BACHELOR OF SCIENCE IN NURSING:

NCMB 418 - CARE OF THE CLIENT WITH LIFE-

THREATENING CONDITIONS, ACUTELY ILL / MULTI-
ORGAN PROBLEMS, HIGH ACUITY AND
EMERGENCY SITUATION (ACUTE AND CHRONIC)
COURSE MODULE COURSE UNIT WEEK
1 5 5

Nursing Care of Clients with Altered Ventilatory Function 2

ü Read course and unit objectives

ü Read study guide prior to class attendance
ü Read required learning resources; refer to unit
terminologies for jargons
ü Proactively participate in classroom discussions
ü Participate in weekly discussion board (Canvas)
ü Answer and submit course unit tasks on time

At the end of this unit, the students are expected to:

Cognitive:
1. Identify diagnostics and presenting signs and symptoms of clients with PE, ARDS and
Acute Respiratory Failure and the nurses’ roles.
2. Discuss and apply emergency nursing management to the client experiencing with PE,
ARDS and Acute Respiratory Failure.
Affective:
1. Listen attentively during class discussions
2. Demonstrate tact and respect when challenging other people’s opinions and ideas
3. Accept comments and reactions of classmates on one’s opinions openly and graciously.

Psychomotor:
1. Participate actively during class discussions
2. Confidently express personal opinion and thoughts in front of the class

1. Schumacher, L., & Chernecky, C. C. (2010). Saunders nursing survival guide: critical care &
emergency nursing. St. Louis, Mo.: Elsevier Saunders. Crouch, R., Charters, A., Dawood,
M., &

2. Bennett, P. (2017). Oxford handbook of emergency nursing. Oxford, United Kingdom:

Oxford University Press.

3. Baid, H., Creed, F., & Hargreaves, J. (2016). Oxford handbook of critical care nursing.
Oxford, United Kingdom: Oxford University Press.

Respiratory emergencies may range from “shortness of breath,” or dyspnea, to complete respiratory
arrest, or apnea. These conditions can result from a large number of causes, but most typically they
involve the lungs.

Pulmonary Embolism (Pulmonary Embolus)

This is a thrombotic or non-thrombotic embolus that lodges in the
pulmonary artery system. It can damage part of the lung due to
restricted blood flow, decrease oxygen levels in the blood, and
affect other organs as well. Large or multiple blood clots can be
fatal. The blockage can be life-threatening
Risk Factors
1. Injury or damage leading to blood clot formation
2. Inactivity for prolonged periods
3. Medical conditions or treatment procedures that cause blood to
clot easily (e.g. surgery, DVT, etc.)

Clinical Manifestations
1. Virchow’s triad: venous stasis, coagulation problems, vessel wall injury
2. Chest pain
3. Tachycardia, tachypnea
4. Anxiety, restlessness
5. Clammy or bluish skin

Diagnostics
1. CXR – to rule out other disorders with the same presenting manifestations
2. ABG analysis
3. D-dimer test – detects clot fragments from clot lysis
4. ECG
5. V/Q scan / Pulmonary angiography / spiral CT scan

Treatment:
1. Oxygenation (ET and mechanical ventilation)
2. Heparin therapy
3. Surgery – umbrella filter, pulmonary embolectomy
4. Prevention of development of DVT

Acute Respiratory Distress Syndrome (ARDS)

This is a syndrome with inflammation and increased permeability of the alveolocapillary membrane
that occurs as a result of an injury to the lungs. This condition is fatal when left undiagnosed or
treated for 48hrs.
Risk Factors
1. Critically ill patients
2. Age (60y/o and above)
3. Malignancy (cancers)
4. Cigarette smoking, COPD

Causes: Aspiration pneumonia or systemic illness (e.g. burns, sepsis, drug overdose)

Clinical Manifestations:
Ø Signs and symptoms are often exhibited within 24-48 hours after initial insult to the lungs
1. Restlessness,
2. Hyperventilation, tachycardia, SOB
3. Hypoxemia
4. Severe: hypotension, cyanosis, decreased UO

