Ch 29 - Resp Critical Care

The nurse has just received report on a group of clients. Which client is the nurse's first priority?

The nurse needs to immediately attend to the mechanically ventilated client with a tracheal deviation. This client is showing signs of a tension pneumothorax that could lead to hypoxemia, decreased cardiac output, and shock.

Four physiologic mechanisms that cause hypoxemia and subsequent hypoxemic respiratory failure - what are they?

1.ventilation/perfusion (V/Q) mismatch. 2.Alveolar hypoventilation 3.Diffusion limitation 4.Shunting/intrapulmonary shunt

Hypercapnic Acute Respiratory Failure: Etiology and Pathophysiology

4 total: Airway and Alveolar Abnormalities CNS Abnormalities Chest Wall Abnormalities Neuromuscular conditions

Which client will the nurse consider to be at the greatest risk for developing acute respiratory distress syndrome (ARDS)?

A 74 year old who aspirates a tube feeding ARDS is a type of acute respiratory failure with hypoxemia that persists even when 100% oxygen is given, decreased pulmonary compliance, dyspnea, bilateral pulmonary edema, and dense pulmonary infiltrates on x-ray (ground-glass appearance). It often occurs after an acute lung injury such as could result from aspiration of acidic gastric contents.

SHUNT

A shunt occurs when blood returns to the left side of the heart without participating in gas exchange in the lungs first. A shunt can be thought of as an extreme V/Q mismatch two types of shunts: 1) anatomic. An anatomic shunt occurs when blood passes through an anatomic channel in the heart (eg, a ventricular septal defect) and bypasses the lungs. 2) intrapulmonary.An intrapulmonary shunt occurs when blood flows through the pulmonary capillaries without participating in gas exchange.

Alveolar Hypoventilation

Alveolar hypoventilation is a generalized decrease in ventilation that results in increased PaCO2 and a consequent decrease in PaO2. It is a common cause of respiratory failure. Alveolar hypoventilation may be the result of: - Restrictive lung diseases - Central nervous system (CNS) diseases - Chest wall dysfunction - Acute asthma - Neuromuscular diseases

Which action will the nurse take first while caring for a client being mechanically ventilation when the high-pressure alarm sounds?

Auscultating the client's breath sounds The nurse will first listen to the client's breath sounds. Assessment always begins with the client. A typical reason for the high-pressure alarm to sound is obstruction of airflow through the ventilator circuit, usually indicating the need for suctioning. Other reasons for the high-pressure alarm to be triggered included biting the endotracheal tube or tension pneumothorax.The nurse is concerned with the assessment of the client first, not with the ventilator or ventilator settings and does not turn off the alarms before assessing the client. Although an excessively high tidal volume could contribute to the high-pressure alarm sounding, this is not the nurse's first concern. The professional nurse possesses the skill to assess ventilator alarms; waiting for the respiratory therapist delays intervention.

Which assessment finding on a client who is being mechanically ventilated with positive end-expiratory pressure indicates to the nurse a possible left-sided tension pneumothorax?

Chest is asymmetrical and trachea deviates toward the right side.Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation toward the unaffected side, dyspnea, absent breath sounds, jugular venous distention, cyanosis, and hyperresonance to percussion over the affected area. If not promptly detected and treated, tension pneumothorax is quickly fatal.Flail chest has paradoxical chest movement with a "sucking inward" of the loose chest area during inspiration and "puffing out" of the same area during expiration. Open pneumothorax presents with decreased breath sounds, hyperresonance, and poor respiratory excursion on the affected side. Pulmonary contusion presents with hemoptysis, dullness to percussion, and crackles or wheezes.

Mr. Oliver, a 74-year-old male, is 72 hours post-emergency surgery for a hip fracture. What are Mr. Oliver's risks factors for pulmonary embolism (PE) development?

Risk factors for venous thromboembolism (VTE) leading to PE include: - prolonged immobility, surgery, advancing age, trauma. (others: obesity, central venous catheters, conditions that increase blood clotting, history of thromboembolism, and smoking.)

Diffuse Limitation

Diffusion limitation occurs when gas exchange across the alveolar-capillary membrane is compromised by a process that thickens, damages, or destroys the alveolar membrane or affects blood flow through the pulmonary capillaries. Diffusion limitation is worsened by conditions affecting the pulmonary vascular bed, such as: - Severe COPD - Recurrent pulmonary emboli Some disease states cause the alveolar-capillary membrane to become thicker (fibrotic), which slows gas transport. These include: - Pulmonary fibrosis - Interstitial lung disease - Acute respiratory distress syndrome

Which action will the nurse instruct a client with an endotracheal tube to perform during the time the tube is being removed?

