ARD/ARF Flashcards
All of the following are risk factors for what?
Aspiration
Chest Trauma
Pneumonia (infectious or aspiration)
Pulmonary Contusion
Inhalation Injury (smoke; toxins)
Pulmonary Embolus
Sepsis, shock
Pancreatitis
Burns
Multiple Blood Transfusions
Cardiopulmonary Bypass
Drug/Alcohol Overdose
Acute Respiratory distress
Name some risk factors of ARDS
Aspiration
Chest Trauma
Pneumonia (infectious or aspiration)
Pulmonary Contusion
Inhalation Injury (smoke; toxins)
Pulmonary Embolus
Sepsis, shock
Pancreatitis
Burns
Multiple Blood Transfusions
Cardiopulmonary Bypass
Drug/Alcohol Overdose
The following describes what?
- Acute onset of less than 7 days of non-cardiac pulmonary edema
- Progressive refractory hypoxemia
- Bilateral infiltrates
- It is further classified in terms of severity through evaluation of the PaO2/FIO2 ratio, the ratio of the partial pressure of oxygen over the fraction of inspired oxygen
ARDS
The following describes what phase of ARDS
- Occurs 24-48 hrs after injury
- Inflammatory mediators activated and released
- Disruption of Alveolar-Capillary Membrane (ACM)
- Fluid moves from capillaries into the interstitial spaces and alveoli
Exudative Phase
THe following describe what phase of ARDS
- Fluid continues to fill the alveoli
- Edema results in severe V/Q mismatch
- Pulmonary HTN develops
- Hypoxemia results
- R-sided heart failure
- Lungs become stiff and non-compliant
Proliferative Phase
The following describes what phase of ARDS
- Pulmonary HTN worsens
- Heart failure worsens
- Diffuse fibrosis and scarring
- Severe tissue hypoxia and lactic acidosis
Fibrotic phase
Name some clinical manifestations of ARDS
- Dyspnea, “can’t get enough air in”
- Tachypnea
- Crackles on auscultation (from non-cardiac pulmonary edema)
- May have decreased breath sounds
- Tachycardia
- Severe hypoxemia DESPITE administration of 100% oxygen (REFRACTORY HYPOXEMIA)
- Deteriorating ABG levels
- Bilateral pulmonary infiltrates
How does a ARDS patients CHXR look?
- Bilateral infiltrates
- Ground-glass apperance
- Whiteout effect/Snowscreen
What is this treatment for ARDS?
- primary treatment for the refractory hypoxemia of ARDS.
- It is initiated as lung compliance decreases, work of breathing increases, and oxygenation continues to be refractory regardless of interventions such as NPPV and other oxygen therapies.
- There are several modes of used in ARDS.
Mechanical ventilation
What type of treatment for ARDS is this?
- The high flow rate results in a “washout” of nasopharyngeal dead space.
- Produces a CPAP effect
- Decreased risk of nosocomial infection 40% failure rate
High flow nasal cannulas (HFNC)
What treatment for ARDS is this?
- Uses a pump to circulate blood through an artificial lung outside of the body where oxygenation and CO2 removal takes place and the blood is returned
- Recent technological improvements have made it safer Many risks
Extracorporeal Membrane oxygenation (ECMO)
What type of treatment for ARDS is this
- A type of mechanical ventilation.
- Lungs are filled with perfluorocarbon liquid to a volume less than or equivalent to function residual capacity and then vented using a standard mechanical vent
- Decreases shunt associated with ARDS
- Still has ongoing research to evaluate its efficacy
High-frequency oscillating ventilation
What phase of ARDS is this?
- Occurs within 24-48 hrs after injury.
- Fluid moved from capillaries to interstitial space to alveoli.
- Protein moves from vascular space. All leads to pulmonary edema which causes V/Q mismatch
Exudative
The following are S/S of what phase of ARDS
- Hyperventilation
- Tachycardia
- CHXR: Bilat infiltrates or pulmonary edema
- V/Q Mismatch
- Respiratory alkalosis
Exudative phase
What phase of ARDS is this?
V/Q Mismatch worsens>pulmonary HTN occurs>R-sided heart failure>Fibrotic changes occur in lungs which cause lungs to become “stiff” and “noncompliant” which increases work of breathing
Proliferative
The following are S/S of what phase of ARDS
- Hypercarbia
- Refractory Hypoxiemia
- Lung Compliance deteriorates
- If pt is vented inspiratory pressures rise d/t decreased lung compliance which requires more pressure
- Increasing PaCO2
Proliferative
What phase of ARDS is this?
