ARDS
B. Hypercapnea (hypercarbia)
A client with ARDS was anxious, is now less responsive & difficulty to arouse. This is likely due to: A. Hypoxia B. Hypercapnea (hypercarbia) C. Alkalosis D. Hyperkalemia
respiratory acidosis
A drop in blood pH due to hypoventilation (too little breathing) and a resulting accumulation of Co2.
Answer: C Rationale: Patient C has an actual circulation problem and requires q 5 min VS while titrating vasoactive drips. Also, need to assess stability due to mechanical ventilation. Patient D would be next with a "potential" perfusion/gas exchange problem and could be experiencing a pulmonary embolism.
A nurse is scheduled to take care of these four patients in a trauma step-down unit. Which one should the nurse assess first based on this information from report? A. A 19-year-old, 2 days post motor vehicle crash, stable on CPAP, with rib fractures, complaining of chest pain 7/10. B. A 40-year-old, 1 day post repair of ruptured spleen following MVA. He is A&OX3, but slightly confused about how he got to the unit C. A 21-year-old, comatose following a fall and flail chest. Receiving mechanical ventilation and titrating vasoactive drips for low blood pressure D. A 60-year-old with a left femur fracture following a farming accident who is experiencing new onset of slight shortness of
MODS (multiple organ dysfunction syndrome)
ARDS can lead to ___ if not corrected
Tachypnea Dyspnea Retractions Hypoxia Tachycardia Decreased pulmonary compliance ABG's: Decreased PO2 and increased dyspnea, patients do not get better
ARDS: Signs and Symptoms
Answer: D Rationale: The patient experiencing hypoxemia will show restlessness and anxiety first due to decreased oxygen flow to the brain. Cyanosis occurs later. Clubbing is a sign of long term hypoxemia. Somnolence may indicate increased PaCO2.
An early sign of hypoxemia is A. Clubbing of the fingernails B. Cyanosis C. Somnolence D. Restlessness and anxiety
respiratory alkalosis
Arise in blood pH due to hyperventilation (excessive breathing) and a resulting decrease in CO2.
blood pressure
As you increase the peep ___ goes down
-Trauma -Pulmonary infection and/or aspiration, -Prolonged cardiopulmonary bypass, -Shock, -Fat emboli -Sepsis.
Causes of ARDS
alarm
If a patient has a leak in their ET tube, the ventilator will do what?
Respiratory alkalosis with hypoxemia
Interpret the following blood gas result: pH = 7.49, PaO2 = 55, PaCO2 = 29, HCO3- = 25.
System/air leak? * If you hear a sound like a duck quacking - there is a leak "gwak" - find it, fix it
Low pressure vent alarms due to?
Barotrauma (such as pneumothorax)
PEEP is increased from 5 to 10 for a patient with ARDS. What is a major pulmonary complication the nurse should assess for related to this change?
ARDS (acute respiratory distress syndrome)
Severe form of ARF - Non-cardiac pulmonary edema with refractory hypoxemia (despite hi flow O2)
True- (example- can get covid pnuemonia)
T/F Covid patients can get co infections
True
T/F Non rebreather should never be hooked up to humidity.
Check ventilator tubing for a leak in the system.
The nurse is caring for a client diagnosed with acute respiratory distress syndrome on mechanical ventilation. As the nurse enters the client's room, the low-pressure alarm is heard. What is the nurse's best action? Assess for condensation in the ventilator tubing. Suction any secretions using closed technique. Check ventilator tubing for a leak in the system. Observe for any kinks in the ventilator tubing.
Provide sedation. *sedation is used to control agitation and anxiety which increases the work of breathing and oxygen consumption.
The nurse is caring for a ventilated patient with respiratory failure who is restless and anxious. The nurse notes that the pulse oximetry saturation is decreasing as the patient becomes more agitated. What action should the nurse take? -Increase the FiO2 on the ventilator. -Suction the lungs. -Provide sedation. -Reposition the patient onto the side.
Liver function tests Renal function test
The nurse is concerned that a client diagnosed with acute respiratory distress syndrome might develop multi-organ dysfunction. Which lab results should the nurse assess? Select all that apply. Liver function tests White blood cell count Complete blood cell count Potassium level Renal function test
-Bilateral infiltrates *During early stages of ARDS, serial CXRs are used to identify bilateral infiltrates which are the hallmark of the disease process
The nurse is reviewing the chest x-ray report of a ventilated patient requiring an FiO2 of 70%. Which finding is most concerning? -Atelectasis -Bilateral infiltrates -5% pneumothorax -Endotracheal tube 4 cm above the carina
-"This medication is likely to cause an elevation in my potassium level; therefore, I will need to restrict my intake of foods high in potassium such as leafy greens and bananas."
