NURS 19 Pulmonary Edema, Hemorrhage, Cardiac arrest

AY 2021- 09/16/2021
2022
Midterm Exam
PULMONARY EDEMA  Tachycardia and JVD
 common complication of cardiac disorders  common signs
 common complication of cardiac disorders  Incessant coughing
 associated with acute decompensated HF  foamy sputum
 cardiogenic or noncardiogenic  confused and then stuporous
 lead to acute respiratory failure and death  bloody sputum
 level of consciousness decreases
ETIOLOGY  crepitant crackles
 Cardiogenic pulmonary edema  diastolic (S3) gallop
 left-sided heart failure  thready pulse
 Noncardiogenic pulmonary edema  decreased cardiac output.
 barbiturate or opiate poisoning  breath sounds diminish
 intravenous (IV) fluids infused in excessive
volumes or at an overly rapid rate DIAGNOSTIC FINDINGS
 transfusion reaction I. ABG analysis
 impaired pulmonary lymphatic drainage  hypoxia with variable partial pressures of arterial
 eclampsia carbon dioxide
 inhalation of irritating gases  metabolic acidosis
 pneumonia II. B-type natriuretic peptide (BNP)
 ARDS or shock lung
 increase in value
III. Chest X-rays
PATHOPHYSIOLOGY
 haziness of the lung fields
 When the left ventricle begins to fail  cardiomegaly
 flood backs up into the pulmonary circulation
 pleural effusion
 pulmonary interstitial edema
 Butterfly appearance
 rapid increase in atrial pressure
IV. Pulse oximetry
 acute increase in pulmonary venous pressure
 decreasing levels of arterial oxygen saturation
 increase in hydrostatic pressure forces fluid
V. Echocardiogram
out of the pulmonary capillaries
 fluid around the heart
 The fluid within the alveoli mixes with air
 producing the classic sign of pulmonary edema  congenital heart defects
 frothy pink sputum  decreased heart flow
 large amounts of alveolar fluid create a diffusion block  decreased pumping actions
 hypoxemia VI. Cardiac catheterization
 elevated central venous and pulmonary artery
 elevated capillary wedge pressures.
VII. ECG
 Previous or current myocardial infarction.

PREVENTION
 assesses the degree of dyspnea
 auscultates the lung fields and heart sounds
 assesses the degree of peripheral edema
 early indicators of developing pulmonary edema:
 hacking cough
 fatigue
 weight gain
 increased edema
 decreased activity tolerance
 alleviated by increasing dosages of diuretics
 upright position with the feet and legs
 reduces left ventricular workload

MEDICAL MANAGEMENT
CLINICAL MANIFESTATION  High concentrations of oxygen by cannula or mask
 BiPAP assisted ventilation
 restless
 If the patient’s arterial oxygen levels remain too
 anxious low
 sudden onset of breathlessness  usually improves acid–base balance
 sense of suffocation  intubation
 tachypneic with noisy breathing  If patient becomes lethargic or somnolent
 low oxygen saturation rates  Bronchodilator
 pale to cyanotic  beta2-agonist
 hands may be cool and moist  anticholinergics

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 NURS 19 Pulmonary Edema, Hemorrhage, Cardiac arrest
AY 2021- 09/16/2021
2022
Midterm Exam
 Diuretics  Venous
 blood pressure is closely monitored  Arterial
 intake and output, daily weights, serum  Types of bleeding
electrolytes, and creatinine are carefully  External hemorrhage
monitored.  Internal hemorrhage
 Vasodilators
 contraindicated in patients who are hypotensive ETIOLOGY
 IV nitroglycerin  External hemorrhage may be caused by:
 Nitroprusside  penetrating trauma
 Positive inotropic agents  lacerations
 Treatment of myocardial dysfunction  Internal hemorrhage
 enhance contractility  blunt or penetrating trauma
 promote vasoconstriction in peripheral vessels  blood dyscrasias
 digoxin  ruptured aortic aneurysm
 amrinone
 Antiarrhythmics PATHOPHYSIOLOGY
 decreased cardiac output  lead to hypovolemic shock
 decrease peripheral vascular resistance, preload,  filling of the vascular compartment; it occurs when
and afterload 15% to 20% of circulating blood volume is loss.
 Morphine  A loss of effective circulating blood volume causes:
 reduce anxiety and dyspnea  inadequate organ
 dilate the systemic venous bed
 can compromise respirations
 resuscitation equipment available in case the Bleeding
patient stops breathing

