Respiratory Exam 2 Lewis

During the Proliferative Phase of ARDS, ____________________ . A. Fluids shift into the alveoli, the alveoli and bronchii collapse, and lose lung compliance B. The lung starts to repair itself; this is where the patient starts to get better or the condition deteriorates. C. Fibrous tissue forms and lungs don't expand well; the effort to breathe increases O2 demand which causes more effort to breathe.

B

When a patient with myasthenia gravis is recieving continuous mechanical ventilation. When the high pressure alarm on ventilator sounds, what should the nurse do? a. check for apical pulse b. suction the clients artificial airway c. increase the oxygen percentage d. ventilate the client with a handheld mechanical ventilator.

B The alarm on the ventilator indicates an obstruction in the flow of oxygen from the machine to the client, that might be caused by respiratory secretions.

Volutrauma

The VOLUME of the air is more than the lungs can handle and physical damage to the lungs occurs. (alveoli fractures- damage or tears to the alveoli)

How do intrapulmonary shunts cause hypoxemia?

The blood flows through the pulmonary capillaries without participating in gas exchange. This unoxygenated blood goes to system which causes a decrease in 02 saturation.

Dobutamine for ARDS

(+) inotrope used for when your heart is failing Renal dilation, but also increases cardiac output

Traumatic Pneumothorax- Open

(Penetrating or "sucking chest wound")

PHASE 3: What happens in the Fibrotic or chronic/late phase?

1. 2-3 weeks after initial lung injury 2. Lung is completely remodeled by sparsely collagenous and fibrous tissues ( formation of scar tissue in lungs) 3. Decreased lung compliance (d/t lung damage). 4. Decreased are for gas exchange (Hypoxemia continues) 5. Pulmonary hypertension ( d/t pulmonary vascular destruction and fibrosis)

What are the 3 phases or ARDS

1. Injury or exudate phase 2. Reparative or proliferation stage 3. Fibrotic or chronic/ late phase

What are the 4 causes of HYPOXEMIC respiratory failure?

1. Mismatch between ventilation and perfusion (V/Q mismatch): 0.8 or 1 2. Shunt 3. Diffusion limitation 4. Alveolar hypoventilation

PHASE 2: What happens in the reparative or proliferation phase?

1. Occurs 1-2 weeks after initial lung injury 2. Influx of neutrophils, monocytes (pt. is really sick), and lymphocytes and fibroblasts proliferations as part of the inflammatory response -> damage the alveoli -> remodeling. 3. Increased pulmonary vascular resistance and pulmonary hypertension may occur in this stage because fibroblasts and inflammatory cells destroy the pulmonary vasculature. 4. Lung compliance continues to decrease as a result of interstitial fibrosis 5. Hypoxemia worsens because of the thickened alveolar membrane, causing diffusion limitation and shunting. 6. This phase is complete when the diseased lung is characterized by dense, fibrous tissue. (If the reparative phase persists, widespread fibrosis results. If the reparative phase is stopped, the lesions will resolve.)

PHASE 1: What happens in the injury/ exudate phase?

1. Occurs 1-7 (usually 24-48 hrs) days after direct lung injury or host insult. 2. Capillary permeability increased. ( d/t neutrophils adhering to pulm. microcirculation causing damage to vascular endothelium). 3. Interstitial Edema ( d/t the engorgement of the peri-bronchial and perivascular interstitial space). 4. Alveoli become filled with fluid. (d/t fluid from interstitial space crossing the alveolar membrane and entering the alveolar space). 5. SURFACTANT Dysfunction ( caused by damage to the alveoli cells. A decrease in synthesis of surfactant cause the alveoli to become unstable and collapse- Atelectasis). 6. Decreased lung compliance and gas exchange (d/t atelectasis- can contribute to hypoxemia. 7. Hyaline membrane formation line the alveoli. (Formed by necrotic cells, proteins, and fibrin. Membranes mak lungs stiff and contribute to the development of fibrosis and atelectasis and gas exchange and lung compliance.) P. 1621/ Slide 6

Manifestations of ARDS

1. Severe dyspnea 2. hypoxia 3. decreased lung compliance 4. Diffuse pulm. infiltrates Slide 4

What mean arterial pressure indicates Pulmonary HTN?

25mmHg at rest and 30 mmHg w/ exercise. Normal is 12-16mmHg

Where are most chest tubes placed?

5th intercostal space

Pulmonary Artery pressure

<18mmHg is ARDS Greater than that is Cardiac Measure of the blood pressure found in the main pulmonary artery. This is measured by inserting a catheter into the main pulmonary artery. The mean pressure is typically 9 - 18 mmHg

During the Acute Exudate Phase of ARDS, ____________________ . A. Fluids shift into the alveoli, the alveoli and bronchii collapse, and lose lung compliance B. The lung starts to repair itself; this is where the patient starts to get better or the condition deteriorates. C. Fibrous tissue forms and lungs don't expand well; the effort to breathe increases O2 demand which causes more effort to breathe.

A

In which phase of acute respiratory distress syndrome (ARDS) does atelectasis occur due to decreased synthesis of surfactant and inactivation of existing surfactant? a. injury b. fibrotic c. proliferative d. refractory hypoxemia

A During the injury phase (exudative phase), atelectasis occurs due to decreased synthesis of surfactant and inactivation of existing surfactant. The fibrotic phase is characterized by remodeling of the lung with collagenous and fibrous tissues. Refractory hypoxemia occurs during the injury (exudative) phase, characterized by a severe V/Q mismatch and shunting of pulmonary capillary blood, which results in hypoxemia unresponsive to increasing concentrations of oxygen.

A client presents c/o dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and JVD. The nurse anticipates that the Dr. will make which Diagnosis? a. Pulmonary Hypertension b. COPD c. Empyem d. Pulmonary TB

A Dyspnea on exertion, weakness, hemoptysis, and right-sided HF are all signs of pulmonary hypertention.

A patient w/ ARDS has an ET and is on mechanical ventilation. When the high pressure alarm on the mechanical ventilator goes off the nurse starts to check for the cause. What conditions trigger the high pressure alarm. a. kinking of the ventilator tubing b. A disconnected ventilator tube c. An ET cuff leak d. a change in the oxygen concentration w/ out resetting the oxygen level alarm

A ET cuff leak and disconnected ventilator tube will trigger the LOW pressure alarm. Changing the 02 level will trigger the oxygen alarm.

What is the arterial oxygen/fraction of inspired oxygen (PaO 2/FIO 2, or P/F) ratio in acute respiratory distress syndrome (ARDS)? a.Less than 200 b.Greater than 400 c.Greater than 300 d.Between 200 and 300

A In acute respiratory distress syndrome, the P/F ratio is less than 200. Under normal circumstances, the P/F ratio would be greater than 400 (e.g., 95/0.21 = 452). With the onset and progression of lung injury and impairment in oxygen delivery through the alveolar-capillary interface, the PaO 2 may remain lower than expected despite increased FIO 2. The P/F ratio is 200 to 300 in acute lung injury. p1620

The nurse is talking with a client about treatment options for a new diagnosis of primary pulmonary hypertension. Which statement indicates to the nurse that the client understands the​ treatment? ​a."I wonder if I can get on a transplant list​ soon. b."A transfusion will help with getting more oxygen with this​ disorder."​ c."The blood pressure in my lungs will get better if I take​ yoga."​ d."The medications will cure my​ disease."

A Lung transplant or heart-lung transplant is the most effective​ long-term treatment for primary pulmonary hypertension. Medications such as calcium channel blockers are used to control pulmonary hypertension but will not cure the disease process. Exercise and lifestyle modifications are indicated for a client with systemic hypertension but will not necessarily affect pulmonary hypertension.