The nurse provided teaching regarding administration of IV push methylprednisolone for a patient with ARDS. Which of the following statements made by the patient indicates further teaching is required? -"This medication will help to decrease inflammation in my lungs." -"This medication is likely to cause my blood sugar to increase and I may need to take insulin while receiving it." -"This medication is likely to cause an elevation in my potassium level; therefore, I will need to restrict my intake of foods high in potassium such as leafy greens and bananas." -"This medication will make me at greater risk for infection."
3. Explain all care activities
The nurse should implement which of the following interventions for a ventilator? 1. Spread out activities 2. Maintain HOB less than 30 degrees 3. Explain all care activities 4. Oral care once a day
Answer: A Rationale: The pulmonary edema is non-cardiogenic, caused by the leak of plasma out of the vascular space and into the alveoli and interstitial spaces of the lungs.
The pulmonary edema associated with ARDS is caused by: A. Increased permeability of the ACM (alveolar-capillary membrane) B. Right ventricular failure with pulmonary hypertension C. Left ventricular failure due to poor oxygenation D. Fluid overload related to resuscitation in the
Barotrauma/Pneumothorax S/S?: Pneumomediastinum Interventions: Make sure volume of each ventilator breath is small and rate is higher. VAP (Ventilator Associated Pneumonia) - EBP Ch 27 &VAP bundle S/S?: starts after 48 hours after pt has been on vent (if prior to 48 hours patient had before they were intubated) Interventions: mouth care q 2 hours; bush teeth with chlorohexidine every 12 hours; HOB up or greater than 30 degrees; given PPI (decrease acidity) Cardiovascular and/or MODS Increased pressure in chest decreases venous return and ventricular filling. Decreases CO. Can cause hypoperfusion of liver and kidneys d/t shock. S/S: Interventions: monitor closely hemodynamically and watch their labs GI S/S: Stress ulcers, constipation, gastric distension
Ventilator complications
3) Alveolar spaces are filled with fluid
WHICH OF THE FOLLOWING BEST DESCRIBES WHAT HAPPENS TO THE ALVEOLI IN ARDS? 1) Alveoli are over expanded 2) Alveoli increase perfusion 3) Alveolar spaces are filled with fluid 4) Alveoli improve gaseous exchange
O2 sat > 90% and PaO2 >60 mmHg
What are the expected outcomes (goal) of mechanical ventilation for a patient with ARDS?
Heparin
What is the treatment for DIC
tidal volume
amount of air inhaled or exhaled with each breath under resting conditions
monoclonal antibodies
artificially produced antibodies used to enhance a patient's immune response to certain malignancies
hemothorax
blood in the pleural cavity
Answer: C Rationale: A patient who is tachypneic for an extended period of time, will blow off quite a bit of CO2 with a resultant respiratory alkalosis.
A patient who is tachypneic for an extended period of time will demonstrate which of the following arterial blood gas results? A. Respiratory alkalosis with hypercapnia B. Respiratory acidosis will a rising pH C. Respiratory alkalosis with hypocapnia D. No changes in the results due to metabolic compensation
Initially: -Hypoxemia/tachypnea/respiratory alkalosis/dyspnea (early) -Anxiety -Tachycardia -Noncardiogenic pulmonary edema -Adventitious breath sounds As Condition Worsens: -Refractory hypoxemia (worsening) -Hypercarbia/acidosis -Increasing lethargy -Accessory muscle use and retractions -Cyanosis -Peak pressures begin to rise (if on ventilator)
Clinical manifestations of ARDS
Respiratory alkalosis *due to hyperventilation
During the early stages of acute respiratory distress syndrome (ARDS), the nurse should monitor for which arterial blood gas change? -Respiratory acidosis -Respiratory alkalosis -Metabolic acidosis -Metabolic alkalosis
Monitor for tachypnea *When providing care to a client who is diagnosed with ARDS, the nurse should monitor vital signs closely. Symptoms of ARDS include an increased respiratory rate, or tachypnea, so the client's breathing must be monitored. The hypoxemia associated with ARDS causes tachycardia, not bradycardia. Additionally, the nurse should monitor the client's blood pressure, as hypotension is anticipated due to the increased intrathoracic pressure and decreased venous return associated with positive end-expiratory pressure (PEEP).