Diagnostic: Chest x-ray = reveals “white out” lungs

Treatment
Ø Goal: improving and maintaining oxygenation and prevent respiratory and metabolic
complications
1. Fluid management to maintain tissue perfusion
2. Corticosteroid therapy to decrease permeability of the alveolocapillary
membrane
3. Nutrition – enteral feeding
4. Supplemental oxygen: Mechanical Ventilation – a form of artificial ventilation
that takes over all or part of the work performed by the respiratory muscles and
organs
ü Modes, Settings, Alarms

Acute Respiratory Failure

= is a change in respiratory gas exchange such that normal cellular function is jeopardized. ARF is
defined as’pO2 of less than 50 mmHg and a pCO2 of greater than 50 mmHg and a pH of less than
7.30. Actual pO2 and pCO2 that define ARF vary, depending on the different factors that influence
patient’s normal arterial blood gasses. For example, if pO2 level of a 75 – year old man is 55 mmHg,
ARF will not be diagnosed until the pO2 have decreased to 50 mmHg or less.

This is a condition in which the blood doesn't have enough oxygen or has too much carbon dioxide,
sometimes one can have both problems.

Respiratory failure is divided into type I and type II.

Ø Type I respiratory failure involves low oxygen, and normal or low carbon dioxide levels.
Ø Type II respiratory failure involves low oxygen, with high carbon dioxide.

Table 1. Types of Acute Respiratory Failure

Type I (Hypoxemic) Type II (Hypercapnic)
Lung failure, respiratory insufficiency Pump failure, ventilatory failure
Failure of lungs and heart to provide adequate Failure of lungs to eliminate adequate CO2
oxygen
PaCO2 < 60mmHg with normal or decreased PaCO2 > 50mmHg
PaO2
Alveolar hypoventilation Increase dead space
Associated with acute diseases of the lungs Drug overdose, neuromuscular disease, chest
(pulmonary edema, ARDS, pneumonia) wall deformity, COPD

Causes of Acute respiratory failure in adults

Ø Impaired ventilation
o Spinal cord injury above C5
o Phrenic nerve damage
o Neuromuscular blockade
o Guillain barre syndrome
 o CNS depression
o Respiratory muscle fatigue
Ø Impaired gas exchange
o Pulmonary edema
o ARDS
o Aspiration pneumonia
Ø Airway obstruction
o Aspiration of foreign body
o Thoracic tumors
o Asthma
o Bronchitis
o Pneumonia
Ø Ventilation – perfusion abnormalities
o Pulmonary embolism
o Emphysema
o
Chronic obstructive pulmonary disease
COPD is an umbrella term that is used to describe various diseases (e.g. chronic bronchitis,
emphysema, chronic asthma). It is a slowly progressive and irreversible disease, although some
patients may show a degree of reversibility with bronchodilator treatment. It usually occurs in
people over 50y of age, and smoking is a major factor in the development of the disease.

Assessment of the breathless patient with COPD

Useful information about the severity of the disease can be gained from the patient’s history. In
mild disease, a ‘smoker’s cough’ is the only abnormal sign. In moderate disease, there is
breathlessness and/ or wheeze on moderate exertion, cough, and generalized reduction in breath
sounds. In severe disease, there is breathlessness at rest, cyanosis, prominent wheeze and/ or
cough, and lung overinflation.
Also consider and record the following:
• current treatment— inhalers, nebulizers, antibiotics, steroids, O2, and theophyllines;
• exercise tolerance;
• previous admissions, especially intensive care or treatment with NIV;
• the reason for ED attendance— it is important to identify whether the exacerbation has
been accompanied by an i in the amount or type of sputum produced. A recent fall or chest
injury may be the cause of the symptoms.

In the ED, assess for the following:

• cough;
• cyanosis;
• sputum— color and amount;
• wheeze;
• tachypnoea;
 • accessory muscle usage;
• lip pursing on expiration;
• chest expansion (which is often poor);
• fever;
• dehydration;
• confusion or reduction in conscious level;
• pain
Consider whether the patient is septic, and treat any signs of sepsis, severe sepsis, or septic shock
immediately.

Investigations
• Continuous monitoring— HR, RR, and SpO2.
• CXR.
• ECG.
• ABG analysis as soon as possible.
• FBC, U&E, and theophylline level (if the patient is taking theophylline).
• Sputum for C&S if purulent.
• Blood cultures if the patient is pyrexial.