NURSING MANAGEMENT Hypovolemia

 positioned upright
 preferably with the legs dangling over the side of hypoperfusion
the bed
 decreasing venous return Cellular anerobic metabolism + Lactic acidosis
 decreasing right ventricular SV
 decreasing lung congestion ↓coag. proteases
 nurse gives the patient simple, concise information in a
reassuring voice
 bedside commode Coagulopathy & Hge
 decrease the energy required by the patient
 monitor urine output ↓tissue perfusion + BS – gut & Muscle↓
 indwelling urinary catheter may be inserted
 continuous ECG monitoring
 frequent measurement of vital signs Underperfused muscle
 Administer supplemental oxygen as ordered, first step
in treatment hypothermia
 Assess the patient’s condition frequently and document
his or her responses to treatment.
 Monitor ABG and pulse oximetry values, and in the HgE hypoperfusion acidosis
patient with a pulmonary artery catheter, pulmonary
end-diastolic and PAWPs
 Watch for complications
 Monitor vital signs every 15 to 30 minutes while
administering nitroprusside in dextrose 5% in water by
IV drip.
 Discard unused nitroprusside solution after 4
hours.  tissue perfusion
 Watch for arrhythmias in patients receiving digoxin
 marked respiratory depression in those receiving
morphine
 sodium restrictions and high potassium diet DEATH

HEMORRHAGE
CLINICAL MANIFESTATION
 loss of a large amount of blood internally or externally in
a short period.  cool, moist skin
 Source of bleeding:  decreasing blood pressure
 Capillary  increasing heart rate

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 NURS 19 Pulmonary Edema, Hemorrhage, Cardiac arrest
AY 2021- 09/16/2021
2022
Midterm Exam
 delayed capillary refill
 decreasing urine volume
 Apprehension
 Signs of internal bleeding
 Ecchymoses
 occult or frank blood in urine
 Obvious bleeding from wound or orifices
DIAGNOSTIC FINDINGS
 decreased hematocrit and hemoglobin
 Guaiac testing may detect occult blood in stool.
MEDICAL MANAGEMENT
I. Fluid Replacement
 two large-gauge IV catheters are inserted
 in an uninjured extremity
 Blood samples are obtained for analysis, typing,
and cross-matching
 isotonic electrolyte solutions
 colloids
 blood component therapy
 Packed red blood cells
II. Control of External Hemorrhage
 Direct, firm pressure is applied:
 over the bleeding area
 the involved artery at a site that is proximal to
the wound
 the injured part is elevated to stop venous and
capillary bleeding, if possible.
 the extremity is immobilized to control blood loss
 If the injured area is an extremity
 tourniquet is applied to an extremity
 when the external hemorrhage cannot be
controlled in any other way
 applied just proximal to the wound
 The patient is tagged with a skin marking pencil or
on adhesive tape on the forehead with a “T,”
 stating the location of the tourniquet and the
time applied
 the tourniquet remains in place until the patient is
in the operating room
 suffered a traumatic amputation
 Time of tourniquet application and removal should
be documented
III. Control of Internal Bleeding
 internal hemorrhage is suspected if:
 tachycardia
 falling blood pressure
 thirst
 apprehension
 cool and moist skin
 delayed capillary refill
 packed RBC, plasma, and platelets are given at a
rapid rate
 arterial blood gas specimens are obtained
 evaluate pulmonary function and tissue
perfusion
 establish baseline hemodynamic parameters
 supine position
 monitored closely until hemodynamic or circulatory
parameters improve
PERAS, L. Pulmonary Edema, Hemorrhage, Cardiac arrest
BLOOD TRANSFUSION
 Administration of blood and blood components
 treat decreased hemoglobin (Hb) level and hematocrit
(HCT).
PACKED BT
 Packed RBCs contain:
 cellular debris
 used when patient has a normal blood
volume
 Perioperative and emergency blood salvage
(most common indication for bt)
 Washed packed RBCs
 commonly used for patients previously sensitized
to transfusions
SELF SUPPLIED BT
 autotransfusion or autologous transfusion
 patient’s own blood is collected, filtrated, and
reinfused.
 Autologous transfusion may be indicated for:
 elective surgery
 nonelective surgery
 perioperative and emergency blood salvage
during and after thoracic or cardiovascular surgery
and hip, knee, or liver resection
 perioperative and emergency blood salvage for
traumatic injury of the lungs, liver, chest wall,
heart, pulmonary vessels, spleen, kidneys, inferior
vena cava, and iliac, portal, or subclavian veins
TRANSFUSING BLOOD AND BLOOD COMPONENTS
Packed Sed blood cells (rBCs)
 To restore or maintain oxygen-carrying
compatibilityABO and Rh Indications
capacity
 To correct anemia and surgical blood loss
 To increase RBC mass
 To improve RBC exchange
 ABO compatibility:
 Type A receives type A or O
 type B receives type B or O
 type AB receives type AB or O
 type O receives type O
 Rh match necessary

