Ch. 15 Acute Respiratory Failure

Intrapulmonary Shunting

- Blood shunted from right to left side of heart without oxygenation - Goes right to left and misses the spot to get oxygen - Blood goes past the lung and returns unoxygenated blood to the left side of the heart

ARF

- failure to oxygenate and/or remove CO2 - altered gas exchange (RA)

hypoventilation causes

-Drug overdose causing CNS depression -Neurological disorders that dec rate and depth of respirations -Abdominal or thoracic surgery leading to shallow breathing patterns

B Fluid prevents the diffusion of gases. It does not cause atelectasis or hypoventilation. Fluid can be present in the alveoli secondary to heart failure; however, there are other causes as well, such as acute respiratory distress syndrome

5. When fluid is present in the alveoli what is the result? a.Alveoli collapse and atelectasis occurs. b.Diffusion of oxygen and carbon dioxide is impaired. c.Hypoventilation occurs. d.The patient is in heart failure.

100

A 31-year-old female admitted to the critical care unit with respiratory distress after getting the "flu." Her condition worsens; SpO2 is 85% on Venturi mask at 50%. ABGs show a PaO2 of 50 mm Hg. Her chest x-ray is showing infiltrates. Calculate Mrs. J.'s PaO2/FiO2 ratio and interpret the findings.

B Enoxaparin, or low-molecular weight heparin, is recommended for patients at high risk for PE. This patient is at high risk and the medication is indicated. It is given subcutaneously, not by mouth. The drug prevents clots from forming but does not dissolve them.

A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse should provide the patient with what explanation? a."I'm going to contact the pharmacist to see if you can take this medication by mouth." b."This injection is being given to prevent blood clots from forming." c."This medication will dissolve any blood clots you might get." d."I will contact your primary care provide to discuss why you are getting this medication."

d

A patient in acute respiratory failure is experiencing carbon dioxide narcosis secondary to increased CO2 retention. What assessment finding should the nurse expect? a. Nasal flaring b. Paradoxical respirations c. Suprasternal muscle retractions d. Somnolence

c

A patient presents to the emergency department in acute respiratory distress. She has a long-standing history of COPD. Which of the following positions should the nurse place this patient in for optimal tissue perfusion? a. In a recliner, leaning back as far as it will go b. Side-lying with head of bed at 15 degrees c. Stretcher with head of bed as high as it will go d. Prone on a stretcher

C Noninvasive measures are often recommended in the initial treatment of the patient with chronic obstructive pulmonary disease to prevent intubation and ventilator dependence. The history of chronic obstructive pulmonary disease increases the risk for ventilator dependence, so noninvasive options are a priority. Bag-valve ventilation with 100% oxygen is not required at this time and could depress the respiratory drive that exists. Emergency tracheostomy is not indicated, as there is an indication of an obstructed airway

A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation? a.Emergency tracheostomy and mechanical ventilation b.Mechanical ventilation via an endotracheal tube c.Noninvasive positive-pressure ventilation (NPPV) d.Oxygen at 100% via bag-valve-mask device

PE Tx

ABCs; oxygen Thrombolytics (dissolve the clots) Heparin Monitor laboratory results for ØBleeding ØThrombocytopenia Surgical procedures ØEmbolectomy ØVena cava umbrella (prevention) •Tiny screen that lets the blood go through but catches the clots from going in the lungs

moderate

ARDS PaO2/FIO2 ratio 101-200 is ___ ARDS

mild

ARDS PaO2/FIO2 ratio 201-300 is ___ ARDS

severe

ARDS PaO2/FIO2 ratio less than 100 is ___ ARDS

200

ARDS diagnosis is confirmed when PaO2/FiO2 ratio is less than ___

PE Dx

Clinical signs and symptoms d-dimer assay (positive) V/Q scan with high probability of PE Duplex ultrasound (DVT) Gold standard: ØReplaces Angiography-High-resolution multidetector computed tomography angiography (MDCTA; spiral CT) Pulmonary angiogram

ARF Management

Correct hypoxemia ØCautious administration of O2 •Don't want them at 100% but assist them the best you can ØNoninvasive positive-pressure ventilation ØVentilatory assistance •Don't put them on ventilators unless you have to Medications ØBeta2 agonists (bronchodilators) ØCorticosteroids ØAntibiotics (depends on cause) ØCautious administration of sedatives

A Proning is considered if the PaO2/FiO2 ratio is low. The patient is not responding to treatment, and all options should be considered. The patient remains at risk for skin breakdown due to immobility; during proning, the risk is in the dependent areas such as the face. Proning is a labor-intensive procedure, and the nurse needs help from team members to ensure a safe turn, including protecting the airway. Continuous lateral rotation is a therapy done in the supine position with a specialized bed.