Fibrosis and scarring severely impair gas exchange and lung compliance. Pulmonary HTN worsens, R-sided heart failure worsens Decreased L-sided heart pre-load
Fibrotic
All of the following are S/S of what phase of ARDS
- Hypotension
- Decreased cardiac output
- Severe V/Q Mismatch
- Diffusion defects
- Intrapulmonary shunting
- Refractory hypoxemia
- Tissue hypoxemia
- Lactic Acidosis
Fibrotic
What are some s/s of the exudative phase of ARDS?
- Hypotension
- Decreased cardiac output
- Severe V/Q Mismatch
- Diffusion defects
- Intrapulmonary shunting
- Refractory hypoxemia
- Tissue hypoxemia
- Occurs within 24-48 hrs of injury
What are some S/S of the proliferitive phase of ARDS?
- Hypercarbia
- Refractory Hypoxiemia
- Lung Compliance deteriorates
- If pt is vented inspiratory pressures rise d/t decreased lung compliance which requires more pressure
- Increasing PaCO2
What are some S/S of the fibrotic phase of ARDS
- Hypotension
- Decreased cardiac output
- Severe V/Q Mismatch
- Diffusion defects
- Intrapulmonary shunting
- Refractory hypoxemia
- Tissue hypoxemia
- Lactic Acidosis
What are some reasons you would not prone a patient with ARDS?
- Spine instability
- Conditions that increase intracranial pressure
- Pregnancy
- Abdominal wounds
- Unstable peripheral fractures or rib fractures
- Need for frequent airway access
When should you start proning a patient with ARDS?
Should be implemented withing 72 hrs of dx
How long should a patient remain in the prone position?
up to 20 hours per day
Name ways a patient can be placed in the prone position
- Manually turning patient
- using mechanical device
- place the patient in trendelenburg or reverse tendelenburg as needed
What needs to be done an hour before proning a patient?
enteral feedings
Medications usde to treat ARDS
- Antibiotics
- Corticosteroids
- Neuromuscular blocking agents
- Sedatives
- IV hydration
- Nutrition: Enteral & Perenteral
- Respiratory tmnt
- Diuretics
- Anticoags
- Analgesics
- Intropic medications
Describe how abx are used in the treatment of ARDS?
Broad spectrum ABX are used initially then after the C&S come back narrow spectum based on the results are started
Nursing Dx for ARDS
- Impaired gas exchange
- Anxiety
- Imbalanced Nutrition
What is this?
This affects ability of the lungs to produce O2 and get rid of CO2. With ARDS and ARF lungs become stiff and noncompliant d/t fibrotic changes. As lungs become more stiff and noncompliant
Lung compliance
the volume of air moved with one breath, one inhalation and exhalation
Tidal volumes
What is this called?
damage d/t mechanical ventilation. Causes can be:
* Inflammatory-cell infiltrates
* Increased vascular permeability
* Pulmonary edema
* Barotrauma
Ventilator-Induced Lung Injury or VILI
What is air in mediastinal space called?
Pneumomediastinum
What is air in the pleural space called?
Pneumothorax
When is treatment for ARDS considered effective?
when pt returns to baseline. Ideally pt will be able to continue previous lifestyle with no long term respiratory issues.
The clinical manisfestations of ARDS are caused by what three things?
- Refractory hypoxemia
- Pulmonary edema
- Lung tissue changes
EARLY signs of ARDS
- Dyspnea
- Tachypnea
- Accessory muscle use
- Crackles
LATE S/S of ARDS
- Diminished or absent breath sounds
- Atelectasis
- Anxiety/Agitation
List components of the nursing assessment for a patient with ARDS
- Hemodynamic monitoring
- Neurological assessment
- Respiratory assessment
- Urine output
- Mechanical ventilation
- Laboratory tests
- Skin assessment
- CHXR
PRIORITY nursing actions for a patient with ARDS
- Suction airway as needed
- Administer meds as prescribed
- Patient positioning
- Prevet/protect from infection
when increasing oxygen delivery for a patient does not improve the hypoxia and the o2 stat worsens
Refractory Hypoxemia
Expected VS of a patient with ARDS
Tachycardia
Tachypnea
Hypotension
Hypoxemia
What type of nutriton is this?
NG tube-preffered method. Associated with aspiration>elevate HOB and turn off feedings when supine
Enteral
What type of nutrition is this?
IV nutrition-associated with infections at IV site
Parenteral nutrition
How often should neuro assessments be done on a patient with ARDS?
At least every 1-2 hrs
How does a patients with ARDS ABG present at the beginning vs as it progresses? What does it begin to look like if tmnt is not working?
Respiratory Alkalosis>Respiratory acidosis
If tmnt not adequate: Metabolic acidosis
What is an early sign of poor oxygen delivery to tissues and/or shock?
Decreased urine output
ARDS patients need to have their ECG monitored because hypoxemia can cause what?
Dysrhythmias
The respiratory assessment of a patient with ARDS at the beginning of the disease process presents as what?