For the patient diagnosed with ARDS, which is the priority nursing assessment? -Monitor for bradycardia -Monitor for tachypnea
***Draw an imaginary line in the middle of the screen. What is above the line indicates what the patient is doing. Below the line are the vent settings that are ordered and the respiratory therapist dials in.
On a ventilator, what is above the line is ___, below the line is ___.
Bleb
Small portion of the lung. Can blow and turn into a tension pneumothorax.
Respiratory alkalosis Rales on auscultation
The nurse anticipates which signs during the exudative phase of acute respiratory distress syndrome? Select all that apply. Respiratory acidosis Respiratory alkalosis Decreased cardiac output Bradycardia Rales on auscultation
1. Tachypnea 2. Tachycardia 3. Labored breathing 4. O2 saturation dropping 5. Any other signs of increasing respiratory distress
The nurse is assessing a patient on a ventilator who started a "weaning trial" 30 minutes ago. Provide three (3) assessment findings indicative the trial is unsuccessful and needs to be stopped?
Respiratory therapy increasing PEEP to 10.
The nurse is assessing a patient receiving mechanical ventilation for ARDS. The patient's vital signs are: 99.5 F (oral) - 122 (monitor) - 31 - 128/88 (lying-L arm-monitor) - 88%. The ventilator settings are: Assist/Control (A/C) with FiO2 of 50%, set rate of 16, Tidal Volume of 550 and PEEP of 5. What collaborative interventions will the nurse anticipate? -Respiratory therapy increasing PEEP to 10. -Respiratory therapy increasing FiO2 to 65% -Nurse decreasing sedation slowly to assess for weaning readiness. -Continuing with current therapy as the goal for mechanical ventilation has been met.
Increased respiratory rate Respiratory alkalosis Increased cardiac output
Which assessment findings would the nurse expect to observe in a client diagnosed with acute respiratory distress syndrome in the exudative phase? Select all that apply. -Decreased heart rate -Increased respiratory rate -Respiratory alkalosis -Increased cardiac output -Productive cough
flail chest (when someone has a flail chest we use a weight to balance chest)
fracture of two or more adjacent ribs in two or more places that allows for free movement of the fractured segment
PEEP (positive end expiratory pressure)
gas pressure remaining in the system between breaths (during relaxation and before the next squeeze)
CPAP
maintains one continuous pressure throughout the respiratory cycle to help keep the alveoli open through inspiration and expiration.
BIPAP
patient receives two different pressures a higher pressure during inhalations assists with the opening of the alveoli and a lower pressure during exhalation keeps the alveoli from collapsing during /t at the end of exhalation.
Terminal Extubation *Try to have family step out- lots of drainage to clean up
removal of client's endotracheal tube
air hunger
The most severe form of dyspnea.
Pulmonary edema not due to heart failure
What is Non cardiac pulmunory edema
C. Insulting agent causes fluid to accumulate in the alveoli which dilutes the surfactant and results in a decrease in lung compliance.
1. Which of the following describes the underlying pathophysiology of Acute Respiratory Distress Syndrome (ARDS)? A. Infectious agent infiltrates the lung parenchyma causing diffuse inflammation and narrowing of the bronchus and bronchioles. B. A clot/emolism limits the ability of gasses to cross into the pulmonary capillaries. C. Insulting agent causes fluid to accumulate in the alveoli which dilutes the surfactant and results in a decrease in lung compliance. D. Diffuse hyperinflation of alveoli results in air trapping and potential for ruptured blebs.