EXHALE

Suctioning a ventilated patient

Each suction pass should be limited to 10-15 seconds with hyperoxygenation before and after to prevent hypoxemia.

Which assessment findings in a postoperative client suggest to the nurse the possibility of a pulmonary embolism (PE) and pulmonary infarction?

Hemoptysis and shortness of breath Symptoms of a PE with infarction include profound shortness of breath and bloody sputum (hemoptysis) from poor gas exchange and hypoxic damage to lung tissues. Paradoxical chest movements are associated with a flail chest, not PE. Tracheal deviation is associated with a pneumothorax. Audible wheezing on inhalation and exhalation is a partial obstruction of the tracheobronchial tree.

Hypoxia, Hypercapnia, and Acidosis

Hypoxia is a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis; Hypercapnia (hypercarbia) is when you have high levels of carbon dioxide in your blood.

For which problems will the nurse specifically assess when the low-pressure alarm of a client's mechanical ventilator sounds? (Select all that apply.)

Leak in the tubing, patient not breathing, Cuff leak in the endotracheal or tracheostomy tube.

Which action is a priority for the nurse to prevent harm for a client with a pulmonary embolism who is receiving a continuous heparin infusion?

Monitor platelets! Daily platelet counts are a safety priority in assessing for heparin-induced thrombocytopenia (HIT), a potential side effect of heparin.

ALI leading to ARDS

SEPSIS is the most common. As a result of sepsis, pancreatitis, trauma, other conditions, inflamatory mediators spread to the lungs causing damage - another instance of a CYTOKINE STORM (indirect) Direct lung injury impairs surfactant production and an excess is diluted. Leads to atelectasis, decreased lung compliance, and SHUNTING (movement of blood in the lungs without gas exchange and oxygenation.

ventilation/perfusion (V/Q) mismatch.

Normally, alveolar ventilation approximates pulmonary capillary perfusion, facilitating optimal gas exchange and creating a V/Q ratio of 4:5. A mismatch occurs when ventilation exceeds perfusion or perfusion exceeds ventilation. It is a common cause of hypoxemia. causes: **Increased respiratory secretions present in the airways (eg, COPD) or alveoli (eg, pneumonia) **Alveolar collapse (atelectasis) **Lung collapse (pneumothorax) **Pulmonary embolus (affects the perfusion portion of the V/Q relationship by limiting blood flow distal to the occlusion)

ARF: Interventions, Take Action!

O2 therapy is always appropriate. (to help keep the paO2 level above 60mm Hg) *if levels do not improve mechanical ventilation may be needed Drugs given systematically (via nebulizer or MDI) prescribed maybe to dilate the bronchioles in an effort to decrease inflammation which would promote more gas exchange *corticosteroids, analgesics (if in pain), Neuro Blockade drugs (if mechanical ventilation is involved) Find an upright, comfortable position to decrease anxiety caused by dyspnea. Assist patient with relaxation, guided imagery, and diversion. *be mindful of energy-conserving measures, minimal self-care or unnecessary procedures. . Encourage deep slow breathing

Which clients will the nurse monitor most closely for respiratory failure? (Select all that apply.)

Pressure on the brainstem may depress respiratory function. Acute pancreatitis is a risk factor for acute respiratory distress syndrome; abdominal distention also ensues, which can limit respiratory excursion. Clients with cervical and high thoracic spinal cord injuries are at high risk for respiratory failure because spinal nerves that affect the diaphragm and inter-costal muscles are affected. Opioids used in client-controlled analgesia are respiratory depressants and can depress the breathing center in the brainstem causing respiratory failure. Pneumonia, whether bacterial or viral, can result in oxygenation respiratory failure, especially in an older client who often has respiratory muscle weakness.Cocaine is a stimulant, which would not cause respiratory failure unless a stroke ensued.

While the family is visiting, Mr. Oliver begins experiencing sudden respiratory difficulties. The family calls the nurse immediately who notes distended neck veins, cyanosis, and BP 80/48. MrOliver states "I am going to pass out!" What should the nurse do first?

RAPID RESPONSE*** rationale: The patient's condition is deteriorating quickly, and lifesaving measures and treatment are needed immediately. The symptom cluster of distended neck veins, syncope, cyanosis, and hypotension is indicative of PE. If this cluster is present, the Rapid Response Team should be notified

What is the nurse's best first action when assessing a client who was intubated a few minutes ago and finds the end-tidal carbon dioxide level is 0 and the SpO2 is 38%?