The nurse is caring for a patient with pulmonary fibrosis. Which is the appropriate nursing intervention included in respiration therapy? a. lateral rotation therapy b. hemodynamic monitoring c. red blood cell transfusion d. Crystalloid fluid administration

A Pulmonary fibrosis is a respiratory complication associated with acute respiratory distress syndrome (ARDS). Lateral rotation therapy is a respiratory therapy where the patient is slowly turned side-to-side by rotating the actual bed frame to less than 40 degrees. Hemodynamic monitoring is a supportive therapy whereby the nurse continuously monitors the trends, detects changes, and makes adjustments as required. Medical therapy involves transfusion of packed red blood cells to increase hemoglobin, which increases the oxygen-carrying capacity of the blood. The nurse administers crystalloid fluids if there is a fall in the cardiac output. p1625

To evaluate both oxygenation and ventilation in a patient with acute respiratory failure, the nurse uses the findings revealed with: a. arterial blood gas (ABG) analysis. b. hemodynamic monitoring. c. chest x-rays. d. pulse oximetry.

A Rationale: ABG analysis is useful because it provides information about both oxygenation and ventilation and assists with determining possible etiologies and appropriate treatment. The other tests may also provide useful information about patient status but will not indicate whether the patient has hypoxemia, hypercapnia, or both.

Which information obtained by the nurse when assessing a patient with acute respiratory distress syndrome (ARDS) who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates a complication of ventilator therapy is occurring? a. The patient has subcutaneous emphysema. b. The patient has a sinus bradycardia, rate 52. c. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. d. The patient has bronchial breath sounds in both the lung fields.

A Rationale: Complications of positive-pressure ventilation (PPV) and PEEP include subcutaneous emphysema. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns, but they are not caused by PPV and PEEP.

The nurse will monitor for clinical manifestations of hypercapnia when a patient in the emergency department has a. chest trauma and multiple rib fractures. b. carbon monoxide poisoning after a house fire. c. left-sided ventricular failure and acute pulmonary edema. d. tachypnea and acute respiratory distress syndrome (ARDS).

A Rationale: Hypercapnia is caused by poor ventilatory effort, which occurs in chest trauma when rib fractures (or flail chest) decrease lung ventilation. Carbon monoxide poisoning, acute pulmonary edema, and ARDS are more commonly associated with hypoxemia.

When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse? a. The patient is somnolent. b. The patient's SpO2 is 90%. c. The patient complains of weakness. d. The patient's blood pressure is 162/94.

A Rationale: Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest.

A 26-year-old patient is admitted to the hospital in severe respiratory distress. His oxygen saturations are 80% despite supplemental oxygen provided by facemask. The physician decides to intubate the patient to help with his breathing oxygenation. Which medication would the nurse most likely administer when assisting with intubation? a.Midazolam (Versed) b.Zolpidem (Ambien) c.Phentermine (Adipex-P) d.Modafinil (Provigil)

A Rationale: Intubation is most often performed by inserting a tube into the mouth and passing it into the trachea in order to provide help and support for a patients breathing. Most registered nurses do not perform endotracheal intubation, but they may assist the physician with placing the tube. The nurse may give medications to sedate the patient during the procedure, since it can be traumatic for the patient. Some medications given for sedation include midazolam, fentanyl, and etomidate.

A patient with acute respiratory distress syndrome (ARDS) has progressed to the fibrotic phase. The patient's family members are anxious about the patient's condition and are continuously present at the hospital. In addressing the family's concerns, it is important for the nurse to a. support the family and help them understand the realistic expectation that the patient's chance for survival is poor. b. inform the family that home health nurses will be able to help them maintain the mechanical ventilation at home after patient discharge. c. refer the family to social support services and case management to plan for transfer of the patient to a long-term care facility. d. provide hope and encouragement to the family because the patient's disease process has started to resolve.

A Rationale: The chance for survival is poor when the patient progresses to the fibrotic stage because permanent damage to the alveoli has occurred. Because of continued severe hypoxemia, the patient is not a candidate for home health or long-term care. The fibrotic stage indicates a poor patient prognosis, not the resolution of the ARDS process.

A patient is brought to the emergency department unconscious following a barbiturate overdose. Which potential complication will the nurse include when developing the plan of care? a. Hypercapnic respiratory failure related to decreased ventilatory effort b. Hypoxemic respiratory failure related to diffusion limitations c. Hypoxemic respiratory failure related to shunting of blood d. Hypercapnic respiratory failure related to increased airway resistance

A Rationale: The patient with an opioid overdose develops hypercapnic respiratory failure as a result of the decrease in respiratory rate and depth.

What is the benefit associated with Acute Respiratory Distress Syndrome Clinical Network (ARDSNet)? a.Reduction in mortality rate b.Increased intrathoracic pressures c.Increased number of ventilator days d.Drop in partial pressure of arterial carbon dioxide (PaCO 2)

A The Acute Respiratory Distress Syndrome Clinical Network (ARDSNet) is a protocol-driven strategy that aims to reduce the mortality rate by avoiding barotrauma and minimizing risks associated with high inspiratory pressures. Ventilating the patient with smaller tidal volumes and minimizing the oxygen requirements reduce intrathoracic pressures. This further enables reduction in the number of days the patient spends on mechanical ventilation. The ARDSNet protocol results in the elevation in the partial pressure of arterial carbon dioxide (PaCO 2).

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 feels anxious c. Bilateral breath sounds clear and pulse oximeter reading is 95% d. The client has JVD and frothy sputum

A The classic signs of ARDS is decreased arterial oxygen level (PaO2) while administering high levels of oxygen; the oxygen is unable to cross the alveolar membrane.

The patient has pulmonary fibrosis and experiences hypoxemia during exercise, but not at rest. To plan for the patient's care, the nurse should know that this patient is experiencing which physiologic mechanism of respiratory failure? a.Diffusion limitation b.Intrapulmonary shunt c.Alveolar hypoventilation d.Ventilation-perfusion mismatch

A The patient with pulmonary fibrosis has a thickened alveolar-capillary interface that slows gas transport; hypoxemia is more likely during exercise than at rest. (Intrapulmonary shunt occurs when alveoli fill with fluid (e.g., acute respiratory distress syndrome [ARDS], pneumonia). Alveolar hypoventilation occurs when there is a generalized decrease in ventilation (e.g., restrictive lung disease, central nervous system [CNS] diseases, neuromuscular diseases). Ventilation-perfusion mismatch occurs when the amount of air does not match the amount of blood that the lung receives (e.g., chronic obstructive pulmonary disease [COPD], pulmonary embolus).

A nurse is caring for a client w/ a chest tube. If it becomes accidentally disconnected what should the nurse plan to do? a. Place the end of the chest tube in a container of sterile saline b. Apply an occlusive dressing and notify physician c. Clamp the chest tube immediately d. secure the chest tube w/ tape

A This prevents air from entering the chest tube, thereby preventing negative respiratory pressure.

The nurse is completing a physical assessment on a client with pulmonary hypertension. Which assessment finding best informs the nurse that the client is experiencing an impairment of oxygen​ exchange? a. pulse ox reading of 89% b.cyanosis of the nail beds c. dyspnea on exertion d.Expectorant of thick mucus

A To best determine the effectiveness of gas​ exchange, the nurse should refer to an arterial blood gas or pulse oximeter. Cyanosis can occur because of altered perfusion as well as decreased oxygenation. Dyspnea on exertion is a sign of intolerance of​ activity, an impairment of carbon dioxide and oxygen exchange. Mucus can cause an impairment of​ oxygenation, but expectoration of the mucus is a desired outcome.

