Critical Care Acute Respiratory Failure

what are signs that compensatory mechanism are not working?

Shallow breathing, decrease respiratory rate, and use of accesorry muscles.

What are s/s of ARF in pts w/Asthma?

-Breathlessness at rest and the need to sit up right. -Speaking single words unable to speak in scentences or phrases. -Lethargy or confusion -Paradoxical Thoracoabdominal movement - Absence of wheezing "SIlent Chest" -Bradycardia -Resipiratory Acidosis, PaCO2 >45, and PaO2 < 60

The nurse is assessing a patient for a possible pulmonary embolus. Assessment findings may include which of the following? (Select all that apply.) A. Acute onset of chest pain B. Hemoptysis C. Low oxygen saturation level D. Pleural friction rub

A. Acute onset of chest pain B. Hemoptysis C. Low oxygen saturation level Chest pain, hemoptysis, and a low oxygen saturation level are signs and symptoms of pulmonary embolus. A pleural friction rub is seen with disorders such as pleural effusion.

Which of the following are nursing interventions to prevent ventilator-associated pneumonia (VAP)? (Select all that apply.) A. Elevate the head of bed to at least 30 degrees. B. Intubate the patient with an endotracheal tube with continuous subglottic aspiration of secretions. C. Maintain a deep level of sedation. D. Provide regular oral care, including the use of chlorhexidine.

A. Elevate the head of bed to at least 30 degrees. D. Provide regular oral care, including the use of chlorhexidine. Maintaining the head of bed at 30 to 45 degrees and providing oral care are two interventions to prevent VAP that the nurse can implement. The special endotracheal tube reduces the risk for VAP; however, this is not a nursing intervention. The patient should be sedated based on specific targets. Deep sedation should be avoided because it prolongs time on mechanical ventilation, increasing the patient's risk for VAP.

The etiology of pulmonary edema in acute respiratory distress syndrome is related to: A. damage to the alveolar-capillary membrane. B. decreased cardiac output. C. tension pneumothorax. D. volutrauma and hypoxemia.

A. damage to the alveolar-capillary membrane.

The nurse is caring for a patient with status asthmaticus in the emergency department. The nurse anticipates what therapies to be ordered? (Select all that apply.) A. Inhaled anticholinergic agent B. Inhaled rapid-acting beta-2 agonists C. Oxygen administration D. Systemic corticosteroids

A. Inhaled anticholinergic agent B. Inhaled rapid-acting beta-2 agonists C. Oxygen administration D. Systemic corticosteroids All are treatment of severe asthma exacerbation (Table 14-4).

Physiological factors that contribute to clotting and pulmonary embolus include: (Select all that apply.) A. altered coagulability of blood. B. damage to vessel walls. C. plaque formation. D. venous stasis.

A. altered coagulability of blood. B. damage to vessel walls D. venous stasis. Altered coagulability, damage to vessels, and venous stasis are part of Virchow's triad of risks for clotting. Plaque formation is not part of Virchow's triad.

Symptoms of early respiratory failure are: A. anxiety and restlessness. B. cyanosis and hyperventilation. C. dyspnea and nasal flaring. D. hypertension and bradycardia

A. anxiety and restlessness. Neurological changes, such as anxiety and restlessness, are early signs of hypoxemia in respiratory failure. Other early signs are tachycardia and increased blood pressure. Cyanosis, dyspnea, and nasal flaring are later signs.

How is PE tx?

ABC; Oxygen Thrombolytic Heparin Sx procedures - Embolectomy - Venacava Umbrella (Fillter)

What are the three cornerstones of care for CF?

ABX Airway Clearance Nutritional Support - enteral nutrition w/pancreatice enzymes

What are common causes of ARF in Pt w/copd?

Acute exacerbation, HF, Dysrhythmias, PE, Dehydration, and electrolye imbalances.

What is COPD?

Airflow limitations due to obstructive bronchiolitis and emphysema.