High Tidal Volume *Because of the loss of lung compliance, research has demonstrated that using lower tidal volumes—the volume of air moved with one breath, one inhalation and exhalation—with mechanical ventilation can help improve oxygenation while also reducing the occurrence of ventilator-induced lung injury (VILI)
A nurse is caring for a client diagnosed with acute respiratory distress syndrome on mechanical ventilation. Which ventilator setting should the nurse question? High tidal volume High positive-end expiratory pressure High-frequency oscillating ventilation Airway pressure release ventilation
PEAK: Lung compliance pressure - amount of pressure to push air in. Watch for increasing pressures—may need suctioning or sedation. ↑ pressure means ↓compliance IE: Inspiration/Expiration- Ratio may vary with the disease process. Ex. COPD - very short inspiration, with a very long expiration F: The true total respiratory rate- So if vent shows 16 in AC below and this shows 20 patient is taking 4 breaths. This can be found in the top right of the vent screen. Vte: Volume of air exhaled with each breath- We Want the volume going in to roughly equal the volume being exhaled. Troubleshooting should include checking for air leaks if the Vte is really low. Modes: The vent can be set to mimic the patient's own respiratory style. We will look into this more on the next slide. TV: Volume of air the vent delivers with assisted breaths. Based on patient's size. Tidal Volume-controls amount of gas delivered with each breath. Normal is about 500-750 ml. for vent settings. FIO2: Amount of oxygen the patient is given. Found in the bottom right corner of the vent screen. Recall room air is 21% O2. Vent is minimum 28-30% O2. PEEP: Positive End Expiration Pressure - the amount of air in the lung at the end of expiration. 5.0 cm is "natural" pressure - this is needed for the patient since the glottis is not closed when on a vent - we must keep the lungs pressurized to avoid lung collapse. PEEP keeps the alveoli from collapsing, allowing maximum gas exchange to continue throughout the respiratory cycle. ***Draw an imaginary line in the middle of the screen. What is above the line indicates what the patient is doing. Below the line are the vent settings that are ordered and the respiratory therapist dials in. ***Vent Alarms: Should always be on. Look at the patient first when the alarms are going off - machines do . If you cannot be sure the vent is functioning properly remove the patient from the vent and ambu bag the patient at 100% O2 (Make sure that you follow your ABC's. Airway - Breathing - Circulation). Also contact Respiratory therapy to come check the vent out. Many times they are able to troubleshoot for us.
All about Vents
Assessments (What abnormals will we watch for?) Lung sounds - crackles SpO2 - low (less than 90) VS- increased HR; decreased BP Hemodynamic Monitoring - Labs - ABGs, lactate (due to anaerobic metabolism; the higher the lactate the less chance of survival), CBC, Cultures, CMP Skin assessment- skin breakdown U/O - decreased Serial CXRs - (every day to check the placement of tubes) Ventilator Alarms - high or low alarm ECG -can cause dysrhythmias due to hypoxia and hypoxemia Actions (What interventions will the RN perform?) Suctioning/ETT care Medications Sedation/analgesia Inotropics/vasoactives Antibiotics Corticosteroids Positioning Postural Draining/CPT Skin interventions HOB ROM Infection prevention (HH, VAP, CLABSI, Foley)
Assessments (What abnormals will we watch for?) Lung sounds - SpO2 - VS- Hemodynamic Monitoring - Labs - ABGs, lactate, CBC, Cultures, CMP Skin assessment- U/O - Serial CXRs Ventilator Alarms - ECG -
1800
Common hang time for TPN
AC (assist control) - all breaths delivered at a specific set TV. Ventilator will only initiate breaths if patient initiated rate falls below set rate SIMV (synchronized intermittent mandatory ventilation)- No ventilator assistance between the set rate. Patient will pull their own volume on breaths outside the set limit PSV (pressure support ventilation) - Gives defined amount of pressure with patient initiated breaths. No ventilator initiated breath
Describe the modes of ventillation
Aspiration
Endotracheal tubes increase risk of ___
-Monitor Pulse oximetry *. Hypoxemia refractory to the administration of oxygen therapy is common in clients who are diagnosed with ARDS; therefore, the priority nursing action is to monitor pulse oximetry readings. A decrease in pulse oximetry readings from the baseline occurs due to intrapulmonary shunting. While auscultating heart sounds may be required, it is more appropriate to auscultate lung sounds as crackles may be present due to fluid buildup or lung sounds may be diminished due to atelectasis and fibrotic changes in the lungs.
For a patient diagnosed with ARDS, which is the priority? -Auscultate heart sounds -Monitor Pulse oximetry
Prone *The nurse should place a client in a prone position while on mechanical ventilation. This may improve oxygenation through increased recruitment of collapsed posterior alveolar units and reduction in the V/Q mismatch. With gravity, the blood flow is directed to the better-aerated anterior portion of the lungs.
For the patient diagnosed with ARDS on ventilation, which is the best position? -semi fowler's -prone
Biting? Blockage? ARDS? *If high alarm going off, breath is being dumped - you must figure out why... but first make sure O2 sat is not dropping.