Subcutaneous emphysema

A characteristic crackling sensation felt on palpation of the skin, caused by the presence of air in soft tissues.

What is a pneumothorax?

A collapsed lung d/t increased air build up in the pleural space.It can be partial or complete.

What is Alveolar Hypoventilation?

A generalized decrease in ventilation that results in an increase in the PaCO2 and a consequent decrease in PaO2. No gas exchange = No air in alveoli

How can a high C02 level lead to metabolic acidosis?

A high C02 level causes the heart to work harder-> leads to tachycardia. It vasoconstricts from the renal system down -> leading to a decrease in U/O -> metabolic Acidosis.

What is ARDS (acute respiratory distress syndrome)?

A sudden and acute form of respiratory failure where the alveolar-capillary membrane becomes damaged and more permeable to intravascular fluid. (Alveoli become filled w/ fluid and this prevents oxygen from getting to your organs)

A nurse must position the patient prone after his diagnosis of acute respiratory distress syndrome (ARDS). Which of the following is a benefit of using this position? Select all that apply. a. Decreased atelectasis b. Reduced need for endotracheal intubation c. Mobilization of secretions d.Decreased fluid accumulation e. Increased response to corticosteroid therapy

A, C, D Prone positioning, or placing the patient face down with the head turned to the side, helps with pulmonary function in the patient diagnosed with ARDS. Studies have shown that patients who are positioned prone and who have respiratory conditions often have improved outcomes of decreased lung atelectasis, mobilization of secretions to enhance suctioning, and decreased fluid accumulation in the lung tissue.

What are the benefits of noninvasive positive pressure ventilation (NIPPV) over other artificial airways? Select all that apply. a.Decreases the work of breathing b.Replaces endotracheal intubation c.Is appropriate for patients with excessive secretions d.Is highly successful in the treatment of pulmonary edema e.Is appropriate for patients with decreased levels of consciousness

A,B Patients with chronic respiratory failure benefit the most from NIPPV. The mechanical ventilation provided by a mask tightly placed over the patient's nose reduces the patient's breathing effort. NIPPV is helpful for patients who require ventilatory support but refuse endotracheal intubation. NIPPV is considered inappropriate for patients with excessive secretions. NIPPV has not been found to be successful for patients with pulmonary edema. NIPPV is not appropriate for patients experiencing low levels of consciousness.

Which signs and symptoms differentiate hypoxemic respiratory failure from hypercapnic respiratory failure (select all that apply)? A. Cyanosis B. Tachypnea C. Morning headache D. Paradoxic breathing E. Pursed-lip breathing

A,B,D Clinical manifestations that occur with hypoxemic respiratory failure include cyanosis, tachypnea, and paradoxic chest or abdominal wall movement with the respiratory cycle. Clinical manifestations of hypercapnic respiratory failure include morning headache, pursed-lip breathing, and decreased or increase respiratory rate with shallow breathing.

The nurse is conducting health teaching for a client with a new diagnosis of pulmonary hypertension. The nurse knows to include which teaching ​topics? SELECT ALL THAT APPLY a.Call the health care provider for a weight gain of greater than 5 pounds in 1 week. b.Avoid spending time with large crowds of people. c.The medications will control all the symptoms of the disease. d.The importance of smoking cessation e.Pulmonary hypertension is a curable disease.

A,B,D Smoking cessation is important for a client with pulmonary hypertension because smoking is an irritant to airways and it has vasoconstrictive properties.The client with pulmonary hypertension should be taught to monitor daily weights and for increasing edema because of the risk for excess fluid volume.The client should be instructed to avoid contracting an upper respiratory infection if at all possible.Medication adherence is very important to teach the client with respect to disease​ management, but there is no guarantee that medications will control all symptoms of the disease.Pulmonary hypertension is a​ chronic, progressive disease. The most effective​ long-term treatment for pulmonary hypertension is heartdash-lung or lung transplant.

A client w/ Pulmonary HTN is being evaluated for a heart-lung transplant. What treatments should the nurse expect this patient to be on? Select all that apply. a. Oxygen b. Aminoglycosides c.Diuretics d. vasodilators e. antihistamines f. Sulfonomides

A,C,D Oxygen- because hypoxia is a potent vasoconstrictor , low 02 provides symptomatic relief Diuretics- used to manage peripheral edema Vasodilators- promote vasodilation of the pulmonary blood vessels, reduce R ventricular overload, and reverse remodeling

A nurse cares for a group of clients on a medicaldash-surgical unit. The nurse knows that which clients are at risk for developing secondary pulmonary ​hypertension? SELECT ALL THAT APPLY a.A​ 43-year-old woman with a​ 5-year history of scleroderma b.A​ 68-year-old woman with rheumatoid arthritis c.A​ 60-year-old man with a​ 5-year history of mitral valve stenosis d.A​ 58-year-old man with a​ 15-year history of HIV infection e.A​ 75-year-old client with peripheral arterial disease

A,C,D Scleroderma is a collagen disease that can cause constriction of pulmonary vessels and lead to secondary pulmonary hypertension. HIV infection may lead to secondary pulmonary hypertension. Mitral valve stenosis can cause elevated pressures in the pulmonary vascular​ system, which leads to secondary pulmonary hypertension. Peripheral arterial disease is caused by obstruction of peripheral​ arteries, generally in the lower extremities. There is not necessarily a relationship between peripheral arterial disease and secondary pulmonary hypertension. Rheumatoid arthritis is an autoimmune disorder affecting the​ joints; it does not lead to secondary pulmonary hypertension.

Which conditions predispose a patient to acute respiratory distress syndrome (ARDS) with an indirect lung injury? Select all that apply. a.Sepsis b.Bacterial pneumonia c.Opioid drug overdose d.Severe massive trauma e.Aspiration of gastric contents

A,C,D Sepsis caused by gram-negative bacteria can predispose patients to the development of acute respiratory distress syndrome (ARDS) with an indirect lung injury. Excessive use of opioid drugs can indirectly lead to an acute respiratory condition. Indirect injury to the lung by a severe massive trauma caused by a head injury can also lead to ARDS. Patients with lung infections such as bacterial or viral pneumonia are directly at risk for ARDS. Aspiration of gastric content into the lungs causes direct infections leading to ARDS or other lung problems.p1620

The nurse is caring for a 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 2 hours d.Maintain intravenous fluids as ordered e.. Place the client in the Fowler's position

A,C,D,E a. Altered LOC is the earliest sign of hypoxemia c. The client is at risk for complications of immobility, therefore, the nurse should turn the client at least every 2 hours to prevent pressure ulcers d.The client is at risk for fluid volume overload, so the nurse should monitor and maintain fluid intake e.Fowler's position facilitates lung expansion and reduces the workload of breathing

A patient sustains a direct lung injury. What does the nurse recognize as the common direct causes of acute respiratory distress syndrome (ARDS) in this patient? Select all that apply. a.Sepsis b.Acute pancreatitis c.Bacterial pneumonia d.Severe massive trauma e.Aspiration of gastric contents

A,C,E Sepsis is an initial manifestation of multisystem organ failure that leads to acute respiratory distress syndrome (ARDS). Patients with lung infections such as bacterial or viral pneumonia also are at risk. Aspiration of gastric content into lungs causes infections leading to ARDS or other lung problems. Indirect injury to the lung results in acute pancreatitis and severe massive trauma. Acute pancreatitis causes lung complications leading to ARDS. Trauma caused by any severe head injury indirectly causes ARDS. p1620

A critically ill patient with acute respiratory failure is being treated for stress ulcers. What actions are included in the management of the patient's condition? Select all that apply. a.Enteral nutrition b.Strict hand washing c.Oral care and hygiene d.Usage of anti-ulcer agents e.Correction of predisposing conditions

A,D,E Enteral feeding should be initiated early to prevent mucosal damage. Stress ulcers can be managed with the use of anti-ulcer agents such as pantoprazole (a proton pump inhibitor) and sucralfate (a mucosal-protecting agent). Stress ulcers can also be managed by taking corrective actions to handle predisposing conditions such as hypotension, shock, and acidosis. Strict hand washing and frequent oral care are strategies to prevent ventilator-associated pneumonia. p1623

CHECK ALL THAT APPLY: Which of the following are the 5 characteristics of ARDS? a.Dyspnea b.Myasthenia Gravis c.Refractory hypoxemia Cyanosis d.Dense pulmonary infiltrates on CXR e.Decreased pulmonary compliance f.Non-cardiac pulmonary edema Chest pain

A,D,E,F

What are the stages of edema formation in ARDS?

