EAQ ARDS

The nurse provides care for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation. After reviewing the patient's medical record, the nurse determines that which assessment is the most important? Anxiety level Cardiac output Peripheral pulses Presence of abdominal rigidity

Cardiac output Rationale Twenty cm of positive end-expiratory pressure (PEEP) is considered to be a high level. As the PEEP level increases, the venous return to the heart, and BP and cardiac output (CO) decrease. As the CO decreases, perfusion to vital organs also decreases, causing damage to vital organs and the brain. It is most important for the nurse to assess the patient's cardiac output because dangerous drops can occur with high levels of PEEP. Assessing for anxiety, assessing the patient's peripheral pulses, and evaluating if abdominal rigidity is present should also be performed, but the priority is assessing cardiac output. p. 1600

Which clinical manifestations of acute respiratory distress syndrome (ARDS) are caused by increased pulmonary capillary permeability during the initial phase of ARDS? Select all that apply. Crackles Tracheal deviation Intercostal retractions Decreasing oxygen saturation Hyperresonance to percussion

Crackles Intercostal retractions Decreasing oxygen saturation Rationale An increase in pulmonary capillary permeability results in fluid movement from the pulmonary capillaries into the interstitial space and alveoli, causing crackles with breathing. Fluid within the alveoli and interstitium also decreases oxygen saturation between the alveoli and pulmonary capillaries, leading to hypoxemia. Interstitial fluid also makes the lungs stiffer and less compliant, increasing the work of breathing and causing labored respirations with intercostal retractions. Tracheal deviation occurs with tension pneumothorax and is not a symptom of ARDS. The lungs have infiltrates with ARDS and will be dull to percussion. pp. 1597-1598

Which pathophysiologic process results in surfactant dysfunction during the injury phase of acute respiratory distress syndrome (ARDS)? Decrease in gas exchange capability Damage to alveolar type I and II cells Engorgement of the peribronchial space Ventilation to perfusion (V/Q) mismatch

Damage to alveolar type I and II cells Rationale During the injury phase of acute respiratory distress syndrome (ARDS), the alveolar type I and II cells (which produce surfactant) will be damaged. Along with accumulation of fluid and proteins, this cell damage results in surfactant dysfunction. The hyaline membranes that line the alveoli lead to the decrease in gas exchange capability. Engorgement of the peribronchial and perivascular interstitial space results in interstitial edema. Ventilation to perfusion (V/Q) mismatch results in hypoxemia. p. 1598

Following a direct lung injury, which pathophysiologic process occurs in the first few days as the patient develops acute respiratory distress syndrome (ARDS)? Destruction of pulmonary vasculature Decreased lung compliance by scarring Development of pulmonary hypertension Engorgement of the peribronchial interstitial space

Engorgement of the peribronchial interstitial space Rationale In the injury or exudative phase of ARDS (the first few days), there is an engorgement of the peribronchial interstitial space because of increased permeability of the alveolar-capillary membrane. Destruction of the pulmonary vasculature occurs one or two weeks later during the reparative or proliferative phase. As the pulmonary vasculature is destroyed, the patient develops pulmonary hypertension. Lung scarring with permanently decreased lung compliance occurs in the fibrotic or fibroproliferative phase, two to three weeks after the initial acute lung injury.

During which phase of acute respiratory distress syndrome (ARDS) does atelectasis occur due to decreased synthesis of surfactant and inactivation of existing surfactant? Injury Fibrotic Proliferative Refractory Hypoxemic

Injury Rationale During the injury phase (exudative phase), atelectasis occurs due to decreased synthesis of surfactant and inactivation of existing surfactant. During the proliferative phase, continued inflammation leads to damage to the pulmonary vasculature, fibrosis, and further decreased compliance. The fibrotic phase is characterized by remodeling of the lung with collagenous and fibrous tissues. Refractory hypoxemia is not a stage of ARDS but is first noticed during the injury (exudative) phase as the patient's hypoxemia continues to worsen despite use of high concentrations of oxygen. pp. 1597-1598

Which pathophysiologic processes occur during the fibrotic phase of acute respiratory distress syndrome (ARDS)? Select all that apply. Remodeled lung Deceased lung compliance Impairment of gas exchange Development of pulmonary edema Formation of hyaline membranes

Remodeled lung Deceased lung compliance Impairment of gas exchange Rationale The fibrotic phase, also known as the chronic or late phase of ARDS, occurs two to three weeks post-lung injury. The lung is completely remodeled by this time with dense and fibrous tissues. The scarring and fibrosis result in the decrease of lung compliance. Impairment in gas exchange is significant because the interstitium is fibrotic in nature. Pulmonary edema occurs in the initial exudative phase of ARDS as the alveolar-pulmonary capillary membrane permeability increases and fluid leaks into the alveoli. Formation of hyaline membranes also occurs in the exudative phase as necrotic cells, proteins, and fibrin line the alveoli, forming membranes that slow gas exchange.

Which pathophysiologic change occur during the fibrotic phase of acute respiratory distress syndrome (ARDS)? Formation to thick alveolar hyaline membranes Damage to alveolar type 1 and 11 cells that make surfactant Remodeling of the lungs by collagenous and fibrous tissues Engorgement of the peribronchial and perivascular interstitial space

Remodeling of the lungs by collagenous and fibrous tissues

Which conditions predispose a patient to acute respiratory distress syndrome (ARDS) by causing an indirect lung injury? Select all that apply. Sepsis Bacterial pneumonia Opioid drug overdose Severe massive trauma Aspiration of gastric contents

Sepsis Opioid drug overdose Severe massive trauma Rationale In indirect lung injury, a problem outside the lung leads to widespread inflammation, which affects the lung as well as other organs. Sepsis caused by gram-negative bacteria can predispose patients to the development of ARDS with an indirect lung injury. Excessive use of opioid drugs can indirectly lead to ARDS. Indirect injury to the lung by a severe massive trauma caused by a head injury can also lead to ARDS. In direct lung injury, pathogens come into direct contact with the lungs as occurs with pneumonia. Aspiration of gastric contents also causes direct lung injury as gastric contents come into contact with lung tissues. p. 1597

Which condition is an example of an indirect lung injury that increases the risk for developing acute respiratory distress syndrome (ARDS)? Near drowning Aspiration Pneumonia Severe trauma

Severe trauma Rationale Severe trauma results in inflammation, which can cause indirect injury to the lungs and increase the risk for developing ARDS. Near drowning causes a direct injury to the lung. Aspiration also results in direct lung injury. Pneumonia is a direct injury to the lung. p. 1597

The nurse provides care for a patient who is in the early phases of acute respiratory distress syndrome (ARDS). The nurse identifies that the patient is placed in the prone position for which primary reason? To reexpand alveoli To consolidate secretions To deliver oxygen to the blood To allow for effective chest physiotherapy

To reexpand alveloi Rationale In the early phases of ARDS, fluid moves freely throughout the lung. Because of gravity, fluid pools independent regions of the lung. As a result, some alveoli are fluid filled (dependent areas) while others are air filled (nondependent areas). When the patient is supine, the heart and mediastinal contents place added pressure on the lungs. Consequently, the supine position predisposes all patients, including those with ARDS, to atelectasis; thus, the patient should be placed in the prone position to reexpand alveoli. Secretions are mobilized and can be suctioned out. Delivering oxygen into the blood is the purpose of extracorporeal membrane oxygenation (ECMO). Continual lateral rotation therapy (CLRT) can provide the means for administering chest physiotherapy. p. 1601