ARDS

You're teaching a class on critical care concepts to a group of new nurses. You're discussing the topic of acute respiratory distress syndrome (ARDS). At the beginning of the lecture, you assess the new nurses understanding about this condition. Which statement by a new nurse demonstrates he understands the condition?

"This condition develops because alveolar capillary membrane permeability has changed leading to fluid collecting in the alveoli sacs." (ARDS is a type of respiratory failure that occurs when the capillary membrane that surrounds the alveoli sac becomes damaged, which causes fluid to leak into the alveoli sac. )

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 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 provides teaching regarding nitric oxide inhalation therapy. Which of the following statements made by the patient indicates teaching was effective?

"This medication will relax vessels in my lungs and help me to breathe better."

You're precepting a nursing student who is assisting you care for a patient on mechanical ventilation with PEEP for treatment of ARDS. The student asks you why the PEEP setting is at 10 mmHg. Your response is:

"This pressure setting helps open the alveoli sacs that are collapsed during exhalation." (This setting of PEEP (it can range between 10 to 20 mmHg of water) and it helps to open the alveoli sacs that are collapsed, especially during exhalation.)

Pharmacological therapy for ARF:

--ARF is irreversible, no cure/definitive drug therapy -Nitric Oxide (relaxes smooth muscle) -Corticosteroids (methylprednisolone) -Surfactant therapy -Treatment of initial insult

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?

-Agitation/anxiety -Confusion

A patient is on mechanical ventilation with PEEP (positive end-expiratory pressure). Which finding below indicates the patient is developing a complication related to their therapy and requires immediate treatment?

-Blood pressure 70/45 (Mechanical ventilation with PEEP can cause issues with intrathoracic pressure and decrease the cardiac output (watch out for a low blood pressure) along with hyperinflation of the lungs (possible pneumothorax or subq emphysema which is air that escapes into the skin because the lungs are leaking air).)

You are caring for a patient with acute respiratory distress syndrome. As the nurse you know that prone positioning can be beneficial for some patients with this condition. Which findings below indicate this type of positioning was beneficial for your patient with ARDS?

-Improvement in lung sounds -PaO2 increased from 59 mmHg to 82 mmHg (Prone positioning helps improve PaO2 (82 mmHg is a good finding) without actually giving the patient high concentrations of oxygen. It helps improves perfusion and ventilation (hence correcting the V/Q mismatch). In this position, the heart is no longer laying against the posterior part of the lungs (improves air flow...hence improvement of lung sounds) and it helps move secretions from other areas that were fluid filled and couldn't move in the supine position, hence helping improve atelectasis.)

Which of the following are nursing interventions for a patient receiving mechanical ventilation?

-Rotate endotracheal tube once a shift. -Verify ventilator settings once a shift. -Provide chest physiotherapy

Which of the following are common insults that may lead to the development of ARDS?

-Sepsis -Aspiration -Pancreatitis -Chest Trauma -Pneumonia -Multiple transfusions (transfusion related acute lung injury)

As the nurse you know that acute respiratory distress syndrome (ARDS) can be caused by direct or indirect lung injury. Select below all the INDIRECT causes of ARDS:

-Sepsis -Trauma -Blood transfusion -Pancreatitis (autodigestion can lead to insult) (Indirect causes are processes that can cause inflammation OUTSIDE of the lungs....so the issue arises somewhere outside the lungs. Therefore, sepsis (infection...as long as it is outside the lungs), blood transfusion, and pancreatitis are INDIRECT causes.)

Non-pharmacologic therapy for ARDS

-prone positioning (bad side down so good side can breathe better) -Chest physiotherapy/postural drainage -LMWH (enoxaparin/lovenox) to prevent VTE/Disseminated intravascular coagulation (DIC) is a condition in which blood clots form throughout the body, blocking small blood vessels---possible ARDS complication

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?

1. Tachypnea 2. Tachycardia 3. Labored breathing 4. O2 saturation dropping 5. Any other signs of increasing respiratory distress

A patient is experiencing respiratory failure due to pulmonary edema. The physician suspects ARDS but wants to rule out a cardiac cause. A pulmonary artery wedge pressure is obtained. As the nurse you know that what measurement reading obtained indicates that this type of respiratory failure is NOT cardiac related?

<18 mmHg (A pulmonary artery wedge pressure measures the left atrial pressure. A pulmonary catheter is "wedged" with a balloon in the pulmonary arterial branch to measure the pressure. If the reading is less than 18 mmHg it indicates this is NOT a cardiac issue but most likely ARDS. Therefore, the pulmonary edema is due to damage to the alveolar capillary membrane leaking fluid into the alveolar sac....NOT a heart problem ex: heart failure.)