A.Normal alveolus and pulmonary capillary. Normal fluid/ gas exchange. B.Interstitial edema occurs with increased flow of fluid into the interstitial space. -> Interstitial Edema C.Alveolar edema occurs when fluid crosses the blood-gas barrier. Compromised gas exchange also known as diffusion limitation. Slide 3 nd pg. 1620

PHASE 1: What manifestations will we see in injury/ exudate phase?

ALL COMPENSATORY MECHANISMS 1.Increase work of breathing 2.Increased Respiratory Rate (Shallow breathing) 3.Decreased tidal wave ( Amount of air the you need to expand lung. Normally 500). 4.Decrease in C02 and tissue perfusion (CO2 vasodilates the brain cells because it follows pH) 5.Diffusion limitation (caused by hyaline formation, worsens hypoxemia) 6.Refractory hypoxemia ( d/t severe V/Q mismatch and shunting of pulmonary capillary blood.)

What is Cor Pulmonade?

Abnormal enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels. Can lead to heart failure.

What are DIRECT conditions that predispose patients to ARDS?

Aspiration of gastric contents or other substances Viral or bacterial PNA Sepsis Less common: Chest trauma Embolism: fat, air amniotic fluid, thrombus Inhalation of toxic substances Near-drowning O2 toxicity Radiation pneumonitis- multiple blood transfusions TABLE 67-6

Hypercapnia produces a INCREASE in ?

Arterial C02 ( PaC02)

What are some airway and alveoli abnormalities and what do they have in common?

Asthma, COPD, Cystic fibrosis The underlying patho of these results in airflow obstruction and air trapping -> leading to respiratory muscle fatigue, ventilatory failure d/t additional work needed to inspire adequate tidal volumes against increased airway resistance and air trapped w/ in alveoli.

Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain? a. fluid intake for the past 24 hours b. baseline ABG levels c. prior outcomes of weaning d. Electrocardiogram

B ABGs baseline will help us assess how the client is tolerating weaning

A patient being treated for chest trauma shows signs of sleep deprivation. What other complication would the nurse expect to find? a. sepsis b. Delirium c. Pulmonary barotrauma d. decreased cardiac output

B Acute respiratory distress syndrome (ARDS) affects the central nervous system and can lead to psychologic complications that cause sleep deprivation and delirium. Sepsis is a systemic inflammatory response to an infection and is not related to the central nervous system. Pulmonary barotrauma is a respiratory complication associated with ARDS, caused by high pressures during mechanical ventilation. Decreased cardiac output is a cardiac complication associated with acute respiratory distress syndrome.

What complication can a high peak airway pressure used in the mechanical ventilation of a patient with acute respiratory distress syndrome (ARDS) cause? a. volutrauma b. Barotrauma c. Stress Ulcers d. VAP

B Barotrauma results from rupture of overdistended alveoli during mechanical ventilation. Critically ill patients with acute respiratory failure are at high risk for stress ulcers. Volutrauma results in alveoli fractures and movement of fluids and proteins into the alveolar spaces. VAP is a frequent complication in ventilated ARDS patients and is due to impaired host defenses, contaminated equipment, invasive monitoring devices, aspiration of gastrointestinal contents, and prolonged mechanical ventilation. p.1623

The nurse is caring for a patient with a shunt due to acute respiratory distress syndrome (ARDS). Which nursing intervention is associated with better symptomatic relief for this patient? a.Mechanical ventilation only b.Mechanical ventilation and high FIO 2 c.Bronchodilators along with corticosteroids d.High fraction of inspired oxygen (FIO 2) only

B Patients with ARDS having a shunt disorder are usually more hypoxemic than patients with ventilation-perfusion (V/Q) mismatch. They often require mechanical ventilation and a high FIO 2 in combination to improve gas exchange. Bronchodilators and corticosteroids are not helpful for immediate relief because the patient does not have bronchospasm and inflammation. p1616

Which medication should the nurse anticipate the health-care provider ordering for the client diagnosed with ARDS? a. An aminoglycoside antibiotic b. A synthetic surfactant c. A potassium cation d. A nonsteroidal anti-inflammatory drug

B Surfactant therapy may be prescribed to reduce the surface tension in the aveoli. The surfactant helps maintain open alveoli, decreases the work of breathing, improves compliance, and helps prevent atelectasis.

What type of diet does a pt who has difficulty breathing need? Ex. COPD a. Full liquid b. High protein c. 1800 calorie ADA d. Low Fat

B Pts that have difficulty breathing have an increased metabolic demand that puts them at r/f nutritional deficiencies.

When the nurse is caring for an obese patient with left lower-lobe pneumonia, gas exchange will be best when the patient is positioned a. on the left side. b. on the right side. c. in the high-Fowler's position. d. in the tripod position.

B Rationale: The patient should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions.

The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next? a. Notify the health care provider of the patient's vital signs. b. Obtain oxygen saturation using pulse oximetry. c. Document the vital signs and continue to monitor. d. Administer PRN acetaminophen (Tylenol) 650 mg.

B Rationale: The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing; the nurse should check for hypoxemia, a hallmark of ARDS. (The health care provider should be notified after further assessment of the patient. Documentation and continued monitoring of the vital signs are needed but do not constitute an adequate response to the patient situation. Tylenol administration is appropriate but not the highest priority for this patient.)

A patient with hypercapnic respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. Which collaborative intervention will the nurse anticipate? a. Administration of 100% oxygen by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning d. Initiation of bilevel positive pressure ventilation (BiPAP)

B Rationale: The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. BiPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.

A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of: a.Pulmonary Embolism b.Right pneumothorax c.Displaced endotracheal tube d.Acute respiratory distress syndrome

B Rationale:Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi.

Which intervention is most likely to prevent or limit barotrauma in the patient with ARDS who is mechanically ventilated? A. Decreasing PEEP B. Use of permissive hypercapnia C. Increasing the tidal volume D. Use of positive pressure ventilation

B To avoid barotrauma and minimize risks associated with elevated plateau and peak inspiratory pressures, the patient with ARDS is often ventilated with smaller tidal volumes and various amounts of PEEP to minimize oxygen requirements and intrathoracic pressures. One result of this protocol is an elevation in PaCO2, also called permissive hypercapnia because the PaCO2 is allowed to rise above normal limits.

The nurse is caring for a patient with acute respiratory distress syndrome (ARDS). What diagnostic findings would be evident in the patient? Select all that apply. a.Increased pulmonary artery wedge pressure b.Decreased compliance on pulmonary function test c.Scattered crackles and rhonchi on chest auscultation d.Increased functional residual capacity on pulmonary function test e.Diffuse and extensive bilateral interstitial and alveolar infiltrates on chest x-ray

B,C,E The patient with ARDS may have scattered crackles and rhonchi on chest auscultation due to fluid-filled alveoli and interstitial edema. The pulmonary function test may show decreased compliance. The chest x-ray may show diffuse and extensive bilateral interstitial and alveolar infiltrates. The pulmonary artery wedge pressure does not increase because the cause of ARDS is noncardiac. The pulmonary function test may show decreased functional residual capacity, which refers to the amount of air remaining in the lungs at the end of normal expiration.

