Advanced Clinical Concepts Flashcards
What is ARDS?
The exchange of oxygen for carbon dioxide in the lungs is inadequate for oxygen consumption and carbon dioxide production within the body’s cells. ARDS is an unexpected, catastrophic pulmonary complication occurring in a person with no previous pulmonary problems. Clients are critically ill and are managed in an intensive care setting. The mortality rate is high (50%).
What are interventions to prevent complications of clients on mechanical ventilation with ARDS?
Interventions to prevent complications of clients on mechanical ventilation with ARDS: • Elevate head of bed (HOB) to at least 30 degrees. • Assist with daily awakening (“sedation vacation”). • Implement a comprehensive oral hygiene program. • Implement a comprehensive mobilization program.
When do you suction a patient with ARDS?
Suction only when secretions are present.
When and how do you perform the Allen test?
Before drawing a sample for ABGs from the radial artery, perform the Allen test to assess collateral circulation. 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. The Allen test is then positive, and the radial artery can be used for puncture. If the Allen test is negative, repeat on the other arm. If this test is also negative, seek another site for arterial puncture. The Allen test ensures collateral circulation to the hand if thrombosis of the radial artery should follow the puncture.
What are the 4 cardinal signs of ARDS in children?
Cardinal signs of Acute Respiratory Failure in children are: 1. restlessness 2. tachypnea, 3. tachycardia 4. diaphoresis.
What PCO2 or PO2 level on what % of O2 signifies respiratory failure?
PCO2 >45 or PO2 <60 on 50% O2 signifies respiratory failure.
What % of O2 should a child in severe distress receive?
100% O2
What PO2 value indicates respiratory failure in adults?
PO2 <60mm Hg
What blood value indicates hypercapnia?
PO2 >45mm Hg
Identify the condition that exists when the PO2 is 60%.
Hypoxemia
List 3 symptoms of respiratory failure in adults.
- dypsnea/tachypnea 2. intercostal and sternal retractions 3. cyanosis
List 4 common causes of respiratory failure in children.
- congenital heart disease 2. infection or sepsis 3. respiratory distress syndrome 4. fluid overload or dehydration
ARDS: Nursing Assessment
A. Dyspnea, hyperpnea, crackles (or rales) B. Intercostal retractions C. Cyanosis, pallor D. Hypoxemia: Po2 60% E. Diffuse pulmonary infiltrates seen on chest radiograph as “white-out” appearance F. Verbalized anxiety, restlessness
ARDS: Nursing Interventions
A. Position client for maximal lung expansion. B. Monitor client for signs of hypoxemia and oxygen toxicity. C. Monitor breath sounds for pneumothorax. D. Provide emotional support to decrease anxiety and allow ventilator to “work” the lungs. E. Monitor client hemodynamically with essential vital signs and cardiac monitor. F. Monitor arterial blood gases (ABGs) routinely. G. Monitor vital organ status: central nervous system (CNS), level of consciousness, renal system output, and myocardium (apical pulse, blood pressure [BP]). H. Monitor fluid and electrolyte balance. I. Monitor metabolic status through routine lab work.
ABGs: pH PCO2 HCO3 PO2 O2% O2 Content (Arterial, Venous) Base Excess
pH: 7.35-7.45 PCO2: 35-45mm Hg HCO3: 21-28mEq/L PO2: 80-100mm Hg O2%: 95-100% O2 Content: Arterial 15-22%, Venous 11-16% Base Excess: 0 +-2mEq/L
What is shock?
Widespread, serious reduction of tissue perfusion (lack of O2 and nutrients) that, if prolonged, leads to generalized impairment of cellular functioning. Severe shock leads to widespread cellular injury and impairs the integrity of the capillary membranes. Fluid and osmotic proteins seep into the extravascular spaces, further reducing cardiac output. A vicious circle of decreased perfusion to all cellular level activities ensues. All organs are damaged, and if perfusion problems persist, the damage can be permanent.
What are the 4 stages of hypovolemic shock?
- Blood loss <10% Apprehension, restlessness; increased HR; cool, pale skin; fatigue. Arteriolar constriction; incr ADH production; art pressure maintained; CO usually normal; selective reduction in blood flow to skin and muscle beds. 2. Blood loss 15-25% Flat neck veins w/ delayed cap refill; incr HR and RR; pallor, diaphoresis, cool skin; decr UO; sunken, soft eyeballs; confusion. Marked reduction in CO; art pressure decline; adrenergic comp response resulting in tachycardia, tachypnea, cutaneous vasoconstriction, and oliguria; decr cerebral perfusion. 3. Progressive Stage Edema; incr blood viscosity; excessively low BP; dysthymia, ischemia, and MI; weak, thready, or absent peripheral pulses. Rapid circ deteroiration; decr CO; decr tissue perf; reduced blood vol. 4. Irreversible Stage Profound hypoTN, unresponsive to vasopressors; severe hypoxemia, unresponsive to O2 admin; anuria, renal shutdown; HR slows with cardiac/respiratory arrest. Inevitable death d/t cell destruct; multiple organ system failure.