Removing the endotracheal tube and ventilating the client with a bag-valve-mask A reading of 0 for the end-tidal carbon dioxide and the very low SpO2 level indicate that the endotracheal tube is not in the airway. Immediate action is needed. While it is present in the client's throat, its presence is preventing air from reaching the airways. Removing the tube and ventilating the client with a bag-valve-mask device is critical to saving the client's life. The nurse will perform these actions while having another health care worker call the Rapid Response Team.If the client's SpO2 was in the normal range, obtaining a different monitor and rechecking end-tidal carbon dioxide level would be a good action. However, the low oxygen saturation level indicates there is no time for rechecking the carbon dioxide level.

There are four main reasons for mechanical ventilation:

Respiratory failure Apnea Hypoxia Respiratory muscle fatigue

Which nursing intervention supports prevention of ventilator-associated pneumonia (VAP)?

Suctioning the patient. Keeping a patent airway is a key intervention to the prevention of VAP. Suctioning the patient is a primary intervention to maintain airway clearance.

What is the best first action when the nurse assesses that the respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures but the ventilator tubing is clear?

Suctioning the tracheostomy tube

Which ventilator mode does the nurse expect will be set for a client with a tracheostomy who is beginning to take spontaneous breaths at his own rate and tidal volume between set ventilator breaths?

Synchronized intermittent ventilation (SIMV) Synchronized intermittent mandatory ventilation (SIMV) is a ventilation mode in which volume and ventilatory rate are preset. It allows spontaneous breathing at the patient's own rate and tidal volume between the ventilator breaths to coordinate breathing between the ventilator and the client.BiPAP and CPAP are not used for clients who have an endotracheal tube. With assist-control ventilation, the preset tidal volume continues even when the client's own respiratory rate increases, which could lead to over-ventilation.

When caring for a group of clients at risk for or diagnosed with pulmonary embolism, the nurse calls the Rapid Response Team (RRT) for intervention for which client?

The RRT needs to quickly assess the client with a diagnosed pulmonary embolism who is showing signs of possible pulmonary infarction or bleeding abnormality secondary to heparin. Tachycardia, along with bloody sputum (hemoptysis), may be a symptom of hypoxemia or hemorrhagic shock, which requires immediate intervention.The client with deep vein thrombosis requires ongoing monitoring and is receiving appropriate treatment. Calf pain is expected in this situation. The client with a right pneumothorax requires ongoing monitoring but demonstrates adequate pulse oximetry of 94%. The client who was extubated 3 days ago requires ongoing nursing assessment, but does not have evidence of acute deterioration or severe complications.

What is the primary emphasis for the nurse who is providing care to a client with acute respiratory distress syndrome (ARDS) currently in the exudative management stage of the disorder?

The exudative phase includes early changes of dyspnea and tachypnea resulting from the alveoli becoming fluid filled and from pulmonary shunting and atelectasis.

When should Mr. Oliver be weaned off of mechanical ventilation? What interprofessional collaboration is warranted to assist with weaning from mechanical ventilation?

When he is able to ventilate independently of the ventilator, when can breathe independently during tracheostomy care/suction, or when he does not require a set volume on the ventilator and can breathe the appropriate volume. Weaning can take place gradually by slowly decreasing the ventilator's preset rate and volume, allowing the patient to take over. Monitoring of oxygenation and vital signs is imperative throughout the weaning process. Collaboration between respiratory therapy, nursing, and the provider -all necessary collaborations

Synchronized intermittent mandatory ventilation (SIMV)

allows spontaneous breathing at the patient's rate and volume SIMV mode has a set rate and volume; however, it allows spontaneous breathing at the patient's rate and volume.

ACUTE RESP FAILURE

an inability of the respiratory system to provide oxygenation and/or remove carbon dioxide from the body -ARF is classified as oxygenation failure resulting in hypoxemia without a rise in CO2 levels or ventilation failure resulting in hypercapnia or hypoxemia

ARF: Assessment, Recognize Cues

symptoms are related to systemic effects of hypoxia, hypercapnia, and acidosis. **assess for Dyspnea, perceived difficulty breathing (hallmark sign of ARF) Monitor Pulse Ox, but more importantly - ETco2 (end-tidal CO2) If this is increased, pt could be close to respiratory failure Get ABGs Others to watch for restlessness, irritability/agitation, confusion, tachycardia (related to hypoxia) decreased LOC, headache, drowsiness, lethargic, seizures (related to hypercapnic failure) effects of acidosis: LOC down, drowsy, confused, hypotension bradycardia, weak peripheral pulses.