During rounds, the primary care provider (PCP) alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse should have what understanding about the benefit of proning? a.It is an optional treatment if the PaO2/FiO2 ratio is less 100. b.It presents less of a risk for skin breakdown because the patient is face down. c.It is possible with minimal help from co-workers. d.It is used to provide continuous lateral rotational turning

ARDS symptoms

Dyspnea and tachypnea Hyperventilation with normal breath sounds Respiratory alkalosis Increased temperature and pulse Worsening chest x-rays that progress to "white out" Increased PIP on ventilation Eventual severe hypoxemia

VAP Prevention

Education in airway management Hand washing with alcohol prior to airway management ØClosed suction Surveillance: XR ØControl cuff pressure ØTake off vent asap Ventilator bundle Prevent transmission ØSterile water in circuit ØDrain condensate AWAY from patient ØAvoid normal saline during suctioning Will spread bacteria around bacterial specific abx Prevent infection and aspiration ØAvoid reintubation ØOral intubation •Chlorhexidine oral care ØETT with continuous aspiration of subglottic secretions ØSedation and weaning protocols ØAseptic suctioning of endotracheal tube (ETT) Nutrition Mobilization HOB elevation

VAP Bundle

Elevate head of bed 30 to 45 degrees ØKeep gastric secretions down and dec occurrence of regurgitation Awaken daily ("sedation vacation") and assess readiness to wean and extubate Stress ulcer disease prophylaxis Venous thromboembolism (VTE) prophylaxis ØCan occur due to bedrest ØNeed anti-embolitics, ROM, SCDs Oral care with chlorhexidine Øto dec bacterial occurrence in mouth and keep it from migrating past the mouth

PE

Embolus results in a lack of perfusion to ventilated alveoli (V/Q mismatch)

c

Evidence-based interventions for the prevention of VAP include: A. Head of bed (HOB) flat with patient supine B. Readiness-to-wean trials every other day C. Regular antiseptic oral care D. Deep vein thrombosis (DVT) prophylaxis on select patients

CF

Genetic disorder Mutation in chloride transport results in "sticky" mucus that obstructs glands: ØLungs (greatest effect) ØPancreas ØLiver ØSalivary glands ØTestes Thick mucus in lungs is medium for infection, chronic bronchitis, and ARF Considered to be a disease of childhood Improvements in care have prolonged life expectancy

D Central nervous system signs, such as restlessness, are early indications of low oxygen levels. Clubbing is a sign of chronic hypoxemia. Cyanosis is a late sign of hypoxemia. Tachycardia and increased blood pressure, not hypotension, may be seen early in hypoxemia

In assessing a patient, the nurse understands that what symptomology is an early sign of hypoxemia? a.Clubbing of nail beds b.Cyanosis c.Hypotension d.Restlessness

C Shunting refers to blood that is not oxygenated in the lungs.

Intrapulmonary shunting refers to what outcome? a.Alveoli that are not perfused. b.Blood that is shunted from the left side of the heart to the right and causes heart failure. c.Blood that is shunted from the right side of the heart to the left without oxygenation. d.Shunting of blood supply to only one lung.

b

Lung-protective strategies for mechanical ventilation to treat acute respiratory distress syndrome while also preventing complications include which of the following? a. Positive end-expiratory pressure (PEEP) 25 cm H2O or higher b. Low tidal volume of 6 mL/kg ideal body weight c. High levels of sedation d. Oxygen levels (FiO2) 0.80-1.00

b

Lung-protective ventilation strategies include: A. Tidal volume (VT) calculated according to current patient weight B. VT at 4 to 8 mL/kg predicted ideal body weight C. Consistent use of 100% fraction of inspired oxygen (FiO2) D. Positive end-expiratory pressure (PEEP) levels of 30 cm H20 for 8 hours each day

Perfusion Interventions

Maintain a patent airway Optimize O2 delivery Minimize O2 demand Identify and treat the cause of ARF Prevent complications

