Module 7

What are the 2 definitive diagnostics for ARDS?

"White out" lungs on CXR Refractory hypoxemia (low O2 in blood despite high O2 % given)

Simone is a 22 year old woman admitted with ARDS following H1N1. Her blood gases on .8 PEEP 10 PC 34 (tidal volumes ~500 cc) and AC 28 are as follows: PaO2 52 PaCO2 46 pH 7.32 HCO3 17 Which one of the following interventions is the priority? A. increase PEEP B. increase FiO2 C. decrease PC D. increase AC

A Her greatest problem is hypoxemia. She is already on FiO2 0.8 with persistent hypoxemia, indicating significant shunt. She needs her lung recruited with additional PEEP to increase the surface area for gas exchange. There would be little benefit (but increased harm) with higher oxygen concentrations. Lowering her PC would actually decrease her tidal volume, potentially decrecruiting more lung. An increase in her AC rate would have little impact on her PaO2 but would reduce her PaCO2 (mild hypercarbia is generally permitted).

The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS? A. Low arterial oxygen when administering high concentration of oxygen. B. The client has dyspnea and tachycardia and is feeling anxious. C. Bilateral breath sounds clear and pulse oximeter reading is 95%. D. The client has jugular vein distention and frothy sputum.

A The classic sign of ARDS is decreased arterial oxygen level (Pao2) while administering high levels of oxygen; the oxygen is unable to cross the alveolar membrane. These are early signs of ARDS, but they could also indicate pneumonia, atelectasis, and other pulmonary complications, so they do not confirm the diagnosis of ARDS. Clear breath sounds and the oxygen saturation indicate the client is not experiencing any respiratory difficulty or compromise. These are signs of congestive heart failure; ARDS is noncardiogenic (without signs of cardiac involvement) pulmonary edema.

After surgery, a client is extubated in the PACU. Which clinical manifestations would the nurse expect if the client is experiencing acute respiratory distress? SATA A. Confusion B. Hypocapnia C. Tachycardia D. Constricted pupils E. Slow respiratory rate

ABC Inadequate cerebral oxygenation produces restlessness and confusion. Tachycardia occurs as the body attempts to compensate for lack of oxygen. A low carbon dioxide level in the blood (hypocapnia) occurs with an increase in respiratory rate. The pupils dilate, not constrict, with hypoxia. An elevated respiratory rate (tachypnea), not a slow rate

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 A. 88 year old with aspiration pneumonia after a stroke B. 19 year old involved in a multi-car accident C. 45 year old who had a five-vessel coronary bypass graft surgery D. 54 year old with a colostomy from diverticulitis E. 62 year old with a left lower lobe removal from lung cancer

ABCE Aspiration is a high risk for ARDS development. Severe trauma such as a car accident is a risk factor for ARDS. Those who have been on cardiopulmonary bypass are at risk. Abdominal surgeries are not higher risk, unless in the presence of sepsis. A pneumoectomy is a risk factor

The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? Select all that apply. A. Assess the client's level of consciousness. B. Monitor urine output every shift. C. Turn the client every two (2) hours. D. Maintain intravenous fluids as ordered. E. Place the client in the Fowler's position.

ACDE Altered level of consciousness is the earliest sign of hypoxemia. Urine output of less than 30 mL/hr indicates decreased cardiac output, which requires immediate intervention; it should be assessed every one (1) or two (2) hours, not once during a shift. The client is at risk for complications of immobility; therefore, the nurse should turn the client at least every two (2) hours to prevent pressure ulcers. The client is at risk for fluid volume overload, so the nurse should monitor and maintain the fluid intake. Fowler's position facilitates lung expansion and reduces the workload of breathing.

Mrs. Habernathy becomes agitated and is at risk for self-exubation. Which one of the following interventions is the priority? A. Apply restraints B. Assess cause of agitation C. Increase dose of sedatives D. Have family sit with Mrs. Habernathy

B Agitation can be caused by a variety of problems such as delirium, pain, anxiety or constipation. An assessment should always be conducted to ensure that treatment options are geared toward the underlying cause, as the wrong treatment may worsen the agitation. A least restraint policy should be utilized; restraints should only be used following a thorough assessment and after attempts at other interventions fail.

The nurse suspects the client admitted with a near-drowning is developing acute respiratory distress syndrome (ARDS). Which data support the nurse's suspicion? A. The client's arterial blood gases are within normal limits. B. The client appears anxious, has dyspnea, and is tachypneic. C. The client has intercostal retractions and is using accessory muscles. D. The client's bilateral lung sounds have crackles and rhonchi.

