Oxygenation/Gas Exchange
B. Initiate mechanical ventilation Rationale: • Refractory hypoxemia with increasing oxygenation is a hallmark sign of acute respiratory distress syndrome (ARDS). An indirect cause of ARDS is neardrowning. This patient needs mechanical ventilation to increase oxygenation and decrease carbon dioxide levels. • The refractory hypoxemia is the key to what is going on with this patient; obtaining a chest x-ray or repeating ABGs is not the priority. A rate of 8 L/min of O 2 is high-level oxygenation. Mechanical ventilation is preferable to increasing the oxygen level again because it will help decrease the patient's work of breathing.
A patient is admitted to the ER following a near-drowning event. Two sets of arterial blood gases (ABGs) were ordered. The first set was done before oxygen therapy; the second was done after the patient received oxygenation therapy with continuous positive airway pressure (CPAP) at 8 L/min for one hour. The nurse reviews the results and expects that which intervention will be prescribed? 1st ABG: pH 7.2 pCO2 48 mmHg HCO3 30 PaO2 75% (before O2) 2nd ABG: pH 7.1 pCO2 50 mmHg HCO3 30 PaO2 60% (received O2) A. Obtain a stat CXR B. Initiate mechanical ventilation C. Repeat ABGs in 30 minutes D. Increase O2 level of CPAP to 10 L/min
Acute Respiratory Distress Syndrome
A syndrome of hypoxemic respiratory failure that leads to alveolar-capillary inflammation and damage causing the lung space to fill with fluid (ventilation-perfusion mismatch or shunt)
Insuffiecient O2 transfer to blood-->hypoxemia (decreased PaO2 and SaO2) Inadequate CO2 removal-->hypercapnia (increased PaCO2)
ARF (Acute Respiratory Failure) occur when 1 or both functions in the lung fails. What are these 2 functions?
Wheezing
Abnormal lung sound Airway narrowing in bronchioles • Musical high pitched noise during inspiration/expiration • Asthma, bronchitis
Rales/Crackles
Abnormal lung sound Secretions in terminal bronchi & alveoli, inspiration • Short, high pitched, intermittent, popping sounds caused by air being force through fluid in alveoli • CHF, pneumonia
Rhonchi
Abnormal lung sound • Secretions in larger airways • Deep low-pitched, rumbling or course sounds. May clear with cough or suction • COPD, Pneumonia
PaCO2 >45 mmHg with pH < 7.35 and/or PaO2 of <60 mmHg
Acute respiratory failure (ARF) occurs when patient meets what clinical criteria?
Rhythm: Regular Heart Rate: 70/min (6 seconds: 7 R- waves. Rate 60-100/min) P Wave: P-wave present for each QRS, normal in shape/size PR Interval: .20 seconds (Normal .12 to .20 sec) QRS Interval: .08 seconds (0.08 to 0.10 sec) & similar across the strip Interpretation: Normal sinus rhythm
Determine the following Rhythm: Heart Rate: P Wave: PR Interval: QRS Interval: Interpretation:
Rhythm: Atrial- chaotic, erratic. Irregular ventricular rhythm Heart Rate: Atria, not measurable, ventricular rate range 65-94. P Wave: Absent P-waves PR Interval: No PR QRS Interval: 0.08 sec, normal Interpretation: Atrial fibrillation
Determine the following: Rhythm: Heart Rate: P Wave: PR Interval: QRS Interval: Interpretation:
more severe symptoms will be
For Hypercapnic Respiratory Failure, the greater the magnitude and faster the rise in PaCO2, the _______ _______ ________ will be
•What is the heart rate? (60-100/min) •Are there P waves? (Yes) •What is the PR interval? (0.12-0.20 seconds) •What is the QRS duration? (0.08-0.10 sec or some use <0.12 seconds) •Are the atrial and ventricular rhythms regular? (Yes) •Is every P wave followed by a QRS complex? (Yes)
For a normal sinus rhythm... What is the heart rate? Are there P waves? What is the PR interval? What is the QRS duration? Are the arterial and ventricular rhythms regular? Is every P wave followed by a QRS complex?