The nurse is caring for a patient with bronchitis. The diagnostic report indicates low cardiac output. Which nursing interventions will help to maintain the cardiac output? Select all that apply a. Administer diuretics. b. Administer inotropic drugs. c. Administer crystalloid or colloid fluids. d. Increase the level of hemoglobin in the blood. e.Lower the positive end-expiratory pressure (PEEP).

B,C,E When there is a decrease in the cardiac output, the nurse administers inotropic drugs, such as dobutamine or dopamine, to increase cardiac output. Crystalloid fluids or colloid solutions are also administered during a low cardiac output. Additionally, positive end-expiratory pressure (PEEP) is lowered to maintain the same balance as that of the cardiac output. Patients undergoing nutritional therapy are placed on fluid restriction and diuretics. The oxygen-carrying capacity of the blood is measured by the number of red blood cells. Transfusion of packed red blood cells increases hemoglobin and in turn increases the oxygen carrying capacity of the blood. p.1625

A patient with alcoholism was involved in a road traffic accident and sustained a minor head injury. What nursing interventions may increase the risk of respiratory failure in such patients? Select all that apply. a. The administration of steroids to relieve pain and edema b.The administration of an opioid analgesic to relieve the pain c.The administration of prophylactic antibiotics to prevent infection d.The administration of benzodiazepines to prevent development of seizures e.The administration of nonsteroidal antiinflammatory drugs to relieve pain and edema

B,D Opioids and benzodiazepines have a respiratory depressant action in a dose-dependent manner. Because the patient is alcoholic and has sustained a head injury, the chance of going into respiratory failure is higher with the use of opioids and benzodiazepines. Steroids, antibiotics, and nonsteroidal antiinflammatory drugs have no respiratory depressive action. Steroids and nonsteroidal antiinflammatory drugs may improve the patient's condition if respiratory failure is caused by brain stem edema.

The nurse measures the hemodynamic parameters of a patient being treated for severe respiratory failure. What does the diagnostic test help the nurse to determine? Select all that apply. a. Oxygenation and ventilation b. Adequacy of tissue perfusion c. End-tidal carbon dioxide (ETCO 2) d. Response to treatment measures e. Accumulation of fluid in the lungs

B,D,E In cases of severe respiratory failure, the hemodynamic parameters such as central venous pressure, pulmonary artery pressure, cardiac output, stroke volume variation, and central/mixed venous oxygen saturation are measured. These data help to determine the adequacy of tissue perfusion and the patient's response to treatment measures. Hemodynamic monitoring also determines that the accumulation of fluid in the lungs is the result of heart or lung problems. For patients in severe respiratory failure requiring endotracheal intubation, end-tidal carbon dioxide (ETCO 2) may be used to assess tube placement within the trachea immediately after intubation. The most common diagnostic study used to evaluate respiratory failure is arterial blood gas (ABG) analysis. An ABG analysis evaluates the oxygenation and ventilation status and acid-base balance.

In a pt w/ COPD why does the oxygen-hemoglobin dissociation Curve shift to the right?

Because there is excess C02 Their body is working harder with an increase in HR, Temp, HCo3 and a DECREASE in PH

During the Fibrotic Phase of ARDS, ____________________ . A. Fluids shift into the alveoli, the alveoli and bronchii collapse, and lose lung compliance B. The lung starts to repair itself; this is where the patient starts to get better or the condition deteriorates. C. Fibrous tissue forms and lungs don't expand well; the effort to breathe increases O2 demand which causes more effort to breathe.

C

Which assessment data indicates 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 hours b. The pulse oximeter reading is greater than 95% c. The client has asymetrical chest expansion d. The telemetry reading shows sinus tachycardia

C Asymmetrical chest expansion indicates the client has a pneuothorax, which is a complication of mechanical ventilation.

A nurse observes constant bubbling in the water seal chamber of a closed chest drainage system. What should the nurse conclude? a. the system is functioning normally b. The client has a pneumothorax c. The system has an air leak d.The chest tube is obstructed

C Constant bubbling = leak A client with pneumothorax will have intermittent bubbling in the water-seal chamber that corresponds to respirations.

All the following medications are ordered for a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) and acute renal failure. Which medication should the nurse discuss with the health care provider before administration? a. IV ranitidine (Zantac) 50 mg IV b. sucralfate (Carafate) 1 g per nasogastric tube c. IV gentamicin (Garamycin) 60 mg d. IV methylprednisolone (Solu-Medrol) 40 mg

C Rationale: Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS

It will be most important for the nurse to check pulse oximetry for which of these patients? a. A patient with emphysema and a respiratory rate of 16 b. A patient with massive obesity who is refusing to get out of bed c. A patient with pneumonia who has just been admitted to the unit d. A patient who has just received morphine sulfate for postoperative pain

C Rationale: Hypoxemia and hypoxemic respiratory failure are caused by disorders that interfere with the transfer of oxygen into the blood, such as pneumonia. The other listed disorders are more likely to cause problems with hypercapnia because of ventilatory failure.

When caring for a patient who developed acute respiratory distress syndrome (ARDS) as a result of a urinary tract infection (UTI), the nurse is asked by the patient's family how a urinary tract infection could cause lung damage. Which response by the nurse is appropriate? a. "The infection spread through the circulation from the urinary tract to the lungs." b. "The urinary tract infection produced toxins that damaged the lungs." c. "The infection caused generalized inflammation that damaged the lungs." d. "The fever associated with the infection led to scar tissue formation in the lungs."

C Rationale: The pathophysiologic changes that occur in ARDS are thought to be caused by inflammatory and immune reactions that lead to changes at the alveolar-capillary membrane. ARDS is not directly caused by infection, toxins, or fever.

A patient is under medical supportive therapy for treatment of acute respiratory failure caused by pneumonia. Which intervention should the nurse follow to increase the oxygen-carrying capacity of the blood? a. Administer inotropic drugs. b. Administer crystalloid or colloid fluids. c. Increase the level of hemoglobin in blood. d. Lower the positive end-expiratory pressure (PEEP).

C The oxygen carrying capacity of the blood is measured by the number of red blood cells. Transfusion of packed red blood cells increases hemoglobin, which increases the oxygen carrying capacity of the blood. Inotropic drugs, such as dobutamine or dopamine, are used to maintain cardiac output. When there is a decrease in the cardiac output, the nurse administers crystalloid fluids or colloid solutions. Alternatively, the level of positive end-expiratory pressure (PEEP) is lowered to maintain the level of cardiac output. p.1619

The nurse is caring for a patient admitted with a barbiturate overdose. The patient is comatose with blood pressure (BP) 90/60, apical pulse 110, and respiratory rate 8. Based upon the initial assessment findings, the nurse recognizes that the patient is at risk for which type of respiratory failure? a. Hypoxemic respiratory failure related to shunting of blood b. Hypoxemic respiratory failure related to diffusion limitation c. Hypercapnic respiratory failure related to alveolar hypoventilation d. Hypercapnic respiratory failure related to increased airway resistance

C The patient's respiratory rate is decreased as a result of barbiturate overdose, which caused respiratory depression. The patient is at risk for hypercapnic respiratory failure resulting from the decreased respiratory rate, and thus decreased CO 2 elimination. Barbiturate overdose does not lead to shunting of blood, diffusion limitations, or increased airway resistance. p1610

Which is part of the nursing management for ARDS? A. Aggressive use of intravenous (IV) fluids B. Administration of a β-blocker C. Use of positive end-expiratory pressure (PEEP) D. Use of the lateral recumbent position

C Use of positive end-expiratory pressure (PEEP)In ARDS, higher levels of PEEP may be used. It increases the functional residual capacity (FRC) and opens collapsed alveoli. The issues in ARDS treatment are respiratory related, not fluid deficit. β-Blockers are part of myocardial infarction management, not ARDS. Some ARDS patients do better when placed in a prone position instead of a supine position. In the supine position, the heart places pressure on the pleural cavity. Changing the patient to a prone position allows air-filled, nonatelectatic alveoli in the ventral portion of the lung to become dependent.