considerationNursing
Use a blood administration set to infuse
blood within 4 hours.
 Administer only with normal saline solution.
 Keep in mind that an RBC transfusion isn’t
appropriate for anemias treatable by
nutritional or drug therapies.
leukocyte-poor RBCs
 Same as packed RBCs
 To prevent febrile reactions from leukocyte
Indications
antibodies
 To treat immunocompromised patients
 To restore RBCs to patients who have had
two or more nonhemolytic febrile reactions
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 NURS 19 Pulmonary Edema, Hemorrhage, Cardiac arrest
AY 2021- 09/16/2021
2022
Midterm Exam
Nursing ABO and Rh

CompatibilityABO and Rh
 Same as packed RBCs  ABO compatibility required
 Rh match necessary  Rh match not required
compatibility

 Use blood administration tubing.

 It may require a 40-micron filter suitable for  Use a blood administration set to infuse.

Nursing consideration
hard-spun, leukocyte-poor RBCs.  Add normal saline solution to each bag of
cryoprecipitate, as necessary, to facilitate
consideration

 Use only with normal saline solution.

transfusion.
 Keep in mind that cells expire 24 hours
after washing.  Keep in mind that cryoprecipitate must be
administered within 6 hours of thawing.
Platelets  Before administering, check lab studies to
 Same as packed RBCs confirm a deficiency of one of the specific
 To prevent febrile reactions from leukocyte clotting factors present in cryoprecipitate.
Indications

antibodies  Be aware that patients with hemophilia A or

 To treat immunocompromised patients vonVIII
Factor Willebrand’s
concentratedisease should only be
Recombinant
 To restore RBCs to patients who have had  To treat hemophilia A

Indications
two or more nonhemolytic febrile reactions  To treat von Willebrand's disease
compatibilityABO and Rh

 ABO identical when possible

 Rh-negative recipients should receive Rh
negative platelets when possible
 Administer by I.V. injection using a filter
needle or use the administration set
supplied by the manufacturer.


considerationNursing

Use a filtered component drip

administration set to infuse.
 If ordered, administer prophylactic
pretransfusion medications, such as
antihistamines or antipyretics, to reduce Albumin 5% (buffered saline)
chills, fever, and allergic reactions.  To replace volume lost because of shock
 Complete transfusion within 20 minutes or from burns, trauma, surgery, or infections
Fresh frozen plasma (FFP) Uncoagulated
Indications

 To treat hypoproteinemia (with or without

 To correct a coagulation factor deficiency edema)
 To replace a specific factor when that factor
Indications

isn't available
 To reverse Warfarin
 To treat thrombotic thrombocytopenic

considerationNursing

purpura Use the administration set supplied by the

manufacturer and set rate based on patient
compatibilityABO and Rh

 ABO compatibility required

condition and response.
 Rh match not required  Keep in mind that albumin isn’t to be used
to treat severe anemia.
 Administer cautiously in cardiac and
pulmonary disease because heart failure
may result from volume overload.

considerationNursing

Use a blood administration set.


Complete transfusion within 20 minutes or
I.
at the fastest rate the patient can tolerate.
 Monitor patient for signs and symptoms of
hypocalcemia because the citric acid in
FFP may bind to calcium.
 Remember that FFP must be infused within
Cryoprecipitate Insoluble plasma portion of FFP
 To treat factor VIII deficiency and fibrinogen
disorders
Indications
TRANSFUSION OF PACKED RED BLOOD CELLS
Preprocedure
 Confirm that the transfusion has been prescribed
 Check that patient’s blood has been typed and
cross-matched.
 Verify that patient has signed a written consent
form
 Explain procedure to patient
 Take patient’s temperature, pulse, respiration,

 To treat significant factor XIII deficiency blood pressure and assess fluid volume status
 Note if signs of increased fluid overload present
 Use hand hygiene and wear gloves
 Use appropriately sized needle for insertion in a
peripheral vein
 Use blood filter to screen out fibrin clots
 Do not vent blood container