Nursing interventions
• Reassurance.
• Nurse the patient in an upright position.
• O2 therapy to keep saturations in the range of 88– 92%
• Nebulizers (may need to be continuous).
• Steroids.
• IV theophylline (for patients who do not respond to nebulizers).
• Assessment for NIV.
• Mouth care.
• IV fluids if the patient is dehydrated.
• Analgesia.
• AVPU and GCS scores.

Non- invasive ventilation

This is increasingly used in ED resuscitation rooms for the treatment of patients with COPD or
heart failure. Evidence suggests that using NIV in patients with COPD reduces mortality and the
need for invasive ventilation. NIV should be considered in patients who meet the following criteria.
• respiratory acidosis (pH <7.35, PaCO2 >6kPa) that persists despite maximal medical
therapy;
• not moribund, GCS score >8
• able to protect the airway;
• cooperative and conscious;
• few co- morbidities;
 • hemodynamically stable;
• no excess respiratory secretions;
• potential for recovery to a quality of life acceptable to the patient.
Ideally, patients should have an anesthetic assessment prior to the commencement of NIV, in
order to determine their suitability and outline what the ceiling treatment should be. A ‘do not
attempt resuscitation’ (DNAR) order may be completed at this time if the patient is not suitable for
invasive ventilation.

Intensive care
Patients with exacerbations of COPD should not be automatically excluded from invasive
ventilation if all other treatments are failing. The assessing anesthetist will consider the following:
• quality of life, ideally involving the family in the discussion;
• O2 requirements when stable;
• co- morbidities;
• forced expiratory volume in 1s (FEV1);
• body mass index (BMI).

Hospital- at- home schemes

Increase numbers of schemes are available to manage patients with exacerbations of COPD in
their own home, thereby either avoiding admission altogether or reducing the length of hospital
stay. Patients may know of a ‘COPD community nurse’ who will be able to give useful clinical
information about the patient and their treatments. If there is a local community scheme, it would
be worth identifying how the ED can become involved in identifying suitable patients.

Pneumonia
Infection of the substance of the lungs is most commonly caused by bacteria. The terms
‘pneumonia’ and ‘chest infection’ are often used interchangeably. It is important to use the term
‘pneumonia’ with caution when discussing the illness with patients and their relatives, as this term
causes more alarm than ‘chest infection’.
• Community- acquired pneumonia (CAP)
o is the name given to a chest infection that was contracted, whilst the patient was
at home.
o commonest causative agent of CAP is Streptococcus pneumoniae, which
accounts for 1/ 3 of infections.
• Hospital- acquired pneumonia
o contracted by patients who are already vulnerable to infection (e.g.
immunocompromised, critically ill, intubated, or ventilated)
o usually have a different bacterial origin and tend to be more resistant to standard
antibiotic therapy.
o patients may present to the ED with signs of a chest infection after a recent
admission
Signs and symptoms
 • Breathlessness.
• Cough.
• Purulent sputum.
• Fever, shivers, aches, and pains.
• Pleurisy.
• Haemoptysis.
• Hypoxia.
• Signs of consolidation either on CXR or on auscultation and percussion of the chest.

Investigations
• Sputum for C&S.
• CXR.
• ABG if SpO2 is <93% on air.
• FBC, U&E, CRP, and LFTs.

Nursing interventions for the patient with pneumonia:

Scoring the severity of pneumonia
In patients with pneumonia, clinical judgement should be used together with the validated CURB-
65 score to assess severity, risk of death, and risk of ICU admission. Scoring in this way can also
guide subsequent treatment and the decision about the need for hospital admission.
One point is given for each of the following:
• Confusion;
• Urea >7mmol/ L;
• Respiratory rate ≥30 breaths/ min;
• Blood pressure low (systolic <90mmHg or diastolic ≤60mmHg);
• Age ≥65y.
Patients with relatively mild symptoms (CURB- 65 score of 0 or 1) with good social support and no
other significant health problems can usually be discharged home.
Patients with more severe symptoms (CURB- 65 score of 2) are at higher risk and should be
admitted.
Patients with a CURB- 65 score of ≥3 are at greatest risk. A score of 3 is associated with a 17%
risk of death.