A client with a 10-year history of emphysema is admitted in acute respiratory distress. During assessment, what does the nurse expect to identify? A Chest pain on inspiration B Prolonged expiration with use of accessory muscles C Signs and symptoms of respiratory alkalosis D Decreased respiratory rate

B Prolonged expiration with use of accessory muscles Accessory muscles are used during respiration because of the increased rigidity of the chest. Sudden pleuritic chest pain is associated with pulmonary embolism, not emphysema. Respiratory acidosis, not alkalosis, is associated with emphysema because of carbon dioxide retention. Clients with respiratory muscle fatigue breathe with rapid, shallow respirations.

aseline arterial blood gases (ABGs) for a COPD patient might show: A. PaO2 50 mm Hg and PaCO2 35 mm Hg. B. PaO2 55 mm Hg and PaCO2 55 mm Hg. C. PaO2 80 mm Hg and PaCO2 50 mm Hg. D. PaO2 75 mm Hg and PaCO2 40 mm Hg.

B. PaO2 55 mm Hg and PaCO2 55 mm Hg. The patient with COPD typically has hypoxemia and an elevated carbon dioxide level (from ppt) COPD base line is usually low PaO2 (60-65) and high PaCo2 (50-60)

How does Intrpulmonary shunting cause hypoxemia?

Blood is unable to reach the lungs for gas exchange. Exp atrial/septal defects, atelectasis, pneumonia and pulmonary edema. Cannot be treated with Higher levels of O2 becuase blood is still unable to reach lungs for has exchange.

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, what does the nurse expect to identify? A. Hypertension B. Tenacious sputum C. Altered mental status D .Slow rate of breathing

C. Altered mental status Altered mental status is secondary to cerebral hypoxia, which accompanies acute respiratory distress syndrome (ARDS); cognition and level of consciousness are reduced. Hypotension occurs because of hypoxia. The sputum is not tenacious, but it may be frothy if pulmonary edema is present. Breathing will be fast and shallow.

A patient in acute respiratory failure is experiencing carbon dioxide narcosis secondary to increased CO2 retention. An expected assessment finding is: A. nasal flaring. B. paradoxical respirations. C. somnolence. D. suprasternal muscle retractions. Incorrect

C. somnolence. Somnolence, lethargy, and coma are seen with CO2 retention. Nasal flaring, paradoxical respirations, and muscle retracts are seen with respiratory muscle fatigue (clinical alert).

Which are the different types of Pneumonia?

Community Acquired Healthcare Acquired Hospital Acquired Ventilator Associated

Which serial respiratroy procedure/test provide important assesment information?

Cx x-ray, pulmonary function test, electrolytes, HgB, Hematocrit, ABG, pulse oximetry reading, end tidal CO2

Which test and studies are used to DX PE?

D-dimmer assay V/Q scan with high probability of PE duplex u/s for DVT CT angiogram MRI Pulmonary Angiogram - Difinitive Dx

Which of the following is appropriate for initial treatment of hypoxemia in a patient admitted with exacerbation of COPD? A. Bag-valve-mask ventilation with oxygen at 15 L/min B. Continuous positive airway pressure (CPAP) via face mask C. Non-rebreather mask with 80% oxygen D. Oxygen via Venturi mask at 40% oxygen

D. Oxygen via Venturi mask at 40% oxygen The initial treatment of hypoxemia is delivery of oxygen at a low flow rate. The Venturi mask allows a designated percentage of oxygen to be delivered. The initial treatment is low-flow oxygen. If the patient fails to respond to this treatment, noninvasive ventilation (CPAP or BiPAP) may be indicated. A non-rebreather mask at 80% delivers a high percentage of oxygen, which may impair the patient's respiratory drive. Bag-valve-mask ventilation is not indicated.