Presence of all criteria 1. Respiratory symptoms begin within 1 week of known clinical insult or new of worsening symptoms during the week. 2. Bilateral opacities on CXR or CT, not explained by effusions, atelectasis, or nodules 3. Moderate to severe impairment of oxygenation (hypoxemia) present, classified as: PaO2/FiO2 (< 300 with a PEEP ≥5 cm or < 200 regardless of PEEP) -Mild ARDS 300-200 (27% mortality) -Moderate ARDS 199-100 (32% mortality) -Severe ARDS <100 (45% mortality) Respiratory failure must not be fully explained by cardiac failure or fluid overload
How would ARDS be Diagnosed?
Only difference is the rate would be <60 beats/min
How would sinus bradycardia differ from normal sinus rhythm (NSR)?
The only difference is the rate would be 101 to 200 beats/min
How would sinus tachycardia differ from normal sinus rhythm (NSR)?
a) Prevents desaturation -Hyperoxygenation prior to suctioning, provide adequate rest & recovery time between various activities, limit physical activity, control anxiety, control fever b) Optimize oxygenation & ventilation -Oxygen therapy by noninvasive or invasive methods, position-elevate HOB, prone c) Promote secretion clearance -Adequate hydration, humidifying supplemental oxygen, incentive spirometry use
Identify an example/s of nursing care that is used for the patient in acute respiratory failure that, a) Prevents desaturation b) Optimize oxygenation & ventilation c) Promote secretion clearance
Lung injury Chest injury or damage to ribs or tissue near lungs Lung conditions that affect the flow of air and blood into and out of the lungs Medical conditions (stroke, spinal cord injuries that affect the muscles and nerves that control breathing) Blood stream infection (sepsis) Blood clot in the lungs (PE) Burns Smoke inhalation Alcohol or drug overdoses Seizures Near drowning
List some causes of ARF
Cigarette smoking Age (young & old) Pulmonary infection/ airway obstruction Chronic lung disease Cardiac failure Traumatic spinal injury/thoracic injury CNS disorders Muscle system abnormalities that are involved with breathing
List some risk factors of ARF
Dyspnea/SOB (hallmark) Tachypnea Orthopnea difficult breathing supine, requires upright position Tachycardia Confusion (altered mental status) Irritability or agitation Restlessness *Symptoms can vary, based on the underlying condition & degree of hypoxia, hypercapnia, & acidosis present
List some s/s of ARF
Impaired Ventilation (hypoventilation)-->Drug overdose Impaired Diffusion--> Pneumonia Ventilation/Perfusion Mismatch-->Pulmonary Emboli
Match these terms 1. Impaired Ventilation (hypoventilation) 2. Impaired Diffusion 3. Ventilation/Perfusion Mismatch A. Pneumonia B. Drug overdose C. Pulmonary Emboli
Small box=0.04 seconds Larg box=0.20 seconds (made up by 5 small boxes)
On EKG paper, each small box is _______ 1 large box is ________
D. It recruits more alveoli Rationale: • Turning the patient to the prone position may recruit new alveoli in the posterior region of the lung and improve oxygenation status. • Cardiac output shouldn't be affected by the prone position. • The prone position doesn't make the patient more comfortable and he often requires sedation to tolerate it. • Skin breakdown can still occur over new pressure points.