Which patient below is at MOST risk for developing ARDS and has the worst prognosis?

A 69-year-old female with sepsis caused by a gram-negative bacterial infection. (Sepsis is the MOST common cause of ARDS because of systemic inflammation experienced. This is also true if the cause of the sepsis is a gram-negative bacterium (this also makes the infection harder to treat...hence poor prognosis). With sepsis, the immune cells that are present with the inflammation travel to the lungs and damage the alveolar capillary membrane leading to fluid to leak in the alveolar sacs.)

Pneumothorax ventilator complication

Accumulation of air in the pleural space, also known as collapsed lungs.

Which of the following best describes what happens to the alveoli in ARDS?

Alveolar spaces are filled with fluid

As the nurse you know that acute respiratory distress syndrome (ARDS) can be caused by direct or indirect lung injury. Select below all the DIRECT causes of ARDS:

Aspiration -Pulmonary infections -Pneumonia -Drowning (Drowning, aspiration, and pneumonia are issues that arise in the lungs (therefore, they are DIRECT causes of lung injury).)

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?

Assess circuits and system for air leaks.

During the exudative/beginning phase of acute respiratory distress syndrome (ARDS), the patient's lung cells that produce surfactant have become damaged. As the nurse you know this will lead to?

Atelectasis (Surfactant decreases surface tension in the lungs. Therefore, the alveoli sacs will stay stable when a person exhales (hence the sac won't collapse). If there is a decrease in surfactant production this creates an unpredictable alveoli sac that can easily collapse, hence a condition called ATELECTASIS will occur (collapse of the lung tissue) when there is a decrease production in surfactant.)

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?

Barotrauma (such as pneumothorax)

The nurse should implement which of the following interventions for a ventilator?

Explain all care activities

Goal for mechanical ventilation

FiO2 (the fraction of inspired oxygen in the air) tritated to the lowest rate to maintain PaO2 >60 mmHg and O2 sat >90% (attempts to avoid FiO2 greater than 50% to avoid toxicity)

PSV (pressure support ventilation)

Gives defined amount of pressure with patient initiated breaths. No ventilator initiated breath.

Ventilator weaning

Gradual lessening of vent support -done when patient is deemed able to sustain effective spontaneous respirations -VS, ABG, dyspnea are used to evaluate -Sedation vacation/drug holiday -SIMV and PSV used for weaning (because the pt is initiating the breaths) Terminal weaning/extubation

A client with ARDS was anxious, is now less responsive & difficulty to arouse. This is likely due to:

Hypercapnia (hypercarbia)----excessive carbon dioxide in the bloodstream, typically caused by inadequate respiration.

A nurse is assessing a patient with multiple trauma who is at risk of developing ARDS. The nurse assesses for which of the earliest signs of ARDS?

Hypoxemia/hypoxia ----> Tachypnea, dyspnea, anxiety, use of accessory muscles, intercostal retractions (breathing from the abdomen), cyanosis (first seen in the buccal membranes), adventitious breath sounds (crackles and rhonchi), mental status changes (initially agitation/confusion ---> lethargy)

Cardiovascular ventilator complication

Increased pressure in chest decreases venous return and ventricular filling, decreases CO. Can cause hypoperfusion of liver and kidneys

Which of the following describes the underlying pathophysiology of Acute Respiratory Distress Syndrome (ARDS)?

Insulting agent causes fluid to accumulate in the alveoli which dilutes the surfactant and results in a decrease in lung compliance.

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:

Intercostal retractions

Interventions for nutritional imbalance:

Leads to: confusion, F&E imbalance, weakness Interventions:

Interventions for Hypoxia:

Leads to: dyspnea, tachypnea, intercostal retractions, tachycardia, cyanosis, atelectasis (Complete or partial collapse of a lung or a section (lobe) of a lung.) Interventions: Bronchodilators, steroids, O2, monitoring PA pressures and CO, mechanical ventilation, CPAP, prone positioning (laying on stomach) and surfactant therapy

Interventions for activity intolerance:

Leads to: irritability, fatigue, confusion, lethargy, self-care deficit Interventions:

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?

Lung sounds and chest rise is asymmetric

Nursing interventions for ARDS:

Maintaining airway patency, promoting spontaneous ventilation, enhancing cardiac output, monitor for ventilator weaning, anxiety/mentation

SIMV (synchronized intermittent mandatory ventilation)

No ventilator assistance between the set rate. Patient will pull their own volume on breaths outside the set limit

What are the expected outcomes (goal) of mechanical ventilation for a patient with ARDS?