High pressure vent alarms due to
Chest x-ray- may not be evident in the 1st 24 hours of onset. You will see bilateral diffuse infiltrates which are the hallmark sign of this disease process, sometimes described as a white out or snow screen pattern, or a ground glass appearance. Chest CT- May show alveolar consolidation and atelectasis. Pulmonary Function Tests: Would show lung compliance with decreased vital capacity, minute volume, and functional vital capacity Laboratory Testing: ABGs - Initially will show hypoxemia with a PaO2 <60 mmHg and respiratory alkalosis (pH > 7.45 & hypocapnia with a PaCO2 <35 mmHg). CBC w/differential - Will help to Determine if the cause is from an infection (WBC count >10K) Sputum, urine and blood cultures - determine source of infection (if applicable) CMP (comprehensive metabolic panel) (Electrolytes, Renal and Liver) and coagulation studies (PT/INR/PTT & D-Dimer)- Look for other systems affected and potentially DIC.
How is ARDS diagnosed?
remove the patient from the vent and ambu bag the patient at 100% O2 (Make sure that you follow your ABC's. Airway - Breathing - Circulation). Also contact Respiratory therapy to come check the vent out. Many times they are able to troubleshoot for us.
If you cannot be sure the vent is functioning properly what should you do?
Answer: B Rationale: In the early stages of acute respiratory failure the nurse would anticipate that the client's respiratory rate is elevated and oxygenation would be decreased resulting in a respiratory alkalosis with hypoxemia.
In assessing a patient's arterial blood gases, who is diagnosed with early stage acute respiratory failure, the nurse would expect to see which of the following results? A. pH 7.38, PaCO2 48mm Hg, HCO3 24mm Hg, PaO2 88mm Hg, SaO2 96% B. pH 7.48, PaCO2 30mm Hg, HCO3 26mm Hg, PaO2 52mm Hg, SaO2 90% C. pH 7.48, PaCO2 44mm Hg, HCO3 30mm Hg, PaO2 70mm Hg, SaO2 94% D. pH 7.34, PaCO2 40mm Hg, HCO3 18mm Hg, PaO2 74mm Hg, SaO2 98%
-hypoxemia and respiratory alkalosis *Initially the nurse should monitor the client's ABG for hypoxemia and respiratory alkalosis, secondary to poor gas exchange and hyperventilation. As the disease progresses, the client will experience respiratory acidosis due to hypercapnia.
Initially, the nurse should monitor the patient with ARDS ABGs for: -hypoxemia and respiratory alkalosis -hypercapnia and acidosis
Typically you will begin patients on 100% NRB for hypoxemia, if refractory and if there is a rise in PaCO2, then ventilatory support for Acute Respiratory Failure is the next step. Also you may use NPPV (Noninvasive Positive Pressure Ventilation) CPAP - continuous pressure throughout inspiratory and expiratory phases BiPAP - pressure throughout both inspiratory and expiratory; however, you have lower pressure during expiration
Management of ARDS
Lung sounds and chest rise is asymmetric
PEEP was increased to 10 for a patient with ARDS 2 hours ago. Which of the following findings would alert the nurse of a potential complication related to PEEP? -BP is 145/92 mmHg -Lung sounds and chest rise is asymmetric -Body temperature is 100.1 F rectally -Lungs with bibasilar crackles on inspiration
Hypoxemic (Type 1) *With hypoxemic respiratory failure gas exchange and oxygenation do not occur because of a V/Q mismatch (lungs are adequately ventilated but not perfused, think of a PE), a shunt (where the lungs are perfused but inadequately ventilated, think of atelectasis or pneumonia), or impaired diffusion (impaired diffusion occurs at the alveolar level, either the distance for gas exchange is increased, such as in pulmonary edema, or the permeability of the alveolar capillary membrane is reduced).
PaO2 <60 mmHg (despite supplemental O2) (hypoxemic respiratory failure) and/or a normal or low PaCO2.
Prone positioning or "Proning" Increases O2 to posterior alveoli that have collapsed (posterior nearly all lower lobes) Blood flow increased to better aerated anterior portion of lungs
Patient positioning can be used as an adjunctive therapy in ARDS. What is this position called?