Patients with acute respiratory distress syndrome (ARDS) are sometimes placed in the prone position. How does this position help the patient? A. It improves cardiac output B. It makes the patient more comfortable C. It prevents skin breakdown D. It recruits more alveoli
Rhythm: Regular Heart Rate: 70/min P Wave: present for each QRS PR Interval: .20 sec (normal .12-.20sec.) QRS Interval: Interpretation: STEMI
Rhythm: Heart Rate: P Wave: PR Interval: . QRS Interval: Interpretation:
Rhythm: Irregular/chaotic Heart Rate: Not measurable P Wave: Not visible PR Interval: Not measurable QRS Interval: Not measurable Interpretation: V-Fib
Rhythm: Rate: P Wave: PR Interval: QRS Interval: Interpretation:
Rhythm: Regular or Irreg Heart Rate: usually 150-250/minute P Wave: seldom seen PR Interval: Not measurable QRS Interval: wide & distorted Interpretation: V-tach, sustained
Rhythm: Rate: P Wave: PR Interval: QRS Interval: Interpretation:
Acute Respiratory Failure (not a disease, but a symptom)
Severe respiratory dysfunction -Inadequate gas exchange between the lungs & blood -Causes your blood O2 level to drop too low as CO2 builds up
Answer: Yes, Prone. Rationale: Unless otherwise contraindicated, prone positioning should be applied as fist line therapy to any patient with moderate or severe ARDS and applied as early as possible after identification of hypoxemic ARDS. Pressure on lungs is significantly lower, opening the alveoli
Should an ARDS patient with PaO2/FiO2 ratio <150 be placed into prone position as part of first line therapy? Yes/No
Prevention Infection control measures • Yearly flu vaccine • Frequent & good handwashing • Remove unnecessary lines & tubes • COVID (wear a mask, maintain 6ft of physical distance, don't congregate in groups, etc.) • Prevent aspiration (i.e., check gastric content amounts, HOB elevated, check for impaired swallowing) Early Recognition Assess the breathing of any patient at increased risk of ARDS • Dyspnea, work of breathing, respiratory effort, change in mental status/restlessness, abnormal lung sounds (crackles). • Vitals (temp, ↑RR, hypotension, tachycardia, & dysrhythmias).
Some prevention and early recognition strategies for ARDS?
Acute Respiratory Distress Syndrome (ARDS) -also known as noncardiogenic pulmonary edema
Sudden & progressive form of ARF in which the capillary membrane becomes damaged & more permeable to intravascular fluid, interfering with gas exchange. Acute onset, usually in 24-72hrs but must be within 1 week after an inciting lung injury or new or worsening respiratory symptoms Hallmarks are severe hypoxemia (persists despite 100% O2 ) & infiltrates (radiographic opacities) High mortality (20%-30%) -considered a medical emergency
Interpret the blood gas -Respiratory acidosis (high CO2) with hypoxemia (low O2) What type of respiratory failure? (hypoxemic, hypercapnic, or both) -Combination; Hypoxemic respiratory (PaO2<60mmHg) & Hypercapnia (>45mmHg with acidosis). Failure of oxygenation and ventilatory failure (COPD) What are some possible nursing diagnoses? -Impaired gas exchange, Ineffective airway clearance, Ineffective breathing pattern What are some nursing interventions? -Keep SpO2 >92% (follow doctor order, maybe less), frequent respiratory assessment, administer medications as ordered (i.e., bronchodilators, antibiotic, steroids), position upright, institute energy conserving measures, use of IS, decrease anxiety via relaxation measures, treat pain...
The arterial blood gas (ABG) result is pH 7.31 PaCO2 58mm/Hg HCO3- 28mmol/L PaO2 54mm/Hg. WR is on O2 2L/min with continued dyspnea. Interpret the blood gas What type of respiratory failure? (hypoxemic, hypercapnic, or both) What are some possible nursing diagnoses? What are some nursing interventions?
Answer: A. The PaO2 indicates severe hypoxemia and respiratory failure. Hypoxemic respiratory failure (PaO2 <60 mmHg). Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient's poor oxygenation. (normal PaO2 is 80-100)
The nurse is caring for a patient who arrived in the ER with acute respiratory distress. Which assessment finding by the nurse requires the MOST rapid action? a) The patient's PaO2 is 45 mmHg b) The patient's PaCO2 is 33 mmHg c) The patient's respirations are shallow d) The patient's respiratory rate is 32 breaths per minute
Type 1: Hypoxemic Respiratory Failure Type 2: Hypercapnic Respiratory Failure
There are two classifications for ARF. What are they?
Sudden Gradual
There are two types of ARF (acute respiratory failure) what are they?
