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Highline Nursing Program N241

RESPIRATORY FAILURE ARDS

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Contents
Definitions and defining characteristics Complications of S/Ss Interventions

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Respiratory Failure
Any impairment in oxygenation or ventilation in the lungs PaO2, PaCO2, pH

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Causes for Hypoxic Resp. Failure

Ventilation-perfusion mismatch Shunt Diffusion limitation Alveolar hypoventilation Combination

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Causes of Hypercapnic Resp. Failure

Imbalance between ventilatory supply and demand Airways and alveoli Central nervous system Chest wall Neuromuscular conditions

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Clinical Manifestations
Sudden vs. Gradual Hypoxemia vs. Hypercapnea
Hypoxemia: Dyspnea, neurological Sx, initial tachycardia and HTN, may progress to dysrhythmia, hypotension, decreased CO Hypercapnea: Dyspnea and headache early, decreased LOC, pursed-lip breathing

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Diagnostic Studies
History and physical assessment ABG analysis Chest x-ray CBC, BMP Sputum/Blood cultures ECG Urinalysis V/Q lung scan Pulmonary artery catheter
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Interventions
Medications: Bronchodilators, Corticosteroids Diuretics, nitrates if heart failure present IV antibiotics Benzodiazepines, Narcotics O2: Airway management: Hydration, humidification, Chest physical therapy, Airway suctioning, Effective coughing and positioning Mechanical ventilation: PPV, BiPAP, CPAP Nutritional

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Augmented Cough

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Noninvasive PPV
Bi-phasic positive airway pressure (BiPAP) Continuous positive airway pressure (CPAP): PEEP (positive end-expiratory pressure)

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Types of Ventilators
Settings: rate, tidal volume, FiO2 Negative pressure Positive pressure
Endotracheal tube, tracheostomy In acute respiratory failure Trigger: ventilator-assisted breath vs. ventilatorcontrolled breath Cycle (duration of inspiration): volume controlled, pressure-cycled
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Complications of mechanical ventilation

Improper ET tube placement Nosocomial pneumonia Barotrauma Decreased cardiac output GI distress
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Care of client on ventilator

Monitoring of ventilator function Continuous assessment of O2 sat, lung Suction Sedation, emotional support Means of communication
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Weaning from the ventilator

Underlying problem must be corrected or stabilized. Readiness for weaning: T-piece or CPAP SIMV, PSV
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Gerontologic Considerations
Physiologic aging results in
Ventilatory capacity Alveolar dilation Larger air spaces Loss of surface area Diminished elastic recoil Decreased respiratory muscle strength Chest wall compliance

Lifelong smoking Poor nutritional status Less available physiologic reserve

Cardiovascular Respiratory Autonomic nervous system
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Nursing Diagnoses
Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern Risk for fluid volume imbalance Anxiety Imbalanced nutrition: Less than body requirements

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CASE 75 YO male has a long history of COPD. He develops a respiratory infection that is unresponsive to treatment. He is admitted to the ED in moderate respiratory distress RR of 32, shallow respirations, anxious, can barely talk, uses his accessory muscles. His wife is yelling at the health care team to do something or he will die ABG: pH 7.14, PaO2 58, PaCO2 60, O2 sat 85%
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1. 2.

What type of respiratory failure does he have? What could have prevented this from happening? What is his priority of care? When he is stable, what teaching should be done for him and his wife? What is his priority of care? What may be needed for improved CO?
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3. 4.

5. 6.

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ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)

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Acute Respiratory Distress Syndrome

Sudden progressive form of acute hypoxemic respiratory failure Alveolar capillary membrane becomes damaged and more permeable to intravascular fluid No pharmacologic therapeutic protocol Mortality > 50%
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Definition

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Statistics
10%-15% of ICU 20% of mechanically ventilated $5 billions/year for healthcare costs

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CLINICAL DISORDERS COMMONLY ASSOCIATED WITH ARDS Direct Lung Injury Indirect Lung Injury Pneumonia Sepsis Aspiration of gastric contents Severe trauma Pulmonary contusion Multiple bone fractures Near-drowning Flail chest Toxic inhalation injury Head trauma Burns Multiple transfusions Drug overdose Pancreatitis Post-cardiopulmonary bypass
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12/5/2011 Copyright 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

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Pathophysiology
Injury or exudative phase: Neutrophils adhere to pulmonary microcirculation Damage to vascular endothelium Reparative or proliferative phase Interstitial and alveolar edema: noncardiogenic Atelectasis resulting in V/Q mismatch refractory hypoxemia Fibrotic or chronic/late phase Lung compliance, Pulmonary hypertension from pulmonary vascular destruction and fibrosis
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Clinical Manifestations: Early

Subjective Sx:

Assessment:

Hx: Tests:
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Clinical Manifestations: Late

Subjective Sx:

Assessment:

Tests:

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Chest X-Ray of Person with ARDS

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Interventions
Goals: Oxygen Mechanical Ventilation Fluid management Positioning Treat underlying causes
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Positioning
Proning