Crackles may be auscultated because of fluid buildup in the alveoli due to increased capillary permeability.
The respiratory assessment of a patient with ARDS later in the disease process presents as what?
they may be diminished because of atelectasis and fibrotic changes in the lungs.
How to prevent ARDS patients from developing thick, dry secretions?
Adequate fluid hydration
S/S of inadequate nutrition
loss of 10% body mass
reduced respiratory muscle strength
If adequate fluid hydration is not given to an ARDS patient what will happen?
CV output & BP will decrease causing decreased perfusion to organs. To correct this fluid resuscitation is required
Labs used to dx and monitor ARDS
- ABG
- Lactic acid/serum lactate
- Liver/Renal function
- CBC
- Blood & Sputum cultures
- CHXR
What will happen if ARDS is not properly treated?
It will progress to multi-organ Dysfunction syndrome
What complication associated with ARDS is this?
Alveolar or Lung rupture which can lead to pneumomediastinum or pneumothorax
Barotrauma
Name S/S of a pneumothorax
-Absent or markly decreased breath sounds
-Cyanosis
Decreased chest expansion unilaterally
-Dyspnea
-Hypotension
-Sharp chest pain
-Subcutaneous
-emphysema AEB crepitus on palpation
-Sucking sound with open chest wound
-Tachycardia
-Tachypnea
-Tracheal deviation to the
-unaffected side with tension pneumothorax
What complication associated with ARDS is this?
Frequent complication of ARDS d/t hypotension and nephrotoxic drugs Prevent with close monitoring
Renal failure
What complication associated with ARDS is this?
Fever
Leukocytosis
Increased respiratory effort
Prulent secretions
Sputum cultures will show infection
Ventilator associated Pneumonia or VAP
The following are S/S of what?
-Absent or markly decreased breath sounds
-Cyanosis
Decreased chest expansion unilaterally
-Dyspnea
-Hypotension
-Sharp chest pain
-Subcutaneous
-emphysema AEB crepitus on palpation
-Sucking sound with open chest wound
-Tachycardia
-Tachypnea
-Tracheal deviation to the
-unaffected side with tension pneumothorax
Pneumothorax
How to prevent barotrauma
Careful application of tidal volume and peep
How to prevent Ventilator associated pneumonia or VAP
- Early dx=early tmnt
- Regular mouth care
- Suctioning
- Change vent circuit per hospital protocol
- Use sterile water for humidification
What complication associated with ARDS is this?
Results from prolonged hypoxemia, hemodynamic instability, inflammation associated with sepsis
Multi-organ dysfunction syndrome or MODS
National patient safety goals for patients with ARDS
- Identity patients correctly
- Improve staff communication
- Use medicines safely
- Use alarms safely
- Prevent infection
- Identify safety risks
- Prevent SX mistakes
NPSG’s goals to improve communication with ARDS patients
- Report abnormal test results to HCP ASAP
- Include important information in hand off report
NPSG’s goals for using medication safely in ARDs patients
- Reconcile medications
- Be cautions with high alert medications
NPSG’s Goals for alarm safety with ARDS patients
Respond to alarms one time and make sure alarms are heard
NPSG’s goals for preventing infection for patients with ARDS
- Hand hygiene
- Proper positioning for clients on mechanical ventilators
- Mouth care every 2 hrs for vented patients
V/Q
Ventilation-Perfusion ratio
an extreme V/Q mismatch where there is no gas exchange
Intrapulmonary shunt
NPPV
NONINVASIVE POSITIVE-PRESSURE-VENTILATION
Meaning and reasoning behind “good lung down”
If the underlying disease is unilateral, positioning with the good lung down improves gas exchange by optimizing the V/Q ratio; gravity ensures the healthy lung maintains adequate blood flow to optimize ventilation to perfusion.
Important teaching for ARDS patients and why it is important
- Teach the patient and family about the Disease process.
- The patient and the patient’s support system should understand the pathophysiology of ARDS, the severity of the disease, and the treatment required.
- Understanding the medications, invasive lines, and mechanical ventilation may help decrease anxiety and provide some sense of control.
It is importnat to allow ARDS patients family/friends to visit when possible why?
Providing time for visiting as possible may help the family stay engaged and involved in the family member’s care. Visiting also provides tremendous support for the patient.
When the gas exchange functions of the lungs (oxygenation and carbon dioxide removal) are compromised. There are two kinds: Hypoxemic respiratory failure & hypercapnic respiratory failure
Acute respiratory failure or ARF
Medications used to treat ARF
Bronchodilators: open airways
Inhaled steroids: Increase effects of bronchodilators
Diuretics: decrease pulmonary congestion
Sedation: for vented patients, to decrease anxiety and agitation
Abx
Sedation/anxiety
Steroids
All of the following are S/S of what?