Shunt (intrapulmonary)
This describes what way of getting hypoxemic respiratory failure? (extreme form of V/Q mismatch) • Blood flows through the pulmonary capillaries without gas exchange (blood leaves with what it came with-low O2 levels & higher CO2 levels) • Caused by: • Alveoli filled with fluid • Ex. ARDS, pneumonia • Oxygen therapy alone ineffective, may need mechanical ventilation with high FiO2
Impaired Diffusion
This describes what way of getting hypoxemic respiratory failure? Fluid in the lung 1. Non-cardiogenic pulmonary edema: • i.e., pneumonia, acute respiratory distress syndrome (ARDS), sepsis, DIC, inhaling harmful fumes- smoke, chemicals, high altitude pulmonary edema. 2. Cardiogenic pulmonary edema (problems with heart) • i.e., CHF, arrhythmias, shock • Damaged lung tissue -Inflammation/ thickening/scarring of the alveolar membrane i.e., severe COPD, pulmonary fibrosis
Ventilation Perfusion Mismatch (V/Q mismatch)
This describes what way of getting hypoxemic respiratory failure? ↑ V/Q • Areas of the lung receive O2, but decreased or no blood flow • Ex: pulmonary emboli (symptoms: severe dyspnea, tachypnea, chest pain, cough, hemoptysis) • ↓ V/Q • Receive blood flow, but no or compromised oxygen exchange • Ex: mucous plug, secretions in airway, pneumonia, asthma, atelectasis • O2 therapy, 1st step to reverse V/Q mismatch, best is to tx underlying cause
Sudden
Type of ARF Asthma severe bronchospasm → decrease in airflow → resulting in rapid respiratory muscle fatigue, acidosis, & ARF
Gradual
Type of ARF COPD develops progressive ↑ PaCO2 over days after a lung infection
Type 1: Hypoxemic Respiratory Failure
Type of ARF Oxygenation failure (most common ) (Inadequate exchange O2 between the alveoli & pulmonary capillaries) PaO2 < 60 mmHg Causes (respiratory/cardiac system disorders or diseases) -Presents: ↓PaO2 and a normal PaCO2 (CO2 di ffuses 20 Ɵmes more rapidly than O2) Nursing Dx: Impaired gas exchange Intervention: Oxygen therapy, suctioning, medications, position, energy conserving measures cause, treat the underlying cause.
Type 2: Hypercapnic Respiratory Failure
Type of ARF Ventilatory failure (Insufficient CO2 removal, body unable to compensate) PaCO2 > 45 mmHg with acidemia. pH< 7.35 Causes: (respiratory system, CNS, chest wall, & neuromuscular system disorders or diseases) -Too little CO2 eliminated or too much CO2 being produced that overwhelms body -Presents: ↑ PaCO2 Nursing Dx: Impaired spontaneous ventilation, Ineffective breathing pattern Intervention: Treat cause, oxygen therapy, medications, position
1. What are WR's risk factors for respiratory failure? -79yr old (older age), COPD (chronic lung disease), Smoker, Cough/pneumonia (pulmonary infection) What symptoms are concerning for possible respiratory failure? -Dyspnea/SOB, requires upright position to breath, restlessness, cough, confusion, tachycardia, tachypnea . What diagnostics/treatments likely to be ordered? Why -Oxygen therapy to support appropriate oxygenation, CXR to evaluate lungs, ABG, CBC, electrolytes, UA, to determine therapy, sputum/blood culture to determine type & extent of infection, EKG, respiratory treatment
WR is a 79-year-old man with known COPD presents to the ER with shortness of breath and inability to get enough air. His wife reports that he has had trouble sleeping due to coughing (productive) and has been confused at times over the past week. He appears restless and is leaning over the bed table. His medical history includes; COPD, current 1 pack/day smoker, HTN, & CAD. WR's vitals: T-99.0 P-100 R-30 BP-159/74 SpO2 88% room air. CXR result reveals left lower lobe pneumonia. . What are WR's risk factors for respiratory failure? 2. What symptoms are concerning for possible respiratory failure? 3. What diagnostics/treatments likely to be ordered? Why?
T wave
Waveform Component of an EKG e is normally a modest upward waveform, representing ventricular repolarization
QRS complex
Waveform Component of an EKG follows the P wave. It normally begins with a downward deflection, then upward deflection, followed by a downward deflection; represents ventricular depolarization (contraction of both ventricles-systole)
PR interval
Waveform Component of an EKG is depolarization and contraction of atria.
P wave
Waveform Component of an EKG is the first deflection, usually positive (upright). It indicates atrial depolarization.