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? A.Chest tube insertion B. Aggressive diuretic therapy C. Administration of beta-blockers D. Positive end-expiratory pressure (PEEP)

D. Positive end-expiratory pressure (PEEP) Mechanical ventilation with PEEP will help prevent alveolar collapse and improve oxygenation. Fluid is not in the pleural space, so chest tube insertion is not indicated. Aggressive diuretic therapy and administration of beta-blockers are contraindicated because of severe hypotension from the fluid shift into the interstitial spaces in the lungs.

A patient presents to the emergency department in acute respiratory distress. She has a long-standing history of COPD. Which of the following positions would be best tolerated by this patient? A. Prone on a stretcher B. Recliner leaning back as far as it will go C. Side-lying with head of bed at 15 degrees D. Stretcher with head of bed as high as it will go

D. Stretcher with head of bed as high as it will go A patient with COPD will be most comfortable in an upright position that facilitates lung expansion. Proning will not be tolerated, and a 15-degree elevation is not high enough. A recliner is sometimes helpful, but not leaning back as far as it will go.

A patient is hospitalized with respiratory distress due to emphysema. She is being treated with O2 via a Venturi mask with 35% oxygen because: A. a nasal cannula will dry the mucous membranes and cause an increased risk of infection. B. her alveoli cannot absorb higher levels of O2 because of the emphysema. C. her alveoli have been damaged and may rupture with higher doses of O2. D. her respiratory center requires low O2 concentration to stimulate breathing.

D. her respiratory center requires low O2 concentration to stimulate breathing. In patients with COPD, the respiratory drive is stimulated by hypoxemia, not increased levels of carbon dioxide. Administration of oxygen in high levels will impair the respiratory drive.

Symptoms of ARDS based on PPT

Decrease surfactant levels, decrease lung compliance, Respiratory alkolosis, Increased peak ispiratory pressure (PIP) on ventilation, Decreasing PaO2 levels, despite increasing FIO2 administration.

What are signs and symptoms of Respiratory Muscle Fatigue?

Diaphorisis, nasal flaring, tachycardia, abd paradox, muscles retractions, intercostal, supersternal, supraclaicular, central cyanosis.

What are cuases of hypoventilation?

Drug overdose = CNS depression CNS Disorders = decreases rate of respiraton (MS) Abd / THor Sx = shallow and painful breathing *unable to rid CO2 that continues to build in the body

What are classic signs of PE?

Dyspnea, Hemoptysis, chest pain.

What are the risk factors of pneumonia?

Elderly (64 and up) Alcohol Abuse Smoking Chronic Disease Head Injury Immunosupression *See Table 14-6 pg419

What is the presentaion of pneumonia?

Fever, Cough, purulent sputum, hemoptysis, Dyspnea/tachypnea, chest pain, adventatious breath sounds.

How do you optimize O2 delivery?

First provide supplemental O2 via NC or Face mask (maintain sats >90). If supplemental O2 does not work non-invasive or invasive ventilation is indicated Position pt for comfort to enhance ventilation matching. (Semi fowler or high fowler, good lung down)

What are the intervention for pt w/ Asthma?

For severe asthma: (Table 14-4). -O2 via NC or face mask - mantain O2 >90% -Inhaled Rapid acting Beta 2 agonist - nebulizer (continous); followed by inermittent on demand tx - Inhaled Anticholinergic - relieves bronchoconstriciton -Systemic Steroids - decreases inflammation

What is cystic fibrosis?

Genetic Disorder, cuases thick mucus to obstuct glands, lungs, pancreas, liver, salivary glands, testes.

How is PE prevented?

Heprin Sequential Compresion Devices Foot pumps Copression Stockings Position change Early Mobility Tx of arterial dysrhythmias (afib/aflutter) Prophylactic anticouagulant tx

What are causes of Hypercapnia (failure of ventilation)?

Hypoventilation and V/Q mismatch

What can cuase Hypoxemia (Failure of Oxygenation)?