An unconscious patient is brought to the emergency department after an overdose of opioids. Which complication does the nurse anticipate in this patient? a. limited lung expansion b. hypercapnia respiratory failure c. decreased carbon dioxide reactivity d. limited nerve supply to respiratory muscles

C With opioid overdose, the central nervous system decreases the carbon dioxide (CO 2) reactivity in the brainstem. Hypercapnic respiratory failure is a significant risk for patients with asthma, chronic obstructive pulmonary disease, and cystic fibrosis. A patient with chest wall abnormalities may experience limited lung expansion. High-level spinal cord injuries may limit nerve supply to the respiratory muscles of the chest wall and diaphragm. p1610

The nurse is caring for a patient on mechanical ventilation. What are the nursing interventions that prevent the development of volutrauma in a patient on a ventilator? Select all that apply. a.Sterile techniques b.Strict hand washing c.Smaller tidal volumes d.Pressure-control ventilation e.Mouth care and oral hygiene

C,D Volutrauma occurs when large tidal volumes are given to a mechanically ventilated patient. Because of the high tidal volume, the alveoli may become damaged and tear, allowing proteins and fluid to move into the alveolar spaces. This can be prevented by giving smaller tidal volumes or pressure-control ventilation. Strict hand washing, sterile technique during endotracheal suctioning, and frequent mouth care and oral hygiene are helpful to prevent ventilator-associated pneumonia and not volutrauma. p1623

What abnormalities/ conditions lead to Hypercapnia?

CNS abnormalities Chest wall abnormalities Airway and alveoli abnormalities Neuromuscular conditions

Who is at risk for Spontaneous pneumothorax?

COPD Asthma Cystic Fibrosis PNA Smoking- it increases the the r/f bleb formation because of the constant vasoconstriction. They become stiff and break. Hx of pneumothorax Tall, thin males between ages 10-30 (ex. long distance runners) because of the increase of air that they take in causes blebs. They may need a blebectomy.

What can cause ventilation/ perfusion mismatch ?

COPD Result of Pain Asthma Atelectasis ( lung collapse, partial or complete) Pulmonary Embolism PNA

What medications are used in the treatment of pulmonary HTN?

Calcium Channel Blockers:Dilate vascular smooth muscles and lower pulm. artery pressure. DO NOT use on pt w/ right sided heart failure. nifedipine(Adalat CC. Procardia) Diltiazem(Cardizem) P5Enzyme Inhibitors: They increase nitric oxide that then promotes smooth muscle relaxation in lung vasculature -> Pulm. dilation. Caution: Do not use w/ NITRO sildenafil (Flolan/ Veletri) Main drug: Sildenafil/VIAGRA!! Watch for hypotension! tadalafil (Adcirca) Vasodilators: promote pulm. dilation and reduce pulm. vascular resistance Epoprostenol (Flolan) Treprostinil (Remodulin) Adenosine (Adenocard) Anticoagulants: Prevent blood clotting Warfarin (Coumadin) Endothelial Receptor agonists: Blocks the constriction of pulm. arteries. Promotes relaxation of pulm. arteries and decreases pulm. artery pressure. Caution: Hepatoxicity bosentan (Tracleer) ambrisentan (Letairis) macitentan (Opsumit) Diuretics:Decrease preload volume. Manages peripheral edema. We can limit fluid, low sodium diet.

Iatrogenic pneumothorax

Can occur d/t laceration or puncture of the lung after a medical procedures. (Ex. trans thoracic needle aspiration, pleural biopsy, they have the potential to cause injury to the lung)

ON TEST!!! PHASE 3: What do we keep an eye out for in this PHASE?

Cardiac Output ( look at b/p)

Traumatic Pneumothorax- Closed

Caused by blunt chest trauma (fall, blow, violent cough, gunshot, stab, sudden deceleration causing a pleural tear)

Treatment of Chylothorax Pneumonia

Chest drainage, bowel rest, dietary modifications (completely FAT FREE). Lipid level can increase tenfold if they eat fat. Octreotide (Sandostin)- used to reduce the flow of lymphatic fluid. It's a growth hormone used to decrease the production and accumulation of fluids. Surgery- thoracic duct ligation and pleurodesis (create an adhesion to stop it).

For which patient would NIPPV be an appropriate intervention to promote oxygenation? A. A patient's whose cardiac output and blood pressure are unstable B. A patient whose respiratory failure is caused by a head injury with loss of consciousness C. A patient with a diagnosis of cystic fibrosis and who is producing copious secretions D. A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis

D A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis. NIPPV is most effective in treating patients with respiratory failure due to chest wall and neuromuscular disease. It is not recommended for patients who are experiencing cardiac instability, decreased level of consciousness, or excessive secretions.

The nurse is reviewing medication orders for a client with pulmonary hypertension. Which medication order would the nurse​ question? a. Nifedipine​ (Procardia) b.Warfarin​ (Coumadin) c.Epoprostenol​ (Flolan) d.Metoprolol​ (Lopressor)

D Metoprolol is a​ beta-adrenergic blocker, which is not indicated in a client with pulmonary hypertension. Calcium channel blockers are given to reduce pulmonary vascular resistance and improve cardiac output. Warfarin is given to a client with pulmonary hypertension to prevent clotting. KNOW THIS!!Epoprostenol​ (Flolan) is a vasodilator indicated for clients with pulmonary hypertension who do not respond to calcium channel blockers.

PEEP therapy has which effect on the heart? a. bradycardia b. tachycardia c. increased B/P d. Reduced Cardiac output

D PEEP reduces C/O by increasing intrathoracic pressure and reducing the amount of blood delivered to the left side of the heart. This can lead to a decrease in B/P

Which patient is having the most difficulty breathing? A. The patient who reports one-pillow orthopnea B. The patient with an inspiratory to expiratory ratio of 1:2 C. The patient who speaks a sentence before breathing D. The patient with paradoxic breathing

D Paradoxic breathing indicates severe distress. The thorax and abdomen normally move outward on inspiration and inward on exhalation. During paradoxic breathing, the abdomen and chest move in the opposite manner, and the pattern results from maximal use of the accessory muscles of respiration. Orthopnea, measured by the number of pillows needed to breathe comfortably, is associated with the use of one to four pillows. One pillow indicates a minor condition. Normal inspiratory to expiratory ratio is 1:2. Speaking in sentences before having to take a breath indicates mild or no distress.

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's arterial oxyhemoglobin saturation (SpO2) from 94% to 88%. The nurse will a. assist the patient to cough and deep-breathe. b. help the patient to sit in a more upright position. c. suction the patient's oropharynx. d. increase the oxygen flow rate.

D Rationale: Increasing oxygen flow rate will usually improve oxygen saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep-breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation

After prolonged cardiopulmonary bypass, a patient develops increasing shortness of breath and hypoxemia. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with a. positioning the patient for a chest radiograph. b. drawing blood for arterial blood gases. c. obtaining a ventilation-perfusion scan. d. inserting a pulmonary artery catheter.