Continuous lateral rotation

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Oxygen Toxicity

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Complications of ARDS
Hospital-acquired pneumonia Barotrauma Volu-pressure trauma High risk for stress ulcers Renal failure

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Nursing Diagnoses
Ineffective airway clearance Ineffective breathing pattern Risk for fluid volume imbalance Anxiety Impaired gas exchange Imbalanced nutrition: Less than body requirements

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CASE 82 Y female brought to the ED from a LTC. 4 DA, aspirated her lunch and has been coughing ever since. 2 DA, diagnosed with aspiration pneumonia started on empiric antibiotic therapy of azithromycin (Zithromax) During the past 24 hours, has developed progressive dyspnea and restlessness On admission to the ED, confused and agitated, at times she is gasping for air. Chest x-ray shows diffuse infiltrates
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1. 2. 3. 4.

Why was she at risk for ARDS? What is her priority of care? What is the goal of her treatment? What are some possible complications that she could develop?

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Hypoxemic respiratory failure is most likely to occur in the patient who has 1. a massive pulmonary embolism. 2. slow, shallow respirations as a result of sedative overdose. 3. respiratory muscle paralysis. 4. thoracic trauma with flail chest.

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A patient with severe chronic lung disease is hospitalized in respiratory distress. The nurse suspects rapid decompensation of the patient upon finding 1. a SpO2 of 86%. 2. blood pH of 7.33. 3. agitation or confusion. 4. a change in PaCO2 level from 48 mm Hg to 55 mm Hg.
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A patients arterial blood gas (ABG) results include pH 7.31, PaCO2 50 mm Hg, PaO2 51 mm Hg, and HCO3 24 mEq/L. Oxygen at 2 L/min is administered and the patient is placed in high-Fowlers position. An hour later the ABGs are repeated with results of pH 7.36, PaCO2 40 mm Hg, PaO2 60 mm Hg, and HCO3 24 mEq/L. It is most important for the nurse to take which of the following actions? 1. Increase the oxygen flow rate to 4 L/min. 2. Prepare the patient for endotracheal intubation and mechanical ventilation. 3. Document the findings in the patients record. 4. Reposition the patient in a semi-Fowlers position.
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When assessing a patient with sepsis which of the following findings would alert the nurse to the onset of acute respiratory distress syndrome (ARDS)? 1. Use of accessory muscles of respiration 2. Fine, scattered crackles on auscultation of the chest 3. SpO2 of 80% 4. ABGs of pH 7.33; PaCO2 48 mm Hg, and PaO2 80 mm Hg
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SIRS and MODS

Highline Community College Nursing Program N241

Contents
Review the definition of SIRS MODS- summarize the S/Ss, tests, and interventions of failing organs/systems.

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SIRS can be diagnosed when two or more of the following are present. (1) Heart rate > 90/ min (2) Body temperature < 36 or > 38C (3) Hyperventilation > 20/min or PaCO2 < 32 mm Hg (4) WBC count < 4000 cells/mm3 or > 12000 cells/mm3, or immature neutrophils > 10%

SIRS and MODS

SIRS (Systemic Inflammatory Response Syndrome) Systemic inflammatory response to a variety of insults Generalized inflammation in organs remote from the initial insult MODS (Multiple organ dysfunction syndrome) Results from SIRS Failure of two or more organ systems Homeostasis cannot be maintained without intervention

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Causes for SIRS

Mechanical tissue trauma: burns, crush injuries, surgical procedures Abscess formation: intra-abdominal, extremities Ischemic or necrotic tissue: pancreatitis, vascular disease, myocardial infarction Microbial invasion: Bacteria, viruses, fungi Endotoxin release: Gram-negative bacteria Global perfusion deficits: Postcardiac resuscitation, shock states Regional perfusion deficits: Distal perfusion deficits

Pathophysiology
Inflammatory response
Release of mediators Direct damage to the endothelium Vasodilation leading to decreased SVR Increase in vascular permeability Activation of coagulation cascade Hyperglycemiahypoglycemia Catabolic state Liver dysfunction Lactic acidosis

Hypermetabolic state

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Interventions
Vigilant assessment and detect early signs Maintenance of tissue oxygenation
Enhance CO

Nutritional and metabolic needs Support of failing organs

CASE 28 YO female, brought to the ED by her mother with confusion, fever, and flu for past week. She has been vomiting for the past 2 days and has noted generalized edema. BP 88/54, HR 112, Temp 103.5F, RR 24 Chest x-ray shows bilateral infiltrates. WBC and lactic acid elevated She is admitted to the ICU with R/O sepsis. Urine output: amber, 15 ml/2 hr.

1.

Nurse notes petechiae and jaundiced skin. What do these signs indicate? What are some treatments that you would anticipate being done for her? How should she receive nutritional support? How would the blood glucose be affected? What can you do to prevent further infections?

2.

3.

4.

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12/5/2011 Copyright 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

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