B The client would have low arterial oxygen when developing ARDS.Initial clinical manifestations of ARDS usually develop 24 to 48 hours after the initial insult leading to hypoxia and include anxiety, dyspnea, and tachypnea. As ARDS progresses, the client has more difficulty breathing, resulting in intercostal retractions and use of accessory muscles.Lungs are initially clear; crackles and rhonchi develop in later stages of ARDS.

Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator? A. The client's urine output is 100 mL in four (4) hours. B. The pulse oximeter reading is greater than 95%. C. The client has asymmetrical chest expansion. D. The telemetry reading shows sinus tachycardia.

C A urine output of 30 mL/hr indicates the kidneys are functioning properly or 120 mL in four (4) hours. This indicates the client is being adequately oxygenated. Asymmetrical chest expansion indicates the client has had a pneumothorax, which is a complication of mechanical ventilation. An increased heart rate does not indicate a complication; this could result from numerous reasons, not specifically because of the ventilator.

Which action would the nurse take to decrease a clients risk for sensory and cognitive disturbances after coronary artery bypass surgery? A. Restrict family visiting times to a few hours daily B. Withhold analgesic medication during the day C. Plan to minimize interruption of sleep at night D. Place the client in a room near the nurses station

C Because sleep deprivation can cause sensory and cognitive disturbances, the nurse will plan to avoid unnecessarily waking the client during the night. Lack of contact with significant others increases anxiety and feelings of isolation, which can lead to disturbances in sensory and cognitive function. Overuse of opiate analgesics my cause delirium, analgesics are needed after surgery to allow clients to do postoperative therapies such as coughing, deep breathing, and ambulating during the day. Rooms near the nurses station are usually noisier and have more light, leading to poor sleep and increased risk for cognitive and sensory changes.

The nurse is caring for clients on a medical unit. Which assessment data indicates a critical oxygenation problem for the client? A. The client with an anterior upper left chest tube is splinting the dressing with a pillow. B. The male client on oxygen is coughing forcefully, making it hard to catch his breath. C. The client who is at rest has circumoral cyanosis and is difficult to arouse. D. The female client complains of shortness of breath while ambulating in the hallway.

C Chest tubes are painful; splinting the insertion site can help to lessen the pain. Coughing indicates the ability to move air in and out of the lungs. This is not a critical issue. This client with a lack of oxygenation at rest, blueness around the mouth, and who is difficult to arouse indicates a decrease in neurological functioning. Dyspnea on exertion is not a critical issue.

The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? A. Confirm that the ventilator settings are correct. B. Verify that the ventilator alarms are functioning properly. C. Assess the respiratory status and pulse oximeter reading. D. Monitor the client's arterial blood gas results.

C Maintaining ventilator settings and checking to ensure they are specifically set as prescribed is appropriate, but it is not the first intervention. Making sure alarms are functioning properly is appropriate, but checking a machine is not priority. Assessment is the first part of the nursing process and is the first intervention the nurse should implement when caring for a client on a ventilator. Monitoring laboratory results is an appropriate intervention for the client on a ventilator, but monitoring laboratory data is not the priority intervention.

Which arterial blood gas (ABG) results support the diagnosis of acute respiratory distress syndrome (ARDS) after the client has received O2 at 10 LPM? A. pH 7.38, Pao2 94, Paco2 44, Hco3 24. B. pH 7.46, Pao2 82, Paco2 34, Hco3 22. C. pH 7.48, Pao2 59, Paco2 30, Hco3 26. D. pH 7.33, Pao2 94, Paco2 44, Hco3 20.

C This ABG is within normal limits and would not be expected in a client with ARDS. These ABG levels indicate respiratory alkalosis, but the oxygen level is within normal limits and would not be expected in a client with ARDS. ABGs initially show hypoxemia with a Pao2 of less than 60 mm Hg and respiratory alkalosis resulting from tachypnea in a client with ARDS. This ABG is metabolic acidosis and would not be expected in a client with ARDS.

The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube (ET) care? A. Do not move or touch the ET tube. B. Obtain a chest x-ray daily. C. Determine if the ET cuff is deflated. D. Ensure that the ET tube is secure.

D Alternating the ET tube position will help prevent a pressure ulcer on the client's tongue and mouth. A CXR is performed immediately after insertion of the ET tube but not daily. The cuff should be inflated but no more than 25 cm H2O to ensure no air leakage and must be checked every four (4) to eight (8) hours, not daily. The ET tube should be secure to ensure it does not enter the right main bronchus. The ET tube should be one (1) inch above the bifurcation of the bronchi.

Name the 2 main treatment options for ARDS

Mechanical Ventilation Prone position

Name 3 causes of ARDS

Sepsis Chest trauma Inhalation injury