Antibiotics if the cause of ARDS is from an infection Watch for nephrotoxicity Drug leveling (peak and trough or random?) Corticosteroids (methylprednisolone) Decreases inflammation, but can have negative side effects. The use of corticosteroids can also effect the body's inflammatory response, making the patient more susceptible to secondary infections. Research is ongoing. Neuromuscular blockers (succinylcholine) Reduces O2 demand Keeps breaths in sync w/vent reducing barotrauma risk With mechanical ventilation the patient almost always needs sedation and/or pain medicine. This allows for maximum patient comfort.
Pharmacologic therapy for ARDS
Hypercapnic (Type 2) *Impaired ventilation occurs when there is reduced ability of the lungs to adequately expand causing hypoventilation. Air movement is minimal and the elimination of CO2 does not take place adequately.
Respiratory acidosis with a PaCO2 greater than 50 mmHg and a pH <7.35, hypoxemia may or may not be present.
True- Acute respiratory failure is not a disease, it is a condition and a result of another type of pathology, disease, or disorder. Treat the underlying cause and the respiratory failure together. *Treatment begins with oxygen, consider a non-rebreather mask with 100% FiO2, remember the reservoir bag should be inflated to ensure that the patient is receiving 100% oxygen.
T/F Acute respiratory failure is not a disease.
-88 year old with aspiration pneumonia after a stroke -19 year old involved in a multi-car accident -45 year old who had a five-vessel coronary bypass graft surgery -62 year old with a left lower lobe removal from lung cancer
The charge nurse is revising the ventilated patients in the intensive care unit for their risk of developing acute respiratory distress syndrome (ARDS). Which patients should be most closely monitored for symptoms? Select all that apply. -88 year old with aspiration pneumonia after a stroke -19 year old involved in a multi-car accident -45 year old who had a five-vessel coronary bypass graft surgery -54 year old with a colostomy from diverticulitis -62 year old with a left lower lobe removal from lung cancer
Answer: D Rationale: The first step in caring for any patient with ARDS is to treat the refractory hypoxemia with positive pressure ventilation.
The nurse anticipates which of the following in the initial care of a patient with ARDS? A. Inotropic agents B. IV fluids C. Anticoagulants D. Positive-pressure ventilation
Answer A Rationale: The patient who has experienced a pneumothorax is at risk for tension pneumothorax if there is a continued accumulation of air into the pleural space
The nurse caring for a patient with a closed pneumothorax will monitor closely for which of these complications? A. Tension pneumothorax B. Flail chest C. Cardiac tamponade D. Pulmonary embolus
Intercostal retractions
The nurse inspects the chest of a patient with ARDS and notices the musculature of between the ribs "dipping in" with breathing. This would be accurately documented as:
Agitation/anxiety Confusion
The nurse is assessing a patient with new onset of Acute Respiratory Distress Syndrome (ARDS). Which mental status change would the nurse anticipate early in the process? SELECT ALL THAT APPLY: -Stupor -Agitation/anxiety -Obtundation -Confusion
-Place on mechanical ventilation *Mechanical ventilation is the primary treatment for the refractory hypoxemia of ARDS.
The nurse is caring for a client being treated for refractory hypoxemia for acute respiratory distress syndrome. Which intervention should the nurse anticipate next? -Apply a non-rebreather mask -Prepare for chest tube placement -Place on mechanical ventilation -The client will receive bedside bronchoscopy
Reposition the client frequently.
The nurse is caring for a client with acute respiratory distress syndrome. What interventions can the nurse take to prevent complications? Reposition the client frequently. Assess for a leak in the system if there is a high-pressure alarm. Limit suctioning. Restrict visitation of family members to evening hours only.
-It provides pressure with each of the patient's own breaths. *Noninvasive positive-pressure ventilation (NPPV), such as bilevel positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP), administered via a tight-fitting face mask, can be used to help increase oxygenation. In BiPAP, the patient receives two different pressures. A higher pressure during inhalation assists with the opening of the alveoli, and a lower pressure during exhalation keeps the alveoli from collapsing during/at the end of exhalation but also allows ease of exhalation. In contrast, CPAP maintains one continuous pressure throughout the respiratory cycle to help keep the alveoli open through inspiration and expiration.
The nurse is caring for a patient in acute respiratory failure whose oxygenation continues to decrease. The patient is currently on a nonrebreather mask with 100% FIO2. The nurse requests an order for the device in this image. How will this benefit the patient? -It provides a higher level of oxygen. -It breathes for the patient so they don't have to. -It provides pressure with each of the patient's own breaths. -It pushes air into the lungs.