V/Q Mismatch Causes

Occurs when either V or Q is dec

pneumonia

Organisms in lower respiratory tract to overwhelm defense mechanisms

Asthma ARF Meds

Oxygen; ventilation in severe cases IV corticosteroids Inhaled bronchodilators; rapid-acting beta2-agonists Teaching ØEnvironmental controls to prevent sx ØUnderstand the differences between meds that relieve and control sx •Medication adherence ØProperly use inhaler devices and to monitor the level of asthma control ØPosition in high-fowlers: don't prone because it's not fluid related and this isn't good for the anxious patient

hypercapnia ARF T2

PaCO2 over 50

225

PaO2 = 90 on 40% O2 (FIO2=0.40) What's the PaO2/FIO2 Ratio?

Causes of V/Q Mismatch

PaO2 can't be maintained Hypoventilation Intrapulmonary shunting ØNot getting oxygenated, mismatch somewhere Ventilation-perfusion mismatch ØSeen in a PE: perfusing the lungs but a clot is blocking a branch and blood passes right by it Diffusion defects Decreased barometric pressure Low cardiac output (non-pulmonary hypoxemia) Low hemoglobin level (non-pulmonary hypoxemia)

hypoxemia ARF T1

PaO2 less than 60

60

PaO2= 60 on 100% O2 (FIO2= 1.0) What's the PaO2/FIO2 Ratio?

B Hypoventilation is common after overdose and results in impaired elimination of carbon dioxide and respiratory acidosis. The overdose depresses the respiratory drive, which results in hypoventilation, not hyperventilation. Hypoxemia is expected secondary to depressed respirations.

The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration? a.Hyperventilation and respiratory acidosis b.Hypoventilation and respiratory acidosis c.Hypoventilation and respiratory alkalosis d.Respiratory acidosis and normal oxygen levels

pneumonia prevention

Pneumococcal vaccine for 65+ and flu vaccine 6 months+

VAP

Pneumonia that develops in a pt who is intubated and ventilated at the time of or within 48 hrs prior to the onset of the event and is now included as one of several problems of oxygenation Aspiration of bacteria from oropharynx or gastrointestinal tract Many potential causes Controversies about best way to diagnose—no "gold standard" ØNew or progressive pulmonary infiltrate with fever, leukocytosis, purulent tracheobronchial secretions

d

Possible treatments for ARF in the pt with COPD include: A. Noninvasive ventilation B. Bronchodilators C. Corticosteroids D. All the above

e

Pt at risk for development of DVT may include: A. Those older than 75 years B. Those who are immobile for longer than 3 days C. Pregnant women D. Patients with burn injury E. All the above

PE Assessment

Symptoms of deep venous thrombosis Chest pain (worse on inspiration) Dyspnea Tachycardia Tachypnea Cough; hemoptysis Crackles, wheezes Hypoxemia

d

The Berlin criteria for ARDs includes: a.Acute onset within 1 week after clinical insult b.Bilateral pulmonary opacities not explained by other conditions c.Alerted partial pressure of PaO2/FiO2 ratio d.All of the above

A Damage to the alveolar-capillary membrane results in noncardiogenic pulmonary edema. None of the other responses apply

The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to form of damage? a.Alveolar-capillary membrane b.Left ventricle c. Mainstem bronchus d.Trachea

c

The etiology of pulmonary edema in acute respiratory distress syndrome is related to: a. tension pneumothorax. b. decreased cardiac output. c. damage to the alveolar-capillary membrane. d. volutrauma and hypoxemia.

B A normal PAOP with hypoxemia is an expected assessment finding in ARDS. Cardiac output of 10 L/min and low systemic vascular resistance are expected findings in sepsis. PAOP of 20 mm Hg and cardiac output of 3 L/min are expected findings in heart failure. PAOP of 5 mm Hg and high systemic vascular resistance are expected findings in hypovolemic shock

The nurse assessing a patient diagnosed with acute respiratory distress syndrome expects what assessment finding? a.Cardiac output of 10 L/min and low systemic vascular resistance. b.PAOP of 10 mm Hg and PaO2 of 55. c.PAOP of 20 mm Hg and cardiac output of 3 L/min. d.PAOP of 5 mm Hg and high systemic vascular resistance.

B 78/0.60 = 130, which meets the criteria for ARDS.

