development of chronic venous disease (Kunimoto et al, 2001). 5. Discuss lifestyle with client to see if occupation requires prolonged standing or sitting, which can result in chronic venous disease 6. If client is mostly immobile, consult with physician regarding use of calf-high pneumatic compression device for prevention of DVT. Pneumatic compression devices can be effective in preventing deep vein thrombosis in the immobile client Geriatric 1. Change positions slowly when getting client out of bed. The elderly commonly have postural hypotension resulting from age-related losses of cardiovascular reflexes (Matteson, McConnell, Linton, 1997). 2. Recognize that if elderly develop a pulmonary embolus, the symptoms often mimic those of heart failure or pneumonia (Hyers, 1999). Home Care Interventions 1. Differentiate between arterial and venous insufficiency. Accurate diagnostic information clarifies clinical assessment and allows for more effective care. 2. If arterial disease is present and client smokes, aggressively encourage smoking cessation. 3. Examine feet carefully at frequent intervals for changes and new ulcerations. 4. Assess client nutritional status, paying special attention to obesity, hyperlipidemia, and malnutrition. Refer to a dietitian if appropriate. Malnutrition contributes to anemia, which further compounds the lack of oxygenation to tissues. Obese patients encounter poor circulation in adipose tissue, which can create increased hypoxia in tissue 5. Monitor for development of gangrene, venous ulceration, and symptoms of cellulitis (redness, pain, and increased swelling in an extremity). Cellulitis often accompanies peripheral vascular disease and is related to poor tissue perfusion