ST segment
Waveform Component of an EKG occurs after ventricular depolarization has ended & before repolarization. Silent time-diastole
Presentation Dyspnea HA (cerbral vasodilation) Pirpheral and conjunctival vasodilation Tachycardia/HTN Drowsiness/confusion/decreased LOC Respiratory acidosis Progression Respiratory center depression, decreased RR Progressive somnolence/coma Tremors, seizures (late) Bradycardia, hypotension, cardiac dyrhythmias (↑ CO2 depresses CNS function & is a strong vasodilator)
What aare some s/s of Hypercapnic Respiratory Failure?
Direct injurty to lungs *Pneumonia* Indirect injury to lungs *Sepsis*
What are 2 presdispoing factors to ARDS?
Too slow respirations -Depressed Respiratory Center in the brain (↓ respir. rate) • i.e., narcotics (opioids), benzodiazepines, alcohol overdoses, brain stem injuries-stroke/trauma-head injury, encephalitis, etc. Too shallow respirations • Conditions that affect the neuromuscular function of breathing or limited lung expansion • i.e., Multiple Sclerosis, Amyotrophic Lateral Sclerosis, Guillain Barre Syndrome, high level spinal cord injury, chest wall injuries/deformities (fractured ribs-pain, kyphoscoliosis) , morbid obesity, etc. Diminished lung function (airflow obstruction & air trapping) • i.e., severe COPD, cystic fibrosis, asthma
What are 3 ways Hypercapnic Respiratory Failure (Type 2) can happen?
Impaired Diffusion Ventilation Perfusion Mismatch Shunt (intrapulmonary)
What are 3 ways Hypoxemic Respiratory Failure (Type 1) can happen?
Supplemental O2 Non-Invasive Ventilation (CPAP/BiPAP) Mechanical Ventilation Mobilization of secretions Minimize activity, energy expenditures Nutritional Support
What are 6 ways to treat Respiratory Failure?
early tachypnea followed by dyspnea, diminished breath sounds, worsening ABGs (PaO2 <60mmHg; PaCO2 >45mmHg) & hypoxemia that persist despite increasing levels of O2
What are some assessment findings you would see in ARDS?
Uncooperative behavior • Facial burns or facial trauma • High risk of aspiration, (patient is vomiting) • Copious secretions • Life threatening hypoxemia & acute asthma
What are some contraindications for non-invasive mechanical ventilation?
• Maintain adequate oxygenation -Mechanical ventilation is frequently required. -Goal: PaO2 >55-80mmHg or SpO2 88-95%) -Non-invasive ventilation may be tried -High flow nasal cannula Continually monitor vitals and SaO2 Proper nutrition Careful fluid management Position prone >12hrs/days (for severe ARDS) Prevent infection
What are some non-pharmacological treatments for ARDS?
• No definitive drug therapy (treat the cause) • Early antibiotic use pneumonia & sepsis • Follow sepsis guidelines • Pressors (to maintain BP, if indicated) • Diuretics, steroids (controversial), Bronchodilators, nebulizer treatments Pain management (i.e., fentanyl, morphine sulfate) While intubated -Sedation to lower O2 consmption Benzodiazepines Ventilator Associated Penumonia prophylaxis (VAP)
What are some pharmacologic therapies for ARDS?
1st signs of acute hypoxemic respiratory failure is change in mental status Dyspnea/SOB • Leads to restlessness, agitation, anxiety Respiratory distress • Tachypnea (↑ RR >24/min) • Use of accessory muscles • Nasal flaring • Unable to speak in full sentences Tachycardia, HTN, (late: dysrhythmias & hypotension) Metabolic acidosis (inadeq tissue perfusion/hypoxia, causing lactic acid production) Cyanosis (late sign) Progression: As hypoxia advances, further altered mental status-confusion, somnolence, and seizure
What are some s/s of respiratory failure (hypoxemia)
Hypocolemia Hypoxia Hydrogen ion (acidosis) Hypo/Hyperkalemia Hypothermia Toxins Tamponade Tension Pneuomthorax Thrombosis (in heart, MI) Thrombosis (in lungs, PE)
What are the 5 H's and T's that cause a deadly heart rhythm?