The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO2 is 0.6 (60%). What is the outcome and the relationship to the ARDS diagnosing criteria? a.46.8; meets criteria for ARDS b.130; meets criteria for ARDS c.468; normal lung function d.Not enough data to compute the ratio

A, B, D Condensate should be drained away from the patient to avoid drainage back into the patient's airway. Prevention guidelines recommend elevating the head of bed at 30 to 45 degrees. A highly recommended strategy includes two to three doses of antibiotic during intubation of those with previous decreased level of consciousness. Regular antiseptic oral care, with an agent such as chlorhexidine, reduces oropharyngeal colonization. Normal saline is not recommended as part of the suctioning procedure, and it may increase the risk for infection.

The nurse caring for a mechanically ventilated patient prepares to include which strategies to prevent ventilator-associated pneumonia should be into the patient's plan of care? (Select all that apply.) a.Drain condensate from the ventilator tubing away from the patient. b.Elevate the head of the bed 30 to 45 degrees. c.Instill normal saline as part of the suctioning procedure. d.Perform regular oral care with chlorhexidine. e.Administer antibiotic therapy as prescribed

D Repositioning the patient will facilitate mobilization of secretions. Elevating the head of bed is an intervention to prevent infection. Venous thromboembolism prophylaxis is ordered to prevent complications of immobility. Sedation is an intervention to manage anxiety, and administration of sedatives increases the risk for retained secretions.

The nurse caring for a patient diagnosed with acute respiratory failure identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. What nursing intervention is relevant to this diagnosis? a. Elevate head of bed to 30 degrees. b. Obtain order for venous thromboembolism prophylaxis. c. Provide adequate sedation. d. Reposition patient every 2 hours.

C Exacerbation of asthma is often related to not adhering to the therapeutic regimen; patient teaching is essential. Follow-up studies will be determined by the physician. Activity is based on the patient's activity tolerance and is not limited. Medications are taken regularly to avoid exacerbation. Only rescue medications are used on a prn basis.

The nurse discharging a patient diagnosed with asthma instructs the patient to prevent exacerbation by taking what action? a.Obtaining an appointment for follow-up pulmonary function studies 1 week after discharge. b.Limiting activity until patient is able to climb two flights of stairs. c.Taking all asthma medications as prescribed. d.Taking medications on a "prn" basis according to symptoms.

a, c

The nurse is assessing a patient for a possible pulmonary embolus. Assessment findings may include which of the following? (Select all that apply.) Select all that apply. a. Acute onset of chest pain b. Nausea c. Hypoxemia d. Decreased level of consciousness

a

The nurse is caring for a patient at risk for respiratory failure. Which assessment findings would alert the nurse to potential respiratory failure? a. Anxiety and restlessness b. Cyanosis and hyperventilation c. Dyspnea and nasal flaring d. Hypertension and bradycardia

A, B, C Patients in respiratory distress are unable to tolerate a flat position. High Fowler's is appropriate. Side lying with head of bed elevated, sitting in a chair, and high Fowler's position are all appropriate ways to position the patient to facilitate gas exchange and comfort. Prone positioning would impede breathing

The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned (Select all that apply.) a.high Fowler's. b.side lying with head of bed elevated. c.sitting in a chair. d.supine with the bed flat. e.prone with face turned to the left

a All are important, but protection of the airway is the most important intervention if the patient is placed in the prone position.

The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following? a.Management and protection of the airway b.Prevention of gastric aspiration c.Prevention of skin breakdown and nerve damage d.Psychological support to patient and family

C Paralysis and additional sedation may be needed if the patient requires nontraditional ventilation. Guided imagery is an excellent non-pharmacological approach to manage anxiety; however, the non-traditional mode of ventilation usually requires that the patient receive neuromuscular blockade. Prone positioning is a treatment for refractory hypoxemia but not indicated until the neuromuscular blockade has been tried.

The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The primary care provider (PCP) orders a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the PCP of this assessment and anticipates what order? a.Continuous lateral rotation therapy b.Guided imagery c.Neuromuscular blockade d.Prone positioning

A, B, C The three cornerstones of care for a patient with CF are antibiotic therapy, airway clearance, and nutritional support. A tracheostomy and cardiac monitoring are not standard treatments for CF.

