RESPIRATORY FAILURE

Results from inadequate gas exchange

 Insufficient O2 transferred to the blood
 Hypoxemia
 Inadequate CO2 removal
 Hypercapnea

RESPIRATORY FAILURE: Clinical Manifestation

 Severe Morning Headache
 Cyanosis – Late Sign
 Tachycardia and Mild Hypertension – Early sign
 Rapid, Shallow breathing pattern
 Tripod position
 Dyspnea
 Pursed-lip Breathing
 Retractions

RESPIRATORY FAILURE: Assessment and Diagnostic Tests

 History and PE
 ABG
 Chest Xray
 CBC, Sputum/blood culture, electrolytes
 ECG
 V/Q lung Scan
 Pulmonary Artery Catheter (in severe cases)

RESPIRATORY FAILURE: Medical Management

 O2 Therapy
 Mobilization of secretion
 Positive Pressure Ventilation
RESPIRATORY FAILURE: Pharmacologic Management
 Bronchodilators
 Corticosteroids
 Diuretics
  Antibiotics
RESPIRATORY FAILURE: Nursing Diagnosis
 Impaired gas exchange
 Ineffective airway clearance
 Ineffective breathing pattern
 Risk for fluid volume imbalance
 Anxiety

RESPIRATORY FAILURE: Planning

 Breath sounds within baseline
 No dyspnea or breathing patterns within patients’ baseline
 Effective cough and ability to clear secretion.

RESPIRATORY FAILURE: Nursing Management

 Assess: health history, medication, surgery, PE
 O2 therapy
 It should be tolerated by the patient
 Maintain 02 sat 90% or more
 Mobilization of secretion
 Hydration
 Chest physiotherapy
 Airway suctioning
 Effective coughing

COR PULMONALE
 COR PULMONALE (LATIN WORD) that means “PULMONARY HEART”
 enlargement of the right ventricle from hypertrophy or dilation or as a secondary
response to disorders that affect the lungs
 Acute: commonly caused by massive pulmonary embolism.
 Chronic: slow and progressive course resulting from worsening lung disease.

COR PULMONALE: Pathophysiology

COR PULMONALE: Clinical Manifestation
1. Dyspnea – caused by the underlying pulmonary disease and resulting cor pulmonale.
2. Chest pain – from increased oxygen demand and increased stress on the RV.
3. Syncope – inability to increase one’s cardiac output with exertion or exercise.
4. Coughing
5. Chest pain – from increased oxygen demand and increased stress on the RV.
6. Anorexia, Nausea/Vomiting, RUQ Pain – this result from hepatic congestion.
7. Peripheral Edema and Increased Abdominal Girth – this result from right-sided heart
failure and hepatic congestion.
8. Sign of right-sided filling pressures:
a. RV heave
 b. Elevated jugular venous pressure
c. Prominent V waves due to tricuspid regurgitation (jugular vein exam)
9. Pulsatile Liver
10. Fluid in peritoneal cavity (ascites)
11. Enlarged liver due to hepatomegaly
12. Edema or swelling of the leg, ankle and foot
13. Signs of hypoxemia:
a. Tachypnea
b. Clubbing
c. Central Cyanosis
d. Polycythemia – caused by increased erythropoietin (EPO) production in
response to chronic hypoxia (low blood oxygen level).

COR PULMONALE: Assessment

History
• history or cardiopulmonary disease
• has experienced orthopnea, cough, fatigue, epigastric distress, anorexia, or
weight gain
• history of previously diagnosed lung disorders
• smokes cigarettes, noting the daily consumption and duration
• color and quantity of the mucus the patient expectorates
• Determine the amount and type of dyspnea and if it is related only to exertion
or is continuous
Physical Examination
• The patient may appear acutely ill with severe dyspnea at rest and
visible peripheral edema.
• Observe if the patient has difficulty in maintaining breath while the history is
taken. 
• Evaluate the rate, type, and quality of respirations.
• Examine the underside of the patient's tongue, buccal mucosa, and conjunctiva
for signs of central cyanosis, a finding in congestive heart failure. 
• Oral mucous membranes in dark-skinned individuals are ashen when the patient
is cyanotic.
• Observe the patient for dependent edema from the abdomen (ascites) and
buttocks and down both legs.
• Inspect the patient's chest and thorax for the general appearance and
anteroposterior diameter. Look for the use of accessory muscles in breathing.
• If the patient can be on supine, check for evidence of normal jugular vein
protrusion.
 •  Place the patient in a semi-Fowler position with his or her head turned away
from you. 
• Use a light from the side, which casts shadows along the neck, and look for
jugular vein distention and pulsation.
• Continue looking at the jugular veins and determine the highest level of
pulsation using your fingers to measure the number of finger-breadths above the
angle of Louis.
• While the patient is in semi-Fowler position with the side lighting still in place,
look for chest wall movement, visible pulsations, and exaggerated lifts and
heaves in all areas of the precordium.
• Locate the point of maximum impulse (at the fifth intercostal space, just medial
of the midclavicular line) and take the apical pulse for a full minute. 
• Listen for abnormal heart sounds.
• Hypertrophy of the right side of the heart causes a delayed conduction time and
deviation of the heart from its axis, which can result in dysrhythmias. 
• With the diaphragm of the stethoscope, auscultate heart sounds in the aortic,
pulmonic, tricuspid, and mitral areas.
•  In cor pulmonale, there is an accentuation of the pulmonic component of the
second heart sound. 
• The S3 and S4 sounds resemble a horse gallop.
•  The presence of the fourth heart sound is found in cor pulmonale. 