D Rationale: Pulmonary artery wedge pressure will remain at normal levels in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema.

A patient in acute respiratory failure w/ a complication of COPD has a PaCO2 of 65 mm Hg, rhonchi audible in the right lung, and marked fatigue with a weak cough. The nurse will plan to a. allow the patient to rest to help conserve energy. b. arrange for a humidifier to be placed in the patient's room. c. position the patient on the right side with the head of the bed elevated. d. assist the patient with augmented coughing to remove respiratory secretions.

D Rationale: The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve PaCO2 and will also help to correct fatigue. If the patient is allowed to rest, the PaCO2 will increase. Humidification may help loosen secretions, but the weak cough effort will prevent the secretions from being cleared. The patient should be positioned with the good lung down to improve gas exchange.

The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider? a. The patient has a cough that is productive of blood-tinged sputum. b. The patient has scattered crackles throughout the posterior lung bases. c. The patient's temperature is 101.5° F after 2 days of IV antibiotic therapy. d. The patient's SpO2 has dropped to 90%, although the O2 flow rate has been increased.

D Rationale: The patient's dropping SpO2 despite having an increase in FIO2 indicates the possibility of acute respiratory distress syndrome (ARDS). The patient's blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate.

A nurse just received report on her client care assignment. Which client should she assess first? a. Client w/ anorexia, weight loss, and night sweats b. Client w/ crackles and fever who is complaining of pleuritic pain. c. Client who had difficulty sleeping, daytime fatigue, and morning headache. d. Client w/ petechiae over the chest who's complaining of anxiety and SOB

D This client is exhibiting S+S of pulmonary embolism which is life threatening.

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct? a. "PEEP will prevent fibrosis of the lung from occurring." b. "PEEP will push more air into the lungs during inhalation." c. "PEEP allows the ventilator to deliver 100% oxygen to the lungs." d. "PEEP prevents the lung air sacs from collapsing during exhalation."

D Rationale: By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient.

A nurse assessing a client for tracheal displacement should know that the trachea will deviate towards the: a. affected side in simple pneumothorax b. affected side in hemothorax c. affected side in tension pneumothorax d. Contralateral side in hemothorax

D. In tension pneumothorax and hemothorax the accumulation of air or fluid causes a shift away from the injured side.

Barotrauma

Damage to the lung from rapid or excessive PRESSURE changes, as may occur when a patient is on a ventilator and is subjected to high airway pressure. (Alveolar air escapes from ruptured alveoli -> this can lead to pulmonary interstitial emphysema, pneumothorax, subcutaneous emphysema, and tension pneumothorax. To avoid this patient is often ventilated at smaller tidal waves.)

High frequency ventilation

Delivers up to 500bpm Its opening up the alveoli up one at a time Can't see a true respirations

Describe ventilation/ perfusion mismatch in Asthma and how it leads to hypoxemia?

Pt. is hyperventilating -> Increase of air in alveoli where it gets trapped -> lung hyperinflation = no release of C02 -> as the alveoli gets bigger the capillary bed is being compressed. They are taking in air, but there is little to no perfusion leading to hypoxemia.

What is Hypercapnia Respiratory Failure?

Excess C02 Imbalance between ventilatory supply and ventilatory demand. Also referred to as ventilatory failure.

True or False Pulmonary HNT is curable.

FALSE Pulmonary hypertension is not curable, but it can be treated if the underlying cause is discovered.

What ARDS phase does this occur in? Remodeling of the lung with collagenous and fibrous tissues

Fibrotic phase

What IS Diffusion limitation?

Gas exchange across the alveolar-capillary membrane is compromised by a process that thickens, damages, or destroys the membrane or affects blood flow through the pulmonary capillaries. Gas moves by diffusion, if there is limited diffusion there is decreased gas exchange. Hypoxemia is a classic sign.

High PEEP level

Higher levels of PEEP are often needed to maintain Pa02 at 60mmHg or greater. Opens collapsed alveoli sacs CAUTION: It can also compromise venous return and decrease preload, CO, and BP

What is refractory hypoxemia?

Hypoxemia unresponsive to increasing concentrations of O2.

Why do we want to administer LOW Oxygen in a patient with pulmonary HTN?

Hypoxia is a potent pulmonary vasoconstrictor, low 02 provides symptomatic relief. Goal is to keep 02 sat >90%

The nurse understands that one way to assess the degree of impairment in gas exchange is to measure the arterial oxygen/fraction of inspired oxygen (PaO 2/FIO 2, or P/F) ratio. What is the P/F ratio in acute lung injury (ALI)? a.Less than 200 b.Greater than 400 c.Greater than 300 d.Between 200 and 300

In ALI, the P/F ratio is between 200 and 300. This indicates compromised gas exchange through the alveoli. Under normal circumstances, when PaO 2 is 85 to 100 mm Hg and FIO 2 is 0.21, the P/F ratio would be greater than 400. The term acute respiratory distress syndrome (ARDS) is used when the P/F ratio is less than 200 (e.g., 80/0.8 = 100) and indicates refractory hypoxemia. p1613

What are 3 important concepts of Hypercapnia Respiratory Failure?

Incorporates 3 important concepts: (1) the Paco2is higher than normal >48mmHg (2) there is evidence of the body's inability to compensate for this increase (acidemia pH<7.35) d/t CO2 retention (3) the pH is at a level where a further decrease may lead to severe acid-base imbalance.

Milrinone for ARDS

Increased contractility, does the job of digoxin Increases HR Decrease PVR Helps the heart to pump more effectively Vasodilates the lungs The pulmonary vessels need to relax Golden drug for pulmonary edema

Complications of pulmonary hypertension include...

Increased workload of right ventricle which can lead to -> RIGHT ventricular hypertrophy, ultimately leading to -> COR pulmonale

What causes the small arteries in the lungs to narrow in diameter?

Inflammation process -> linning of the vessels are no longer working properly d/t remodeling -> your scar tissues cannot stretch well, it is still (vascular scarring) -> you can't pump ->decreased compliance.

Refractory hypoxemia ( hypoxemia unresponsive to increasing concentrations of oxygen) occurs during what ARDS phase?

Injury ( exudative) phase

What can cause Acute Respiratory Failure?

Insufficient 02 transfer to the blood Inadequate 02 saturation of hemoglobin Inadequate C02 removal

What is a P/F ratio?

It helps us figure out what stage of ARDS we are in. Pa02 divided by FI02= P/F ratio displayed as a decimal Above 400 is considered normal

What are two surgical interventions for a pt w/ pulmonary HTN?

Lung Transplant Atrial Septostomy- palliative procedure that involves the creation of an intra-atrial right to left shunt to decompress the right ventricle. Pressure is built up in right atrium side that it moves to the left side.

What is the primary cause of death in ARDS

MODS

pH 7.2 PaC02 40 HCO3 15

Metabolic acidosis

What are the 3 different P/F ratios in ARDS and their ranges?

Mild >200- greater or equal to 300 Moderate 100-greater or equal to 200 Severe <100 Table 67-5

What amount of chest tube drainage requires you to notify someone?

More than 100 ml/hr. We need to monitor it. Possibly need to give fluids.

Why are pt.s with COPD less likely to have AM H/A vs. Hypoxemia patients?

Pts w/ COPD are used to living in a hypercapnic state and are used to the increased levels of CO2 Hypoxemic patients are more likely to have an AM H/A because they are not used to having that much CO2

What are causes of Alveolar hypoventilation?