The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply.) a.Airway clearance therapies b.Antibiotic therapy c.Nutritional support d.Tracheostomy e.Cardiac monitoring

a, b, c, d

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.) Select all that apply. a. Oxygen administration b. Inhaled rapid-acting beta-2 agonists c. Systemic corticosteroids d. Inhaled anticholinergic agent

B Change in the character of sputum may signal the development of a respiratory infection in the patient with COPD. Additional symptoms include anxiety, wheezing, chest tightness, tachypnea, tachycardia, fatigue, malaise, confusion, fever, and sleeping difficulties

The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia? a.Bradycardia b.Change in sputum characteristics c.Hypoventilation and respiratory acidosis d.Pursed-lip breathing

D Mobility helps to prevent deep vein thrombosis and pulmonary embolus. Oral care, head of bed elevation, and coughing and deep breathing assist in preventing pneumonia

The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which intervention? a.Antiseptic oral care b.Bed rest with head of bed elevated c.Coughing and deep breathing d.Mobility

B The influenza vaccine reduces the risk of pneumonia by over a half. The pneumococcal vaccine is important but only protects against pneumococcal infection. Cold, drafty environments will not cause infection. Immunity for pneumonia does not occur as a result of getting it

The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse should provide instruction? a."If you get the pneumococcal vaccine, you'll never get pneumonia again." b."It is important for you to get an annual influenza shot to reduce your risk of pneumonia." c."Stay away from cold, drafty places because that increases your risk of pneumonia when you get home." d."Since you have been treated for pneumonia, you now have immunity from getting it in the future."

c

The nurse is drawing labs on a patient with COPD in the critical care unit. Which baseline arterial blood gases (ABGs) should the nurse expect for this patient? a. PaO2 50 mm Hg and PaCO2 35 mm Hg b. PaO2 80 mm Hg and PaCO2 50 mm Hg c. PaO2 55 mm Hg and PaCO2 55 mm Hg d. PaO2 75 mm Hg and PaCO2 40 mm Hg

a

The nurse is listening to a lecture on the physiological consequences of acute respiratory distress syndrome (ARDS). Which statement indicates that teaching has been effective? a. "ARDS is associated with decreased compliance." b. "ARDS is associated with Pulmonary fibrosis." c. "ARDS is associated with decreased physiological dead space." d. "ARDS is associated with increased resistance."

a

The nurse is orienting a new RN in the care of a patient with respiratory distress due to emphysema. The patient is being treated with O2 via a Venturi mask with 35% oxygen. Which statement by the new RN indicates that teaching has been effective, when the nurse questions the new RN about the use of the Venturi mask? a. "Her respiratory center requires low O2 concentration to stimulate breathing." b. "Her alveoli cannot absorb higher levels of O2 because of the emphysema." c. "A nasal cannula will dry the mucous membranes and cause an increased risk of infection." d. "Her alveoli have been damaged and may rupture with higher doses of O2."

A Patients with ARDS often have hypoxemia refractory to treatment. Surfactant levels are often diminished in ARDS. Compliance decreases in ARDS. In early ARDS, hyperventilation may occur along with respiratory alkalosis

The patient diagnosed with acute respiratory distress syndrome (ARDS) would exhibit which symptom? a.Decreasing PaO2 levels despite increased FiO2 administration b.Elevated alveolar surfactant levels c.Increased lung compliance with increased FiO2 administration d.Respiratory acidosis associated with hyperventilation

30-45

To prevent VAP, what is the recommended elevation for HOB?

ARDS Tx

Treat the cause Oxygenation and ventilation ØOptimal Positive end-expiratory pressure (PEEP) ØPossible nontraditional modes of ventilation: high-frequency, pressure-control, and inverse-ratio Comfort ØSedation ØPain relief ØNeuromuscular blockade Decrease O2 consumption Positioning ØProne positioning •Makes the work of breathing easier - gravity helps pull secretions away ØContinuous lateral rotation therapy Fluid and electrolyte balance Adequate nutrition Pharmacologic intervention Psychosocial support

A, C Diagnostic criteria for ARDS include acute onset within 7 days of clinical insult, bilateral infiltrates, or "white out," on chest x-ray study and a low PaO2/FiO2 ratio. Decreased cardiac output and a high PAOP are seen in pulmonary edema associated with cardiac causes. Decreased cardiac output and a high PAOP are seen in pulmonary edema associated with cardiac causes.