Prevention and early recognition of patient at high risks for the syndrome
What is the nursing priority for ARDS?
Pleural effusion
What is this term? Collection of fluid around the lungs (pleural space). • Limit's expansion of the lung. • Common Symptoms: • Dyspnea, worsening • Cough • Chest pain/ pain on inspiration • Lung auscultation: may or may not detect changes, depends on size • Diminished or absent breath sounds on affected area
Atelectasis
What is this term? Complete or partial collapse of the lung. Air sacs (alveoli) within the lung become deflated • Most common cause: airway obstruction from retained exudates & secretions. i.e., postop • Symptoms • Depends on size & how rapid it developed • Rapid: pain on affected side, sudden dyspnea, & cyanosis • Slowly developing, may be asymptomatic or minor symptoms (mild SOB, coughing) • Lung auscultation: • Diminished or absent breath sounds in affected area
Pulmonary Edema
What is this term? Fluid accumulation in the alveoli (air sacs) & interstitial spaces of lungs • Most common cause: L sided heart failure • Symptoms: • SOB • Tachypnea • Hypoxemia • Frothy secretions • Lung auscultation: rales/crackles
Hypoxemia
What is this? Decreased level of O2 in the blood. Can lead to hypoxia if not corrected.
Hypoxia
What is this? Decrease delivery of O2 to the tissues. ↓ oxygen in your tissues
Type 2 Moblitz II (more p-waves than QRS complexes)
What type of 2nd degree AV block is this? More serious (often leads to 3rd degree & associated with poor prognosis). • Risk Factors: same as Type 1, except often associated with anterior wall MI. • Some impulses from SA node not conducted to ventricles. Occurs in ratios • 2:1 ( 2 P-wave to 1 QRS) • 3:1 (3 P-waves to 1 QRS) & so on. • ↓ HR often results in ↓ CO with ↓BP & myocardial ischemia. • Treatment: permanent pacemaker
Type 1 Moblitz I (Wenckebach)
What type of 2nd degree AV block is this? Think: PR- "longer, longer, longer drop, now you have Wenckebach" • Risk Factors: • Can result from: drugs (i.e., digoxin or ϐ‐blocker); CAD, inferior MI & other disease that slow AV conduction • Least serious of the 2 types. May cause mild dizziness • Treatment: If symp
Hyperkalemia in ECG. Prolonged PR interval, flat or absent P waves, wide QRS, tall peaked T waves, ST segment depression
What would you interpret from this EKG?
Hypokalemia in ECG. Flattened or inverted T wave, development of U waves, & depressed ST segment
What would you interpret from this EKG?
C. Patient becomes less agitated and is difficult to arouse. Rationale: When a patient with dyspnea becomes less agitated and more lethargic, it suggests respiratory muscle fatigue and that the patient is unable to continue the increased work of breathing. The nurse will need to act such as activating the rapid response team and ventilating the patient manually. Three-word dyspnea will be reported to the health care provider and may need actions such as oxygen administration and positioning for maximal lung expansion but does not suggest imminent respiratory arrest. A patient who can breathe more comfortably with the head at a 45-degree angle has moderate dyspnea and is not at risk for respiratory arrest. Pursed-lip breathing is used by many with asthma & COPD to help improve expiration but does not necessarily indicate severe respiratory distress.
Which assessment finding in a patient who reports dyspnea requires the most rapid action by the nurse? A. Patient can only speak three words between breaths. B. Patient requests that the head of bed be at a 45- degree angle. C. Patient becomes less agitated and is difficult to arouse. D. Patient who is using pursed-lip breathing to prolong expiration.