-Reduce the tidal volume. -Decrease the FiO2. -Partial liquid ventilation
The nurse is caring for a patient with acute respiratory distress syndrome (ARDS) whose condition is deteriorating. What ventilatory options may be considered to improve the refractory hypoxemia? Select all that apply. -Reduce the tidal volume. -Increase the PEEP. -Decrease the FiO2. -High-frequency oscillating ventilation -Partial liquid ventilation
-Moderate Mild ARDS 200-300 on ventilator settings that include positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP) ≥5 cm H2O Moderate ARDS 100-200 on ventilator settings that include PEEP ≥5 cm H2O Severe ARDS Less than 100 on ventilator settings that include PEEP ≥5 cm H2O
The nurse is caring for a patient with acute respiratory distress syndrome with a severity ratio of 101 on positive end-expiratory pressure (PEEP). What category of severity is this patient? -Mild -Moderate -Progressive -Severe
117 (70/0.6=116.666667) *classified in terms of severity through evaluation of the PaO2/FIO2 ratio. the ratio of the partial pressure of oxygen over the fraction of inspired oxygen. To determine this ratio, divide PaO2 by FIO2. In a healthy individual, the PaO2 averages 90 mm Hg (normal is 80 to 100). Breathing room air, the FIO2 is 21% (or 0.21), so the equation is 90/.21 or a PaO2/FIO2 ratio of approximately 428. If a patient has a PaO2 of 70 mm Hg while receiving 70% (0.7) FIO2, the ratio is 100, which is diagnostic for severe ARDS (Table 27.8).
The nurse is caring for a patient with an increased risk for developing acute respiratory distress syndrome (ARDS). Calculate the ARDS ratio if the patient's PaO2 is 70 on an FiO2 of 60%. Round to the nearest whole number. Enter numeral only.
-Assess for purulent secretions. *Patient at risk for VAP (ventilator associated pneumonia.
The nurse is caring for a ventilated patient with acute respiratory distress syndrome whose temperature is 37.8ᵒ C. What action should the nurse take? -Deliver the scheduled intravenous antibiotic. -Administer the ordered antipyretic. -Assess for purulent secretions. -Send a sputum for culture.
-"This medication will relax vessels in my lungs and help me to breathe better."
The nurse provided teaching regarding nitric oxide inhalation therapy. Which of the following statements made by the patient indicates teaching was effective? -"This medication causes systemic relaxation of my blood vessels and may drop my BP a lot." -"This medication is likely to cause my blood sugar to increase and I may need to take insulin while receiving it." -"This medication will relax vessels in my lungs and help me to breathe better." -"This medication will make me at greater risk for infection."
Answer: B Rationale: If a chest tube becomes disconnected from the drainage system, it is imperative to submerge the end in sterile water to provide a water seal until a new drainage system is connected.
The nurse understands the priority action for a patient with a chest tube that has come disconnected from the chest drainage system is which of the following? A. Immediately cover the end of the chest tube with a sterile dressing. B. Immediately submerge the end of the chest tube in sterile water. C. Immediately reconnect the end of the chest tube with the drainage system. D. Immediately page the provider to insert a new chest tube.
Answer: B Rationale: Tracheal deviation is a classic manifestation of tension pneumothorax.
The nurse understands tracheal deviation in a newly admitted patient to the emergency department is typically caused by which of the following? A. Hemothorax B. Tension pneumothorax C. Flail chest D. Subcutaneous emphysema
3. Sepsis (and aspiration are the most likely to develop ARDS).
The nurse would carefully assess a patient with which of the following for the development of ARDS? 1. Gastroenteritis 2. Type II Diabetic 3. Sepsis 4. Cellulitis
-Intermediate Early • Dyspnea • Restlessness • Anxiety • Fatigue • Increased blood pressure (from baseline) • Tachycardia Intermediate • Confusion • Lethargy (due to increased CO2) • Pink skin coloration (due to increased CO2) Late • Cyanosis • Coma
The patient with a severe pneumonia is showing confusion, lethargy, and a pink complexion. What stage of respiratory failure are they exhibiting? -Early -Intermediate -Advanced -Late
Exudative (24-48 hours post injury) - Proliferative causes r sided heart failure Fibrotic decrease of L heart function due to the R heart function results in severe tissue hypoxia and lactic acidosis
What are the 3 stages of ARDs
Sepsis
What is the #1 cause of ARDs?