COR PULMONALE: Diagnostic Exam

 Chest Xray
 ECG
 Echocardiogram
 V/Q scan
 Pulmonary Function test
 Chest Computed Tomography Scan
 Right Heart Catheterization – gold standard

COR PULMONALE: Medical Management

- The goal of treatment is to CONTROL SYMPTOMS
 It is important to treat medical problem that cause pulmonary hypertension,
because they can lead to Cor Pulmonale.

COR PULMONALE: Medical Management

Intensive Care Unit
 The patient with an acute exacerbation of cor pulmonale requires mechanical
ventilation and is usually admitted to an intensive care unit.
   Patients admitted with heart failure related to ARDS or pulmonary embolism who
require specialized treatment, such as hemodynamic monitoring, may also be admitted
to a special care unit.
 Oxygen Therapy
 Relieves pulmonary vasoconstriction, thereby improving cardiac output and
tissue perfusion
 Diuretics
 For chronic right heart failure or elevated RV filling pressures
 For peripheral edema
 Pulmonary Vasodilators
 Leads to pulmonary artery vasodilation

COR PULMONALE: Surgical Management

Phlebotomy
 COPD patients with hematocrit ≥ 65%: phlebotomy
 The most common treatment for polycythemia vera is having frequent blood
withdrawals, using a needle in a vein (phlebotomy). This decreases blood
volume and reduces the number of excess blood cells.
Surgical Embolectomy
 Indicated in massive pulmonary embolism with acute Cor Pulmonale (if
thrombolysis fails or is contraindicated)
Heart-Lung Transplant
 for patients who failed therapy

COR PULMONALE: Nursing Management

Diuretics
Furosemide:
 Weigh patient daily to assess fluid loss and drug effectiveness. 
 If used to treat hypertension, check blood pressure often; antihypertensive
effect may not appear for days.
 Assess patient for electrolyte imbalances electrolyte imbalances
Pulmonary Vasodilators
 Monitor patient’s blood pressure, pulse rate, and heart rate and rhythm by
continuous ECG as appropriate during therapy. Keep emergency equipment and
drugs available.
 Explain that regular tablets can be crushed but that capsules and E.R. tablets
must be swallowed whole. 
  Tell patient that stopping drug suddenly may have life-threatening effects.
Phlebotomy
Check the patient's arm and apply a bandage
 Assess the insertion site for continued bleeding or bruising.
 If the site isn't actively bleeding, then apply a pressure bandage with gauze and
tape. 
 If the site is still bleeding, continue to hold pressure and recheck the site in a few
minutes.
Surgical Embolectomy
 Advise to drink plenty of fluids when traveling, exercising, or in dry climates or
high altitudes. Dehydration can increase blood clotting.
 Instruct to take anticoagulant (blood-thinning) medication exactly as directed.
The patient may need to take warfarin (Coumadin) for six months or longer to
decrease the risk of having more blood clots.
 Encourage to wear elastic compression stockings, which prevent blood from
pooling and clotting in veins
 Advise to walk or flex legs every hour on long plane or car trips
 Nursing Management
 The patient requires bedrest and assistance with the activities of daily living if
hypoxemia and hypercapnia are severe
 Reposition the bedridden patient frequently to prevent atelectasis.
 Provide meticulous skin care.
 Reinforce proper breathing strategies for the patient: breathe in through the
nose and out slowly through pursed lips, using abdominal muscles to squeeze
out the air; inhale before beginning an activity and then exhale while doing the
activity, such as walking or eating.
 Nurses can teach patients to control their anxiety, which affects their
breathlessness and fear. 
 Teach the patient the use of relaxation techniques.
 Explain the importance of maintaining a low-sodium diet.
 Review nutrition counseling and the prescribed fluid intake.
Oxygen Therapy 
 Oxygen supplied to the home comes in compressed gas, liquid, or concentrator
systems. Portable oxygen systems allow the patient to exercise, work, and travel.
To help the patient adhere to the oxygen prescription, the nurse should:
 explain the proper flow rate and required number of hours for oxygen
use as well as the dangers of arbitrary changes in flow rate or duration
of therapy.
 reassure the patient that oxygen is not “addictive” and explains the need
for regular evaluations of blood oxygenation by pulse oximetry or
arterial blood gas analysis.