Admission
Patients who require hospital admission will need the following interventions.
• Nurse in an upright position.
• Give supplemental O2 to maintain saturations at >93% (careful administration is required in
patients with COPD)
• Administer IV fluids if the patient is dehydrated.
• Give IV antibiotics.
• Give analgesia.
• Give an antipyretic.

Sepsis
The elderly are particularly vulnerable to developing sepsis from pneumonia, and general
assessment of the breathless patient should identify any signs of sepsis

Simple and spontaneous pneumothorax

A pneumothorax is the collection of air in the pleural space that surrounds the lungs (E see Fig. 7.5).
A tear in the lung tissue causes inspired air to pass though it into the pleural space. It can occur
following trauma or as a consequence of lung disease (e.g. COPD, asthma, cystic fibrosis, bullous
lung disease), or it can occur spontaneously (usually in tall, thin young men).

Spontaneous pneumothorax
The phenomenon of spontaneous pneumothorax (SP) in tall, thin young men is interesting. The ♂:♀
ratio of SP is 6:1. It is thought that tall, thin men are more prone to the rupture of bullae (blisters on
the pleura that arise from a rupture in the alveolar wall) in the apex, because they are subject to
more distending pressure as the thorax is longer. There is also a significant relationship between
smoking and the development of SP. This should be emphasized to patients in an attempt to
discourage them from smoking. The lifetime risk of SP in ♂ smokers is 12%, compared with 0.1% in
non- smokers. The risk of recurrence in the first 4y can be as high as 54%, and smoking is a
significant risk factor for this.
Signs and symptoms
• Breathlessness.
• Unilateral pleuritic chest pain.
• Cough.
• R educed or absent breath sounds on the affected side.
• Hyper- resonance on percussion of the affected side.
• decrease chest wall movement on the affected side.

Nursing assessment
• PMH.
• Previous SP— the patient may already have had an SP and know their symptoms well.
• Lung disease— patients with underlying lung disease are more likely to need admission for
observation, even with a small pneumothorax or one that has been successfully re- inflated
with needle aspiration.
• Pulse.
• RR.
• BP.
• SpO2.
• Temperature.
• Pain score.
• AVPU and GCS scores.

Investigation
• CXR — relatively asymptomatic patients can often be sent directly to X- ray after a brief
assessment. Those with abnormal observations will need further assessment or intervention before
X- ray.

Nursing interventions
• Reassurance— chest pain and breathlessness can be very frightening. If the patient has had a
previous SP, they may be anxious about needle aspiration or chest drain insertion.
• Nurse the patient upright.
• O2— to maintain saturations at >93%.
• Analgesia.
Management
• Patients who are not breathless, have a small SP and have no underlying lung disease can be
discharged home, with clear written and verbal advice to return to the ED if breathlessness occurs.
Early follow- up should be arranged.
• Patients with underlying lung disease require observation and highflow O2 (this improves the rate
of re- inflation by 4- fold), if not contraindicated in COPD. These patients are likely to require more
active intervention with needle aspiration or a chest drain, even if they have a small SP.
• Symptomatic patients with small SPs will require needle aspiration. If this is unsuccessful, a chest
drain is usually indicated
• For patients with large SPs and no underlying lung disease, needle aspiration is still the treatment
of choice. However, patients with underlying lung disease (particularly those >50y of age) usually
need a chest drain.

Classification of SP by size:
• Small SP has a visible rim of <2cm between the lung edge and chest wall.
• Large SP has a visible rim of ≥2cm between the lung edge and chest wall.

Respiratory failure – a syndrome in which the respiratory system fails in one or both of its gas
exchange functions: oxygenation and carbon

pCO2 – partial pressure of carbon dioxide usually from the arterial blood. This is measuring about
35 – 45 mmHg

pO2 – partial pressure of oxygen usually from the arterial blood. This is measuring about 80 – 100
mmHg

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Lentz, S., et. al. (2020, July 4). Initial emergency department mechanical ventilation strategies for
COVID-19 hypoxemic respiratory failure and ARDS, The American Journal of Emergency
Medicine. Retrieved from
https://www.sciencedirect.com/science/article/pii/S0735675720305866
Read and summarize the research article by Lentz, et.al found in ScienceDirect.com. Explain its
objectives, methods, and results, then reflect on its implication(s) in today’s nursing practice.

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