O2 sat > 90% and Pa)2 >60 mmHg

Artificial Airways

OPA/NPA ETT Tracheostomy

You're providing care to a patient who was just transferred to your unit for the treatment of ARDS. The patient is in the exudative phase. The patient is ordered arterial blood gases. The results are back. Which results are expected during this early phase of acute respiratory distress syndrome that correlates with this diagnosis?

PaO2 40, pH 7.59, PaCO2 30, HCO3 23 (This option demonstrates respiratory alkalosis. In the early stages of ARDS (exudative) the patient will start to enter in respiratory alkalosis. The patient starts to have tachypnea (the body's way of trying to increase the oxygen level but it can't). They will have a very low PaO2 level (normal PaO2 is 80 mmHg), the blood pH will become high (normal is 7.35-7.45) (alkalotic). In the late stage, the patient can enter into respiratory acidosis.)

Patient nutririon

Parenteral (TPN via CL) Enteral (NG or OG tube feeding) -feeding based on how well the gut works

CPAP

Patient breathes on his or her own, just pressure to keep airway open

Which clinical manifestation is highly indicative of ARDS (as opposed to some other complication)?

Refractory hypoxemia

Diagnostics for ARF:

Refractory hypoxemia ABG---initially respiratory alkalosis r/t tachypnea----> progressing to respiratory and metabolic acidosis Other Diagnostics---Chest x-ray/CT (fluid), CBC/chemistries/blood cx (cause), sputum cultures

What is the purpose of nitric oxide?

Relaxes smooth muscle to dilate airways and increase gas exchange for patients with ARDS---vasodilator

Interpret the following blood gas result: pH = 7.49, PaO2 = 55, PaCO2 = 29, HCO3- = 25.

Respiratory alkalosis with hypoxemia

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.

The nurse would carefully assess a patient with which of the following for the development of ARDS?

Sepsis (and aspiration are the most likely to develop ARDS).

Definition of Acute Respiratory Distress Syndrome (ARDS):

Severe form of ARF--- noncardiac pulmonary edema with refractory hypoxemia (despite hi flow O2)

Which of the following interventions should the nurse anticipate implementing for a patient with ARDS?

Space out interventions, providing frequent rest periods

GI ventilator complication

Stress ulcers, constipation, gastric distension Intervention: Salem sump pump

Endotracheal tube

Terminates at bifurcation of the trachea into the bronchi. Air filled cuff (balloon) keeps in place and prevents air leakage around it

You're providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% non-rebreather mask. Which finding below is a HALLMARK sign and symptom that the patient is developing acute respiratory distress syndrome (ARDS)?

The patient's PaO2 remains at 45 mmHg. (A hallmark sign and symptom found in ARDS is refractory hypoxemia. This is where that although the patient is receiving a high amount of oxygen (here a 100% non-rebreather mask) the patient is STILL hypoxic. The patient's arterial oxygen level is remaining at 45 mmHg (a normal is 80 mmHg but when treating patients with ARDS a goal is at least 60 mmHg). Yes, the patient can be tired and confused from a low oxygen level BUT this question wants to know the HALLMARK sign and symptom.)

High pressure ventilator alarm

Urgent/Red alarm -Biting, blockage, ARDS (decrease in lung compliance)

AC - Assist Control Ventilation

all breaths delivered at a specific set TV. Ventilator will only initiate breaths if patient initiated rate falls below set rate

Low pressure ventilator alarm

indicates an air leak in the ET tube, a deflated cuff, or partial extubation.

HAP (hospital acquired pneumonia)

is a lower respiratory tract infection that develops in hospitalized patients after 48 hours, excluding infections already existing

PEEP

positive end expiratory pressure---added to keep alveoli open and promote better gas exchange----> adverse effects: increased pressure in chest, decreased CO and increase risk of barotrauma such as pneumothorax -pt must be intubated, given in addition to CPAP, AC, SIMV (if patient can protect own airway and doesn't require Endotracheal Tube (ETT), can receive Bipap or CPAP)

Barotrauma ventilator complication

pressure-related ear discomfort that can be caused by pressure changes when flying, driving in the mountains, scuba diving, or when the Eustachian tube is blocked

A patient has been hospitalized in the ICU for a near drowning event. The patient's respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS?

white-out infiltrates bilaterally (This is a finding found in ARDS....pronounced white-out infiltrates bilaterally.)