Neuromuscular disease Acute Asthma Restrictive lung disease (obesity, scoliosis) CNS disease Chest wall dysfunction

What is the appropriate first step to reverse hypoxemia caused by V/Q mismatch? Why?

O2 therapy, because not all gas exchange units are affected.

Renal Failure in ARDS

Occurs from decreased renal tissue oxygenation from hypotension, hypoxemia, or hypercapnia. (May also be caused by nephrotoxic drugs used for infection associated with ARDS. ex vancomycin).

Respiratory Therapy: Mechanical ventilation

PEEP High frequency ventilation Permissive hypercapnia- Intentional limiting of airway pressures and tidal volumes during mechanical ventilation, thereby allowing PaCO2 to rise above normal, in order to minimize the risk of lung injury.

Hypoxemia Produces a DECREASE in ?

Pa02 in Sa02

PEEP

Positive pressure applied at the end of expirations the end of ventilator breaths. PEEP is usually applied at 3-5 cm H20 increments until oxygenation is adequate ( compensates for loss of glottic formation).

What ARDS phase does this occur in? Inflammatory response occurs and there is an increased pulmonary vascular resistance, which may cause pulmonary hypertension.

Proliferative Phase

Nitric oxide for ARDS

Promotes respiration It's a massive pulmonary vasodilator It's able to diffuse because it's lighter than O2 so it's able to diffuse through the scar tissue

Ideal positioning for ARDS

Prone if possible. It increases oxygen concentration Helps V/Q Moves secretions and improves atelectasis

What is pulmonary hypertension?

Pulmonary hypertension is characterized by abnormally high blood pressure in the pulmonary artery. It develops when most of the very small arteries throughout the lungs narrow in diameter, increasing the resistance of blood flow through the lungs.

What is the definitive diagnostic test to test for Pulmonary hypertension?

RIGHT sided cardiac catheterization. It can also determine C/O and pulmonary vascular resistance

pH 7.52 PaC02 30mmHg HC03 26 P02 77

Respiratory Alkalosis

Initially, what will ABG usually indicate for someone with ARDS in PHASE 1?

Respiratory Alkalosis d/t hyperventilation and also mild hypoxemia. If not treated it will lead to respiratory acidosis.

Barotrauma in Iatrogenic pneumothorax

Rupture of over distended alveoli and bronchioles from so much pressure during manual or mechanical ventilation

What is the main cause of ARDS?

Sepsis Slide 5

What are INDIRECT conditions that predispose patients to ARDS?

Sepsis (esp. gram neg infection) Severe massive trauma Less common: Acute pancreatitis Cardiopulmonary bypass Disseminated intravascular coagulation Opioid drug overdose Severe head injury Shock states Transfusion-related acute lung injury

What are causes of diffusion limitation?

Severe COPD Hypoxemia present during exercise ARD Recurrent PE Pulmonary fibrosis Interstitial lung disease

Types of pneumothorax

Spontaneous Iatrogenic Tension Pneumohemothorax

True or False Hypoxemia a is a potent pulmonary vasoconstrictor and a common initiating factor in pulmonary hypertension.

TRUE With hypoxemia, alveolar walls are destroyed, leading to a loss of pulmonary capillaries. The pulmonary vessels may become obstructed with microemboli, further decreasing alveolar walls and pulmonary capillaries.

VAP- Ventilator associated PNA prevention

Strict infection control measures: Strict hand washing, sterile technique during ET suctioning, frequent mouth care and oral hygiene. Elevate HOB 45 degrees or more to prevent aspiration

Treatment for Tension pneumothorax

THIS IS A MEDICAL EMERGENCY!!! Needle decompression followed by chest tube insertion w/ chest drainage system. As the pressure increases, there is a decrease in venous return and cardiac output falls. Patient is likely to die from inadequate cardiac output or severe hypoxemia.

Esophageal procedures and pneumothorax

Tearing during a gastric tube insertion can allow air from the esophagus to enter the mediastinum and pleural space.

Chylothorax Pneumonia

The presence of lymphatic fluid in the pleural space. The thoracic duct is disrupted either traumatically or from a malignancy and the lymphatic fluid fills the pleural space. During heart surgery they nip the lymphatic duct and it leaks white milky fluid made of lipids and protein from the small bowel.

What is the treatment of pulmonary HTN focused on?

Treatment of pulmonary hypertension is focused on slowing the course of the disease, preventing thrombus formation, and reducing pulmonary vasoconstriction. •DECREASE PRELOAD •VASODILATE- vasculature of the lungs. Main drug: Sildenafil/VIAGRA!! •ANTICOAGULANTS •TREATMENT OF HYPOXIA- low flow oxygen •ATRIAL SEPTOSTOMY •LUNG TRANSPLANT

True or False Acute Respiratory is not a disease but a condition

True. Respiratory failure is not a disease but a symptom of an underlying pathology affecting lung function, O2 delivery, cardiac output (CO), or the baseline metabolic state.

Spontaneous Pneumothorax

Typically occurs d/t the rupture of small blebs (air filled sacs) located on the surface of the lung. Too much intake of air, but you don't have enough alveoli, they eventually pop.

What should we encourage a pt w/ Pulm. HTN to report?

Unexplained SOB Syncope Chest discomfort and edema of the feet and ankles

Management of ARDS PHASE 1:

Ventilator management often includes pressure-control type of ventilation. (Pressure-control ventilation helps keep the inspiratory and plateau pressures from becoming too high -> This prevents alveolar over-distention and rupture, by reducing the amount of pressure going into the stiff, noncompliant lungs, further lung injury may be prevented.)

What are Complications of ARDS?

Ventilator-associated pneumonia Barotrauma Volutrauma Subcutaneous emphysema High risk for stress ulcers Renal failure

What form of oxygenation best promotes adequate gas exchange in a pt w/ COPD

Venturi Mask Pt w/ COPD retains C02 which inhibits the stimulation of breathing by the medullary center in the brain. We don't want to give unmonitored amounts of oxygen because it may depress ventilation. Venturi Mask delivers a specified, controlled amount of oxygen consistently and accurately.

Stress Ulcer management

Zantac is the better drug over protonix

Hemothorax

a collection of blood in the pleural cavity

Tension Pneumothorax

a type of pneumothorax in which air that enters the chest cavity cannot escape. An increase in air accumulation in the pleural space -> increase in intra-pleural pressure -> compression of the lung on the affected side and pressure on the heart and great vessels. Can result from either open or closed wound (one way valve). Can occur w/ mechanical ventilation, resuscitative efforts, and clamped chest tubes in pneumothorax pt.

Manifestations of Tension pneumothorax

dyspnea, marked tachycardia (We want to catch it here!), tracheal deviation, decreased or absent breath sounds on affected side, neck vein distention, cyanosis (LATE), and perfuse diaphoresis. Patient can become confused or agitated, in distress.

What is the purpose of pursed-liped breathing?

it helps prevent early airway collapse

Autotransfusion

process of infusing a patient's own blood to restore volume.

Pulmonary HTN Diagnostics

•CARDIAC CATHERIZATION •EKG •X-RAY- White out •PFTS- pulmonary fx test •ECHOCARDIOGRAM- measures the pressures in right and left ventricles, measures Ejection Fraction. •CT

Manifestations of Pulmonary HTN

•DYSPNEA ON EXERTION •FATIGUE- d/t decreased oxygenation because of congestion in the lungs. •CHEST PAIN- Myocardium is working hard ->The blood isn't getting there -> in the absence of glucose from the blood the heart breaks down the muscle, fat, protein -> When you use fat for energy it produces Lactic Acid -> Lactic Acid causes irritation of the nerve cells that line the heart and the coronary arteries. •SYNCOPE- d/t poor profusion