Relaxes smooth muscle to dilate airways and increase gas exchange for patients with ARDS.
What is the purpose of nitric oxide?
Refractory hypoxemia w/respiratory acidosis Goal/Outcome: FiO2 titrated to lowest rate to maintain PaO2 > 60 mmHg and O2 sat > 90%. Keep the FiO2 less than 50% to avoid toxicity. Decreases tidal volumes to prevent barotrauma (alveolar rupture). Increased PEEP (positive end expiratory pressure) to keep alveoli open and promote better gas exchange. Adverse effects of too much PEEP: Increased pressure in the chest, decreased Cardiac Output and increased risk of barotrauma, alveolar rupture, such as a pneumothorax. If patient can protect own airway and doesn't require ETT, can receive BiPAP or CPAP
What is the rationale for mechanical ventilation?
REDUCE O2 DEMAND
What reason would we put a patient on neuromuscular blockers
Prone *Patient positioning can be utilized as an adjunctive therapy in ARDS—specifically, placing the patient in a prone position. The proning of a patient while on mechanical ventilation may improve oxygenation through increased recruitment of collapsed posterior alveolar units and reduction in the V/Q mismatch. Via gravity, blood flow is directed to the better-aerated anterior portion of the lungs. It is best used in patients with severe ARDS if other ventilator strategies have not been successful.
When caring for a client diagnosed with acute respiratory distress syndrome who is on mechanical ventilation, the nurse should place the client in what position to improve oxygenation? Fowler's Semi-Fowler's Trendelenburg Prone
Stacking Breaths
When patient is not allowed enough time to exhale
4. Refractory hypoxemia
Which clinical manifestation is highly indicative of ARDS (as opposed to some other complication)? 1. Tachypnea 2. Dyspnea 3. Anxiety 4. Refractory hypoxemia
-Left-sided heart failure *There are more than 50 causes for the development of ARDS. The most common cause is sepsis. Other causes include pneumonia, severe trauma, aspiration, massive transfusions, cigarette smoking, cardiopulmonary bypass, pneumonectomy, PE, and drug/alcohol overdose.
Which finding in the client's history should the nurse rule out as a contributing factor in the development of acute respiratory distress syndrome? -Pulmonary embolism -Recurrent pneumonia -Left-sided heart failure -Drug/alcohol overdose
Liver/ Renal function *The nurse should monitor liver and renal function tests since abnormal values indicate the client is progressing from ARDS to MODS, which necessitates immediate nursing action. While the nurse should assess the client's CBC, this is done to monitor the white blood cell (WBC) count as an indicator of infection.
Which is the priority lab for the nurse to monitor when caring for the patient with ARDS?
-Sepsis -Aspiration -Pancreatitis -Chest Trauma -Pneumonia -Multiple transfusions (transfusion related acute lung injury)
Which of the following are common insults that may lead to the development of ARDS? SELECT ALL THAT APPLY: -Sepsis -Aspiration -Diabetes -Systemic hypertension -Pancreatitis -Chest Trauma -Pneumonia -Multiple transfusions (transfusion related acute lung injury)
-Rotate endotracheal tube once a shift. -Verify ventilator settings once a shift. -Provide chest physiotherapy
Which of the following are nursing interventions for a patient receiving mechanical ventilation? SELECT ALL THAT APPLY: -Head of bed less than 30 degrees -Oral care every 8 hours -Rotate endotracheal tube once a shift. -Verify ventilator settings once a shift. -Provide in line suctioning of endotracheal no more than once a day. -Provide chest physiotherapy
-Assess circuits and system for air leaks.
Which of the following assessments should the nurse perform for a patient receiving mechanical ventilation via endotracheal tube when the ventilator has a "low pressure" alarm? -Auscultate airways and inspect tube for blockages. -Assess if patient is biting tube. -Assess circuits and system for air leaks. -Ensure the batteries are functioning appropriately.
Space out interventions, providing frequent rest periods
Which of the following interventions should the nurse anticipate implementing for a patient with ARDS? -HOB less than 30 degrees -Cluster all care -Position with the good lung down -Space out interventions, providing frequent rest periods
Decreased blood pressure
Which vital sign change should the nurse anticipate while caring for a client diagnosed with acute respiratory distress syndrome on mechanical ventilation? Decreased respiratory rate Decreased temperature Decreased heart rate Decreased blood pressure
pan culture
culturing everything, not sure where the infection is sputum, urine, stool, everything
