Advanced Clinical Concepts

Question 1

Acute Respiratory Distress Syndrome (ARDS)

Answer 1

• A life-threatening lung condition that prevents enough oxygen from getting into the lungs and into the blood
• The exchange of oxygen for carbon dioxide in the lungs is inadequate for oxygen consumption and carbon dioxide production within the body’s cells
• An unexpected, catastrophic pulmonary complication occurring in a person with no previous pulmonary problems
• ARDS is characterized by:
  1. Hypoxemia that persists even when 100% oxygen is given
  2. Decreased pulmonary compliance
  3. Dyspnea
  4. Non-cardiac associated bilateral pulmonary edema
  5. Dense pulmonary infiltrates on radiography
• No abnormal lung sounds are present on auscultation b/c the edema of ARDS occurs first in the interstitial spaces, not in the airways

Question 2

Interventions to prevent complications of clients on mechanical ventilation with ARDS

Answer 2

• Elevate HOB to at least 30 degrees
• Assist with daily awakening (“sedation vacation”)
• Implement a comprehensive oral hygiene program
• Implement a comprehensive mobilization program

Question 3

Common causes of Respiratory Failure

Answer 3

1. Exacerbation of chronic obstructive pulmonary disease (COPD)
2. Pneumonia
3. Tuberculosis
4. Contusion
5. Aspiration
6. Inhaled toxins
7. Emboli
8. Drug overdose
9. Fluid overload
10. Disseminated intravascular coagulation (DIC)
11. Shock

Question 4

Respiratory Failure (Assessment)

Answer 4

• Dyspnea, hyperpnea, crackles (or rales)
• Intercostal retractions
• Cyanosis, pallor
• Hypoxemia: PO2 < 50 mm Hg with FiO2 > 60%
• Diffuse pulmonary infiltrates seen on chest radiograph as “white-out” appearance
• Verbalized anxiety; restlessness

Question 5

Respiratory Failure (Interventions)

Answer 5

• Position client for maximal lung expansion
• Monitor client for signs of hypoxemia and oxygen toxicity
• Suction only when secretions are present
• Monitor breath sounds for pneumothorax (presence of air or gas in the cavity between the lungs and the chest wall, causing collapse of the lung)
• Provide emotional support to decrease anxiety and allow ventilator to “work” the lungs
• Monitor client hemodynamically with essential vital signs and cardiac monitor
• Monitor arterial blood gases (ABGs) routinely
• Monitor vital organ status: central nervous system (CNS), level of consciousness (LOC), renal system output, and myocardium (apical pulse, blood pressure)
• Monitor fluid and electrolyte balance
• Monitor metabolic status through routine lab work

Question 6

Common causes of Respiratory Failure in Children

Answer 6

• Congenital heart disease
• Respiratory distress syndrome
• Infection, sepsis
• Neuromuscular disease
• Trauma and burns
• Aspiration
• Fluid overload and dehydration
• Anesthesia and narcotic overdose

Question 7

Arterial Blood Gas (ABGs) Normal Values

Answer 7

• pH = 7.35 - 7.45
• PCO2 = 35-45 mm Hg
• HCO3 = 21-28 mEq/L
• PO2 = 80-100 mm Hg
• O2 Saturation = 95%-100%
• Base Excess = 0 +/- 2 mEq/L

Question 8

Cardinal Signs of Respiratory Distress in Children

Answer 8

• Restlessness
• Tachypnea
• Tachycardia
• Diaphoresis

Question 9

The Allen Test

Answer 9

• The Allen Test assess collateral circulation; ensures collateral circulation to the hand if thrombosis of the radial artery should follow the puncture
• Make the client’s hand blanch by obliterating both the radial and the ulnar pulses
• Then release the pressure over the ulnar artery only
• If flow through the ulnar artery is good, flushing will be seen immediately –> Positive (+)

Question 10

Shock

Answer 10

• Widespread, serious reduction of tissue perfusion (lack of O2 and nutrients) that, if prolonged, leads to generalized impairment of cellular functioning
• Life threatening medical condition that occurs due to inadequate substrate for aerobic cellular respiration

Question 11

Typical Signs of Shock

Answer 11

• Low BP (hypotension)
• Tachycardia
• Low Urine Output
• Confusion or Loss of Consciousness

Question 12

Those at risk for development of shock include

Answer 12

• Very young and very old clients
• Post-myocardial infarction (MI) clients
• Clients with severe dysrhythmia
• Clients with adrenocorticoid dysfunction
• Persons with history of recurrent hemorrhage or blood loss
• Clients with burns
• Clients with massive or overwhelming infection

Question 13

Types of shock

Answer 13

1. Hypovolemic Shock - r/t external or internal blood or fluid loss (the most common cause of shock)
2. Cardiogenic Shock - r/t ischemia or impairment in tissue perfusion resulting from MI, serious arrhythmia, or heart failure –> decreased cardiac output
3. Distributive Shock (Anaphylactic, Neurogenic, and Septic Shock) - results from excessive vasodilation and the impaired distribution of blood flow
   - Anaphylactic - r/t allergens (anaphylaxis), can be acute and life threatening with respiratory distress r/t bronchial constriction leading to airway obstruction; vascular collapse may follow
   - Neurogenic - related to injury to the descending sympathetic pathways in the spinal cord. This results from loss of vasomotor tone and sympathetic innervation to the heart
   - Septic - r/t to endotoxins released by bacteria, which cause vascular pooling, diminished venous return, and reduced cardiac output
4. Obstructive - physical obstruction related to tamponade, emboli, compartment syndrome that impedes the filling or outflow of blood resulting in reduced cardiac output
   * All types of shock can lead to systemic inflammatory response syndrome (SIRS) and result in multiple organ dysfunction syndrome (MODS)
   * If cardiogenic shock exists in the presence of pulmonary edema (i.e. from pump failure), position client to reduce venous return (high Fowler position with legs down) to decrease further venous return to the left ventricle