Dyspnea
Somnolence
Restlessness
Confusion
Tachycardia
HTN
Dysrythmias
Decreased LOC
HA
Change in respirations and breath sounds
ARF
What kind of ARF is this?
PaO2 <60, normal or low PaCO2 D/T disease processes that produce V/Q mismatch i.e. pulmonary edema, PNA, PE
S/S: restless, confusion, anxiety, & agitation. If no adequate tmnt>cyonotic>coma
Hypoxemic or type 1
What type of ARF is this?
- Respiratory Acidosis PaCO2 >50, pH <7.35,
- hypoxemia may or may not be present. D/T hypoventilation i.e. acute asthma, impaired chest wall movement, myasthenia gravis, OD, peripheral nervous system disorders, chest wall trauma
S/S: HA, confusion, decreased LOC or increased somnolence, tachycardia, tachypnea, dizziness, flushed, a pink coloring to the skin
Hypercapnia or type 2
Components of pulmonary rehabilitation for ARF patients
- Breathing techniques
- Energy Conservation
- Exercise
Breathing techniques for ARF patients
pursed-lip breathing and diaphragmatic
To help teach an ARF patient energy conservation what should the nurse do?
Work with the patient to determine priorities in daily living.
What kind of exercises should be taught to ARF patients to improve respiratory status?
Aerobic exercises
Important teaching points for ARF patients
- Disease process
- Medications
- Pulmonary rehabilitation
- Infection
- Diet and adequate hydration
- Smoking cessation
Important things to monitor in ARF patients what why?
- Airway: Check for patency, dyspnea w/ exertion, need for suction
- VS: BP, HR, & HR will be increased. Fever can develop r/t infection & inflammation
- ABG’s
- cardiac monitor-Monitor for dysrhythmias
- neuro: change in LOC=impending resp failure
- breath sounds: Crackles=pulmonary edema, rhonchi=PNA, COPD, Absent=hypoventilation
- skin color: cyanosis or CO2 poisoning
How do you treat ARF
Treat the underlying condition
What is the goal when treating a patient with ARF
The goal is to have SpO2 greater that 94% unless COPD pt
If supplemental oxygen, mechanical ventilation, and medications do not halt the progression of respiratory failure what will happen?
the patient is at high risk for cardiac failure, multiple organ dysfunction, and death.
When is treatment for ARF considered successful?
When patient returns to baseline
Nursing dx for ARF
Impaired Gas exchange
Ineffective breathing pattern
Risk factors for ARF
V/Q Mismatch
Pulonary edema
PNA
PE
Asthma
Overdose
Myasthenia gravis
Anything that impairs ventilation
Anything that impairs chest wall movement
Risk factors for Hypoxemic respiratory failure
- Pulmonary edema
- Pnemonia
- Pulmonary edema
- Think obstructed airway
Risk factors for Hypercapnic Respiratory Failure
- Asthma
- Narcotic ovedose
- Myasthenia gravis
- Think pump failure
The following are S/S of what kind of ARF
restless, confusion, anxiety, & agitation. If no adequate tmnt>cyonotic>coma
Hypoxemic respiratory failure
The following are S/S of what kinf of ARF?
HA, confusion, decreased LOC or increased somnolence, tachycardia, tachypnea, dizziness, flushed, a pink coloring to the skin
Hypercapnic respiratory failure
EARLY s/s of ARF
- dyspnea
- restlessness
- anxiety
- fatigue
- Increased BP
- Tachycardia
- Tachypneic
INTERMEDIATE s/s of ARF
- Confusion
- Lethargy
- Pink skin color
LATE s/s of ARF
- Cyanosis
- Coma
Labs and Radiology tests used for ARF
- ABG
- Venous blood gas (venous O2 stat)
- HGB&HCT
- CHXR
- CT Scan
- Sputum culture
Nursing interventions for ARF
- Administer O2 as ordered
- Elevate HOB - high fowlers
- Position patient “good lung down”
- Chest physiotherapy and suctioning
- Administer IV fluids/hydration
- Nutritional support
- Be prepared for vent support
Examples of Impaired airways or things that would cause hypoventilation
- Airway obstruction
- Respiratory muscle weakness/paralysis (Neuromuscular disease such as myasthenia gravis)
- Chest-wall injury
- Anesthesia
- Opioid administration
These would all be causes of Hypoxic respiratory failure
Examples of conditions that would cause V/Q Mismatch
- COPD
- Restrictive lung diseases (sarcoidosis, pulmonary fibrosis)
- Atelectasis
- Pulmonary Embolism
- Pneumothorax
Examples of conditions that impair alveolar diffusion
- Pulmonary edema
- ARDS
These would be causes of Hypercapnic Respiratory Failure