Hypoventilation, intrapulmonary shunting, ventilation-perfusion mismatching, diffusion defects, decrease barometric pressure Non-pulmonary conditions include low cardiac output, low hemoglobin,

what is the clinial picture of ARDS?

Initial signs: restlessness, diorientation, change in level of consciousness. HR and temp maybe increased. Chest- xray usually normal. Progesses to: Decrease PaO2, severe dsypnea, use of accessory muscles, tachycardia, central cyanosis, respiratory alkolosis, no response to supplemental O2, leads to metabolic acidosis, . Lung sounds: Crackles, rhonchi, Ches xray- bilateral infiltrates "ground glass appearance" or complete opacity "white out".

What are signs of cerebral hypoxia and carbon dioxide narcosis from CO2 retention?

Lethargy, samnolence, coma, respiratory acidosis

How does diffusion cause Hypoxemia?

Longer diffusion time (gas exchange) between avioli and blood which causes hypoxemia. Late sign of diffussion problem is hypercapnia.

what are clinical findings that often dx ARDS?

Lung insult (indirect or direct), followed by respiratory distress with dyspnea, tachypnea, hypoxemia, and does not respond to O2 tx and PEEP.

What are interventions for ARF?

Maintaing Patent Airway Optimizing O2 delivery Minimizing O2 Demand (rest, rest, rest) Treating the cause of ARF Preventing Complications

Which assesment do you begin with in ARF?

Neurological Assesement. watch for mental status change, anxiety, restlessness, confusion, progression to lethargy, severe somnolence, and coma.

How do you manage COPD?

O2 supplementation -Initial tx - Continous supplementation (Venturi Mask - slow and concentrated O2) *Do not deliver high concentrations of O2; O2 should be titrated slowly Bronchodialator Tx *Watchout for tachycardia, tremors, dysrhythmias, hypovolemia, bronshospasm and dyspenea Corticosteroids *watchout for hyperglycemia and infections Abx Ventilory Assistance *Only if initial tx of low flow rate does not work -Pt wiht ARF from COPD benefit from early tx w/Non-invasive Positive Pressure Ventilation (NPPV) -Delivers positive airway presure through NC, Oronasla , Full face Mask. -Do not use pt w/respiratory arrest, hemodynamic instability, thick/copious secretions, change in mental status, uncoperative, extreme obisity, head or facial trauma/surgery. Intubation/Mechanical Ventilation -pt not responding to aggresive tx, mental status change, severe dyspnea, respiratory fatigue, respiratory acisosis, sig. hypoxemia, or hypercapnia.

Interventions for ARDS

Oxygenation - intubation or mechanical ventilation based on lung protective strategies. Sedation and Comfort - promote comfort/sleep/rest/ decrease annxiety, prevents self-extubation/harm, ensure adequate ventilation. -Monitor of ventilation dyssynchrony and delirium Prone Positioning (when Pao2/Fio2 <100) - alters V/Q, shifts perfusion from posterior lung base to anterior (improves ventilation and oxygentaion, removes secretions, ehances recruitment of ariway. Monitor for gastric aspiration, peripheral nerve damage, pressure ulcers, corneal ulceration, facial edema. Turn off feeding tube 1 hour prior Pharmocological Tx- Furosemide with albumin- pt w/low protein. Corticosteroid - pt w/severe ARDS and prior day 14 Psychosocial- warm, nurturing evironment makes pt feel safe. explain procedures, equipment, changes in pt's condition /outcome to family. Allow pt participate in care, verbalize fear and ask questions (reduces stress/anxiety). encourage family to stay w/pt, display personal items/pictures-minimizes isolation/depression.

What are the core measures of Pneumonia?

Pg 420 1. First dose of abx given w/in 6 hrs of arrival to the hospital. 2.Correct abx given 3.Blood cultures are obtain w/in 24 hrs for all pt in ICU, with BC draw in ED prior to abx tx. 4. Smoking cessation advice given and documented. 5.Pneumococcal and Influenza vaccine are administered to appropriate candidates.