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 NURS 19 Pulmonary Edema, Hemorrhage, Cardiac arrest
AY 2021- 09/16/2021
2022
Midterm Exam
II. Procedure  Check blood product for any unusual color or
 Obtain packed red blood cells after the IV line is clumps
started  Make sure that platelets or FFP units are given
 Double-check labels with another nurse or immediately after they are obtained
physician  Infuse each unit of FFP over 30–60 minutes per
 Confirm patient’s identification patient tolerance
 Check blood for gas bubbles and any unusual  Infuse each unit of platelets as fast as patient can
color or cloudiness tolerate to diminish platelet clumping during
 Make sure that PRBC transfusion is initiated within administration.
30 minutes  Observe patient closely throughout transfusion for
 after removal of PRBCs from blood bank any signs of adverse reaction
refrigerator.  Monitor vital signs at the end of transfusion
 For the first 15 minutes, run the transfusion slowly  Flush line with saline after transfusion
—no faster than 5 mL/min. III. Postprocedure
 If no adverse effects occur during the first 15  Obtain vital signs and auscultate breath sounds
minutes, increase the flow rate unless patient  Dispose of used materials properly
is at high risk for circulatory overload  Document procedure in patient’s medical record
 Monitor closely for 15–30 minutes to detect signs  Monitor patient for response to and effectiveness
of reaction of procedure
 Note that administration time does not exceed 4  platelet count may be ordered 1 hour after
hours because of increased risk of bacterial platelet transfusion
proliferation.  If patient is at risk for transfusion-associated
 Be alert for signs of adverse reactions circulatory overload
 Change blood tubing after every 2 units  monitor closely for 6 hours after transfusion
 decrease chance of bacterial contamination
III. Postprocedure On additional information:
 Obtain vital signs and breath sounds 1. FFP requires ABO but not Rh compatibility
 If signs of increased fluid overload present 2. Platelets are not typically crossmatched for ABO
 Diuretic compatibility.
 Dispose of used materials properly 3. Never add medications to blood or blood products.
 Document procedure in patient’s medical record
 Monitor patient for response to and effectiveness CARDIAC ARREST
of procedure.  the heart is unable to pump and circulate blood to the
 If, patient is at risk, monitor for at least 6 body’s organs and tissues
hours for signs of transfusion transfusion-  caused by a dysrhythmia
associated circulatory overload  pulseless electrical activity
 monitor for signs of delayed hemolytic
reaction ETIOLOGY
 acute MI
On additional information:  V-fib
1. Never add medications to blood or blood products
 V-tach
2. if blood is too thick to run freely, normal saline may be
 severe trauma
added to the unit
3. If blood must be warmed, use an inline blood warmer with  hypovolemia
a monitoring system.  metabolic disorders
 brain injury
TRANSFUSION OF PLATELETS OR FRESH-FROZEN  respiratory arrest
PLASMA  drowning
I. Preprocedure  drug overdose
 Confirm that the transfusion has been prescribed
 Verify that patient has signed a written consent CLINICAL MANIFESTATION
form  ineffective respiratory gasping
 Explain procedure to patient  pupils of the eyes begin dilating in less than a minute
 Take patient’s VS  seizures may occur
 Note if signs of increased fluid overload present  Pallor and cyanosis
 Use hand hygiene and wear gloves  Immediate loss of consciousness
 Use a 22-gauge or larger needle for placement in  Absence of palpable pulses and heart sounds
a large vein
II. Procedure
 Obtain platelets or fresh-frozen plasma (FFP) from NURSING MANAGEMENT
the blood bank  Determine responsiveness and notify the practitioner
 Double-check labels with another nurse or and resuscitation team.
physician  Initiate CPR.
 Monitor cardiac rhythm.

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 NURS 19 Pulmonary Edema, Hemorrhage, Cardiac arrest
AY 2021- 09/16/2021
2022
Midterm Exam
 Assist with ET intubation and mechanical ventilation.
 Follow ACLS protocols; administer medications as
ordered.
 Assist with defibrillation for ventricular fibrillation or
pulseless ventricular tachycardia.
 Administer a patent I. V. line if it is not already in place.
 Administer emergency drugs, as ordered.
 Provide client and family teaching
 Promote family coping.
 Address the possibility of organ donation with the
client's family, keeping in mind that this is a difficult time
for them.

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