What are the diagnostic criteria for acute respiratory distress syndrome (ARDS)? (Select all that apply.) a.Bilateral infiltrates on chest x-ray study b.Decreased cardiac output c.PaO2/FiO2 ratio of less than 200 d.Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg e.Acute onset within 7 days of clinical insult

C High-resolution multidetector CT angiography (MDCTA), also called spiral CT, is the preferred tool for detecting a PE. It is highly accurate for direct visualization of large emboli in the main and lobar pulmonary arteries. MDCTA does not always visualize small emboli in distal vessels, but a pulmonary angiogram has the same limitation. ABG would only indicate hypoxemia and/or acid-base abnormalities. A chest x-ray study is nonconclusive. A ventilation-perfusion scan is nonconclusive.

What diagnostic procedure is required to make a definitive diagnosis of pulmonary embolism? a.Arterial blood gas (ABG) analysis. b.Chest x-ray examination. c.High resolution multidetector CT angiogram. d.Ventilation-perfusion scanning.

C A filter may be inserted as a prevention measure in patients who are at high risk for thromboembolism. Aspirin is not a preventive therapy. Thrombolytics are given to treat, not prevent, pulmonary embolism. Heparin is administered as a prophylaxis in acute care settings. Coumadin is given for long-term prevention in patients at high risk for VTE.

What is a strategy for preventing thromboembolism in patients at risk who cannot take anticoagulants? a.Administration of two aspirin tablets every 4 hours. b.Infusion of thrombolytics. c.Insertion of a vena cava filter. d.Subcutaneous heparin administration every 12 hours

C Acute respiratory distress syndrome results in damage to the pneumocytes, increased capillary permeability, and noncardiogenic pulmonary edema

What is the basic underlying pathophysiology of acute respiratory distress syndrome? a.A decrease in the number of white blood cells available. b.Damage to the right mainstem bronchus. c.Damage to the type II pneumocytes, which produce surfactant. d.Decreased capillary permeability.

B The most common cause of a pulmonary embolus is deep vein thrombosis. The other responses are less common causes.

What is the most common cause of a pulmonary embolus? a.An amniotic fluid embolus. b.A deep vein thrombosis from lower extremities. c.A fat embolus from a long bone fracture. d.Vegetation that dislodges from an infected central venous catheter.

B Inhaled bronchodilators and intravenous corticosteroids are standard treatment for the exacerbation of asthma; they promote dilation of the bronchioles and decreased inflammation of the airways. Proning and continuous lateral rotation are therapies to treat hypoxemia secondary to acute respiratory distress syndrome. Sedation is not recommended

What is the treatment for an acute exacerbation of asthma? a.Corticosteroids and theophylline by mouth b.Inhaled bronchodilators and intravenous corticosteroids c.Prone positioning or continuous lateral rotation d.Sedation and inhaled bronchodilators

A, B, C Graduated compression stockings, sequential compression devices, and anticoagulation can reduce the risk for DVT. Duplex ultrasonography (compression ultrasound) is a noninvasive imaging study that is useful in detecting lower-extremity DVT not preventing them. Physical activity can also reduce the risk; bed rest increases the risk.

What strategies are appropriate for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE) in an at-risk patient? (Select all that apply.) a.Graduated compression stockings b.Heparin or low-molecular weight heparin c.Sequential compression devices d.Strict bed rest e.Providing education regarding compression ultrasound

a

Which abg alterations in pneumonia are expected? Hypoxemia and respiratory alkalosis Normal o2 and respiratory acidosis Hypoxemia and metabolic acidosis Normal Values

C Although the patient with a severe exacerbation of asthma hyperventilates, gas exchange is impaired, which causes respiratory acidosis

Which acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma? a.Metabolic acidosis b.Metabolic alkalosis c.Respiratory acidosis d.Respiratory alkalosis

B Increased peak inspiratory pressures are often early indicators of ARDS. Oxygen saturation decreases in ARDS. Chest x-ray study will show progressive infiltrates. In ARDS, a PaO2/FiO2 ratio less than 200 is a criterion

Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS) in a patient admitted with respiratory distress? a.Increased oxygen saturation via pulse oximetry b.Increased peak inspiratory pressure on the ventilator c.Normal chest radiograph with enlarged cardiac structures d.PaO2/FiO2 ratio > 300