A. Agitation B. Confusion C. Restlessness Rationale: Hypoxemia refers to decrease in arterial oxygen and may manifest as agitation, confusion, and restlessness because of inadequate oxygen delivery to the brain. Vomiting is not associated with hypoxemia. Morning headaches are a symptom of hypercapnic respiratory failure, as elevated PaCO 2 levels cause cerebral vasodilation and mild intracranial pressure increases. • 1st sign of respiratory failure is a change in mental status • ↓ O2 → restlessness, confusion, agitation • ↑ CO2 → morning headache, decreased RR, & decrease LOC
Which clinical manifestations of respiratory failure are associated with hypoxemia? (Select all that apply) . A. Agitation B. Confusion C. Restlessness D. Vomiting E. Morning headache
B. Pneumothorax Rationale: A result of excessive pressure applied to lung tissue by mechanical ventilation is a pneumothorax. • Hypertension is not a direct complication; however, a patient undergoing mechanical ventilation may be anxious and fearful, resulting in high BP; consider sedation in this event. • Electrolyte imbalance is not a related complication. • Mechanical ventilation does increase intrathoracic pressure, which may then decrease in cardiac output, not increase.
Which common complication would the nurse immediately notify the health care provider when a patient who is receiving mechanical ventilation has right-sided breath sounds but no breath sounds on the left side of the chest? A. Hypertension B. Pneumothorax C. Electrolyte imbalance D. Increased cardiac output
All of the above
Which conditions can trigger ARDS? Smoke inhalation B. Pancreatitis C. Septicemia D. Near drowning in salt water E. Aspiration F. Pneumonia G. COVID-19 H. All the above
ACD Rationale: Heart rate and cardiac output increase as a compensatory mechanism for hypoxemia early in the development of ARDS. • Respiratory alkalosis (low PaCO 2) will be observed because of rapid shallow breathing that occurs in response to hypoxemia. • Hypoventilation may occur later when the patient experiences respiratory muscle fatigue and is no longer able to compensate for hypoxemia. As the patient becomes unable to compensate further, the PaCO 2 will start to rise, causing respiratory acidosis.
Which findings will the nurse observe due to compensatory mechanisms in a patient who is in the earliest stage of acute respiratory distress syndrome (ARDS)? (Select all that apply). A. Tachycardia B. Hypoventilation C. Respiratory alkalosis D. Rapid & shallow respirations E. Increase in arterial carbon dioxide (PaCO2)
BCD Rationale: Respiratory failure is classified as hypoxemic or hypercapnic. Respiratory failure results when gas exchanging functions are inadequate (i.e., insufficient oxygen is transferred to the blood or inadequate carbon dioxide is removed from the lungs). Although respiratory failure may be secondary to cardiac failure, not all cases of respiratory failure are secondary to cardiac failure and not all heart failure leads to respiratory failure. Respiratory failure is not a disease but a symptom of an underlying pathologic condition affecting lung function, oxygen delivery, cardiac output, or the baseline metabolic state
Which information would the nurse educator include when explaining respiratory failure to new nursing staff members? (Select all that apply ) A. Respiratory failure is inevitable after cardiac failure. B. Respiratory failure is categorized as hypoxemic or hypercapnic. C. Respiratory failure is insufficient oxygen transfer into the blood. D. Respiratory failure is inadequate carbon dioxide removal from the lungs E. Respiratory failure is a disease that presents with various respiratory symptoms.
ADE Rationale: During a weaning trial, the patient is placed in a comfortable sitting or semirecumbent position. Obtain baseline vital signs and respiratory parameters. The patient should be closely monitored for signs and symptoms that may signal intolerance and a need to end the trial. Do not anesthetize or walk the patient.
Which interventions would the nurse perform when weaning a patient from artificial ventilation? (Select all that apply). A. Obtain baseline vital signs and respiratory parameters. B. Make the patient walk 10 feet and then proceed with the trial C. Anesthetize or restrain the patient to avoid any resistance during extubation. D. Place the patient in a comfortable sitting or semi- recumbent position E. Closely monitor for symptomology signaling intolerance and a need to end the trial.
A. 24-year-old male admitted with blunt chest trauma and aspiration Rationale: All patient scenarios create a risk for ARDS. However, the trauma patient with direct chest injury and known aspiration is at greatest risk. ARDS risk factors include direct lung injury (most commonly aspiration of gastric contents), systemic illnesses, and injuries. The most common risk factor for ARDS is sepsis. Other risk factors include bacteremia, trauma with or without pulmonary contusion, multiple fractures, burns, massive transfusion, near drowning, post-perfusion injury after cardiopulmonary bypass surgery, pancreatitis, and fat embolism.