What is distributive shock?
Distributive Shock (Anaphylactic, Neurogenic, and Septic Shock)—results from excessive vasodilation and the impaired distribution of blood flow.
Relationship between shock, SIRS, and MODS?
All types of shock can lead to systemic inflammatory response syndrome (SIRS) and result in multiple organ dysfunction syndrome (MODS).
How do you position a patient with cardiogenic shock with pulmonary edema?
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.
Shock: Nursing Assessment
A. Vital signs 1. Tachycardia (pulse >100 bpm) 2. Tachypnea (respirations >24 min) 3. BP decrease (systolic 1.020 indicates hypovolemia.
Shock: Nursing Interventions
A. Monitor arterial pressure by understanding the concepts related to arterial pressure (Table 3-3). B. Monitor BP, pulse, respirations, and arrhythmias every 15 minutes or more often, depending on stability of client. C. Assess urine output every hour to maintain at least 30 mL/hr. D. Notify health care provider if urine output drops below 30 mL/hr (reflects decreased renal perfusion and may result in acute renal failure). E. Administer fluids as prescribed by provider to improve preload: blood, colloids, or electrolyte solutions until designated CVP is reached (Table 3-4). F. Remember client’s bed position is dependent on cause of shock. G. Administer medications IV (not intramuscular [IM] or subcutaneous) until perfusion improves in muscles and subcutaneous tissue. H. Keep client warm; increase heat in room or put warm blankets (not too hot) on client. I. Keep side rails up during all procedures; clients in shock experience mental confusion and may easily be injured by falls. J. Obtain blood for lab work as prescribed: complete blood count (CBC), electrolytes, blood urea nitrogen (BUN), creatinine (renal damage), lactate (sepsis), and blood gases (oxygenation and ventilation). K. When administering vasopressors or adrenergic stimulants, such as epinephrine (Bronkaid), dopamine (Intropin), dobutamine (Dobutrex), norepinephrine (Levophed), or isoproterenol (Isuprel): 1. Administer through volume-controlled pump. 2. Monitor hemodynamic status every 5 to 15 minutes. 3. Watch intravenous site carefully for extravasation and tissue damage. 4. Ask health care provider for target mean systolic BP (usually 80 to 90 mm Hg). L. When administering vasodilators, such as hydralazine (Apresoline), nitroprusside (Nipride), or labetalol hydrochloride (Normodyne, Trandate) to counteract effects of vasopressors: 1. Wait for precipitous decrease or increase in BP if prescribed together. 2. If drop in BP occurs, decrease vasodilator infusion rate first; then increase vasopressor. 3. If BP increases precipitously, decrease vasopressor rate first; then increase rate of vasodilator. 4. Obtain blood work as prescribed: CBC, electrolytes, BUN, creatinine (renal damage), and blood gases (oxygenation). 5. Glucose levels should be maintained at 140 to 180 mg/dL. M. Provide family support: 1. Notify appropriate support persons for families waiting during crisis—call spiritual advisor, other family members, or anyone the family thinks will be supportive. 2. At intervals, notify family of actions and progress or lack of progress in realistic terms. 3. Collaborate with health care provider before notifying family of medical interventions.
Arterial Pressure: MAP CO PR CVP
Arterial Pressure: MAP: level of pressure in central art bed measured indirectly via BP or directly via art cath; MAP = CO x TPR = [SBP + 2DBP] / 3 CO: vol of blood ejected by LV per unit of time; SV x HR = norm 4-6L/min PR: resistance to blood flow CVP: pressure in RA; norm 2-6mm Hg
What is DIC? + random case study of woman in automobile accident
Coagulation disorder with paradoxical thrombosis and hemorrhage. You are caring for a woman who was in a severe automobile accident several days earlier. She has several fractures and internal injuries. The exploratory laparotomy was successful in controlling the bleeding. However, today you find that this client is bleeding from her incision, is short of breath, and has a weak, thready pulse, cold and clammy skin, and hematuria. What do you think is wrong with the client, and what would you expect to do about it? These are typical signs and symptoms of DIC crisis. Expect to administer IV heparin to block the formation of thrombin (Coumadin does not do this). However, the client described is already past the coagulation phase and into the hemorrhagic phase. Her care would include administration of clotting factors, along with palliative treatment of the symptoms as they arise. (Her prognosis is poor.)