A, B, C, D Options A, B, C, and D are components of the IHI ventilator bundle. Oral care with chlorhexidine has recently been added to the IHI bundle. Swabbing alone provides comfort care

Which of the following are components of the Institute for Healthcare Improvement's (IHI's) ventilator bundle? (Select all that apply.) a.Interrupt sedation each day to assess readiness to extubate. b.Maintain head of bed at least 30 degrees elevation. c.Provide deep vein thrombosis prophylaxis. d.Provide prophylaxis for peptic ulcer disease. e.Swab the mouth with foam swabs every 2 hours

c

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

A, B, C, D Ventilatory support for ARDS typically includes PEEP to restore functional residual capacity, open collapsed alveoli, prevent collapse of unstable alveoli, and improve arterial not venous oxygenation

Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of acute respiratory distress syndrome (ARDS)? (Select all that apply.) a.Increase functional residual capacity b.Prevent collapse of unstable alveoli c.Improve arterial oxygenation d.Open collapsed alveoli e.Improve venous oxygenation

d

Which of the following treatments should the nurse anticipate administering to a hypoxic patient admitted with exacerbation of COPD? a. Continuous positive airway pressure (CPAP) via face mask b. Bag-valve-mask ventilation with oxygen at 15 L/min c. Non-rebreather mask with 80% oxygen d. Oxygen via Venturi mask at 40% oxygen

B, C, D A comprehensive oral care protocol is an intervention for preventing VAP. It includes oral suction, brushing teeth every 12 hours, and swabbing. Chlorhexidine gluconate has been effective in patients who have undergone cardiac surgery but brushing the teeth should be avoided for at least 2 hours after its use.

Which statement is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.) a.Tooth brushing is performed every 2 hours for the greatest effect. b.Implementing a comprehensive oral care program is an intervention for preventing VAP. c.Oral care protocols should include oral suctioning and brushing teeth. d.Protocols that include chlorhexidine gluconate have been effective in preventing VAP. e.Avoid brushing teeth for two hours after chlorhexidine use.

A PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. Dyspnea, hemoptysis, and chest pain have been called the "classic" signs and symptoms for PE, but the three signs and symptoms actually occur in less than 20% of cases. Bradycardia and hyperventilation are not classic signs of PE. Most critically ill patients are at high risk for VTE and all should receive prophylaxis

Which statement is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)? a.PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. b.Bradycardia and hyperventilation are classic symptoms of PE. c.Dyspnea, chest pain, and hemoptysis occur in nearly all patients with PE. d.Most critically ill patients are at low risk for VTE and PE and do not require prophylaxis.

D Thrombolytics are useful in the management of pulmonary embolus and are given to dissolve the clot. Heparin will prevent further clot formation, but it will not dissolve the clot. Aspirin is not a thrombolytic agent. An embolectomy is a surgical procedure to remove the clot. Heparin will prevent further clot formation, but it will not dissolve the clot.

Which treatment can be used to dissolve a thrombus that is lodged in the pulmonary artery? a.Aspirin b.Embolectomy c.Heparin d.Thrombolytics

ARF in COPD

Worsening V/Q mismatch (e.g., secretions and bronchoconstriction can lead to ARF) ØLot of secretions you can't get out and can lead to failure Causes: acute exacerbations, CHF/ pulmonary edema, dysrhythmias, pneumonia, dehydration, and electrolyte imbalances Condition is chronic respiratory failure, but the have exacerbations and acute failure

ARDs

acute and diffuse injury to the lungs and leading to respiratory failure

VAP Tx

bacteria specific abx

V/Q Mismatch

blood supply isn't getting the O2 supply.

pneumonia inc risk

elderly, alcoholic, smokers, chronic diseases, head injury, immunosuppression

diffusion

movement of gas from an area of high concentration to a low concentration

bc the pt are noncompliant with meds

what's the main reason asthma exacerbations occur?

CF Tx

ØAntibiotic therapy ØAirway clearance ØNutritional support ØVentilatory support ØPseudomonas aeruginosa is the most common pathogen found in adult patients with CF Focus of care is to prevent respiratory failure ØCan't fix it, but want to prevent it from accelerating lung transplantation

asthma exacerbation causes

ØBronchodilators no longer working ØNoncompliance with medications ØHyperventilation with air trapping results in respiratory acidosis Severe hypoxemia

PE Virchows Triad

ØVenous stasis ØAltered coagulability ØDamage to vessel wall