Which patient is at greatest risk of developing acute respiratory distress syndrome (ARDS)? A. 24-year-old male admitted with blunt chest trauma and aspiration B. 56-year-old male with a history of alcohol abuse and chronic pancreatitis C. 72-year-old male post heart valve surgery receiving 1 unit of packed red blood cells D. 82-year-old female on antibiotics for pneumonia
Answer: A. All are at risk for ARDS. However, the trauma patient with direct chest injury & known aspiration is at greatest risk. ARDS risk factors include direct lung injury (commonly aspiration of GI contents), systemic illness, and injuries. The most common risk factor for ARDS is sepsis. Other risk factors, bacteremia, trauma, multiple rib fxs, burns, massive transfusion, near drowning, post-perfusion injury after cardiac bypass surgery, pancreatitis, & fat embolism.
Which patient is at greatest risk of developing acute respiratory distress syndrome (ARDS)? a) 24-year-old male admitted with blunt chest trauma and aspiration b) 56-year-old male with a history of alcohol abuse and chronic pancreatitis c) 72-year-old male post heart valve surgery receiving 1 unit of packed red blood cells d) 82-year-old female on antibiotics for pneumonia.
C. A patient who has a massive pulmonary embolism. Rationale: Hypoxemic respiratory failure is oxygenation failure because the primary problem is inadequate O 2 transfer between the alveoli and the pulmonary capillary bed (blood). • A massive pulmonary embolism is an example of a cause of hypoxemic respiratory failure. No oxygen transfer when there's no blood flow to a lung area. PaO2 <60 mmHg • Sedative overdose, respiratory muscle paralysis, and flail chest are examples of hypercapnic respiratory failure. Hypercapnic respiratory failure is also referred to as ventilatory failure because the primary problem is insufficient CO 2 removal.
Which patient is at highest risk for hypoxemic respiratory failure? A. A patient who has respiratory muscle paralysis. B. A patient who has fractured ribs and a flail chest. C. A patient who has a massive pulmonary embolism. D. A patient who has slow breathing from a drug overdose.
D. The patient who has decreased ventilation because of myasthenia gravis crisis Rationale: NIPPV is most effective in treating patients with respiratory failure resulting from chest wall and neuromuscular disease. Patients who have unstable heart rate and BP and need positive pressure ventilation are intubated since it is more difficult to maintain hemodynamic stability with NIPPV. Since NIPPV requires that the patient be able to breathe spontaneously, a patient with decreased level of consciousness will not be a good candidate. NIPPV requires use of a tight-fitting mask and is not a good positive pressure ventilation method for patients with copious respiratory secretions who will need frequent suctioning.
Which patient with respiratory failure is a good candidate for noninvasive positive pressure ventilation (NIPPV)? A. The patient whose heart rate and BP are unstable. B. The patient who has a head injury with loss of consciousness & decrease respirations C. The patient with cystic fibrosis who has copious respiratory secretions D. The patient who has decreased ventilation because of myasthenia gravis crisis
C. Give furosemide 40 mg IV Rationale: • Because sepsis leads to vasodilation, fluid infusions are used to maintain BP; diuretic use would lead to further hypovolemia and lower BP. Normal saline or other crystalloid or colloid solutions are used to maintain fluid status. • Enteral feeding is started as early as possible in patients with ARDS and will require nasogastric tube placement. • The prone position can improve oxygenation and is beneficial to patients with severe ARDS.
Which prescribed intervention for a patient with sepsis, hypotension, and acute respiratory distress syndrome (ARDS) would the nurse question? A. Infuse normal saline at 100 mL/hour B. Insert a nasogastric tube for enteral feeding C. Give furosemide 40 mg IV D. Place the patient in prone position for 12 hours/day
Answer: B. By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent lung damage (i.e., fibrotic changes that occur with ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient.
Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient's caregiver is accurate? a) "PEEP will push more air into the lungs during inhalation." b) "PEEP prevents the lung air sacs from collapsing during exhalation." c) "PEEP will prevent lung damage while the patient is on the ventilator." d) "PEEP allows the breathing machine to deliver 100% O2 o the lungs.".