Which factors increase the risk for ARF in older adults?

Physiological changes: decrease in chemoreceptor and central nervous system function. (Change in Mental status often confused with dimentia or normal sign of aging) Lower ventilatory response to hypoxemia/hypercapnia (unable to compensate due to existing heart problem or meds)

What is ventilator -associated pneumonia?

Pt with ETT - Aspiration of bacteria in from oropharynx or GI tract

what are the most common risk factors of ARDS?

Spesis (Indirect Cause) - most common cause Pneumonia (Direct Cause) Trauma ( Direct Cuase) Aspiration of gastric contents (DIrect Cause).

What is the clinical presentaion of Pulmonary Embolism?

Syncope, hypotension, extreme hypoxemia, or cardiac arrest. Other s/s apprehension or anxious, impending doom, chest wall tenderness aggravated by deep inspiration, tachypnea, tachycardia, crackles, wheezing, hemoptysis.

How can you prevent VAP ?

Table 14-4 1.Effective infection control measrures -staff education / hand hygiene 2.Conduct Surviellence of ICU infections 3.Ventilator Bundle - HOB 30-45 degrees - Sedation vecation - DVT Prophylaxis - Peptic Ulcer Prophylaxis - *Daily Oral Care w/ Cholorhexidine 4. Prevent transmission of microorganisms - Use sterile water in circuit -Change circuit when visibly soiled - Drain the Condensate away form the pt - Avoid NS during suctioning 5. Prevent Aspiration - Avoid intubation / reintubation - Intubate pt orally - Use orogastric tube - Use ETT w/ continous aspiration of subglottic secrestions. - Sedation and weaning protocols 6. Other prevention strategies - Enteral nutrition - Mobilization program.

How does the heart respond to ARF?

Tachycardia and increased BP. If ARF progressess it may lead to dysrhythmias, angina, brady cardia, hypotension, and cardiac arrest.

While conducting a respiratory assessment the nurse knows the body's copensatroy menchanism to hypoxemia is?

Tachypnea and increase tidal volume.

What consist of the Ventilator Bundle?

Ventilator Bundle - HOB 30-45 degrees - Sedation vecation - DVT Prophylaxis - Peptic Ulcer Prophylaxis - *Daily Oral Care w/ Cholorhexidine

which are the three mechanisms of PE?

Virchow Triad: 1.Venous Stasis 2.Altered Coagubility of blood 3.Damage to the wall vessels

What is ARF ?

altered gas exchange: respiratory system fails to oxygenate or eliminate CO2. There are two types. Oxygenation (Hypoxemic): PaO2 < 60 mm hg and CO2 is normal or low Ventilation (Hypercapnic): PaCO2 is >50mm hg and with ph < or equal to 7.30 Occurs over minutes or hrs, little time for compensation.

What is Ventilation-perfusion mismatch and what causes it?

there is an imbalance between the ventilation and perfusion. MOST common cuase of Hypoxemia. Causes of V/Q mismatch is pneumonia, PE, COPD, Fibrosis, Asthma, Pulmonary HTN. Tx responds to 100% O2

What are signs and symptoms of asthma?

wheezing dyspnea, chest tightness, cough, tachypnea, tachycardia, pulsus paradoxus >25 mm Hg, agitaion, possible use of accessory muscles, suprasternal retractions. Peak Expiratory flow < 50% pt's normal.

What is ARDS (Acute Respiratroy Distress)?

when fluids/proteins fill aveolar sacs due to lung injury. Causes "Stiff lungs", decrease surfactant, impaired gas exhange, v/q mismatch. Three criteria to meet ARDS dx: Pao2/FiO2 ratio less than 200 Bilateral infiltrates Pulmonary Artery Occulision Pressure (PAOP) less than 18mm hg or no evidence of Lt artrial HTN.