ARDS Flashcards
ARDS definition
Rapid onset of noncardiac pulmonary edema
Progressive refractory hypoxemia
Extensive lung tissue inflammation
Small blood vessel injury
Multisystem organ failure
Pathophysiology of ARDS
Acute lung injury
Unregulated systemic inflammatory response
Damaged capillary membranes leak
Damage alveolar membrane
Fluid enters alveoli
Significant tissue hypoxia results
Metabolic acidosis
Risk Factors for ARDS
Direct Insults
Direct insults
Aspiration of gastric contents
Inhalation injuries
Smoke inhalation
Salt water inhalation
Risk Factors for ARDS
Indirect Insults
Indirect insults
Overall body sepsis
Trauma
Gastrointestinal infections
The greatest risk factor for ARDS is
Aspiration
Initial manifestations of ARDS begin
24–48 hours post insult
Early signs of ARDS
Dyspnea and tachypnea are early signs
S/S of ARDS
Progressive respiratory distress
Hypoxia
Hypercapnia
Agitation, confusion, and lethargy
Diagnostic Tests for ARDS
ABG analysis to determine oxygen levels
Chest x-ray to determine fluid in lungs
Blood tests such as CBC, blood chemistry, and blood cultures
Sputum culture to determine cause of infection
Pharmacological Therapy
No definitive drug therapy
Nitric oxide
- Reduces intrapulmonary shunting
- Improves oxygenation
Surfactant therapy
NSAIDS and corticosteroids are being studied
Nonpharmacologic Therapy
Mechanical ventilation Artificial airways Proper nutrition Adequate amounts of fluids Other clinical therapies
The mainstay of ARDS management is
Mechanical Ventilation
Types of ventilators
Negative vs Positive pressure
Noninvasive
Negative-pressure ventilators
*Create negative pressure externally to draw chest outward and air into lungs
Positive-pressure ventilators
*Push air into lungs
Noninvasive ventilation (NIV)
- Uses face mask
- Sleep apnea
ARDS
What is happening?
A: Atelectasis
R: Refractory hypoxemia (hallmark sign)
D: Decreased lung compliance
S: Decreased surfactant
Complications of Mechanical Ventilation Why? HAP Barotrauma, pneumothorax Cardiovascular effects GI effects
Hospital-acquired pneumonia (HAP): loss of humidity and filtering from upper airway
Barotrauma: PEEP
Pneumothorax: PEEP
Cardiovascular effects: Increased pressure in the chest decreases cardiac output
Gastrointestinal effects: Misplacement of tube (monitor for abdominal distention)
Artificial Airways
What do they do?
Oropharangeal vs Naropharangeal
Inserted to maintain patent air passage
Oropharyngeal airways
*Stimulate gag reflex
Nasopharyngeal airways
- Better tolerated by alert clients
- Frequent oral care important
Artificial Airways
Endotracheal tubes
General anesthesia, emergency situations
Specialized education to insert
Guided by laryngoscope
Client unable to speak while tube in place
Artificial Airways
Tracheostomies
Long-term airway support
Opening to trachea through neck
Percutaneous or surgical insertion
Nursing Considerations
Fluids and Nutrition
Monitor I & O
Renal perfusion
Catheter
Arterial line
What effect does Mechanical Ventilation have on Cardiac Output?
increased intrathoracic pressure can decrease CO sec return of blood to the heart. Urine Output is an early sign.
Other Clinical Therapies for ARDS Position? Medications? I/O? Swan Ganz?
Prone positioning
Antibiotics
Low-molecular-weight heparin
Careful fluid replacement
Attention to nutrition
Swan-Ganz line to monitor
- Pulmonary artery pressures
- Cardiac output
Weaning from ventilator support
When to start?
Why wean?
When: Begins after underlying process corrected
T-piece, CPAP
SIMV, PSV
Why: Reconditioning respiratory muscles
Terminal weaning
Modes with positive pressure ventilators
Continuous positive airway pressure (CPAP)
Bilevel ventilator (BiPAP)
Assist-control mode ventilation (ACMV)
Synchronized intermittent mandatory ventilation (SIMV)
Positive end-expiratory pressure (PEEP)
Pressure-support ventilation (PSV)
Pressure-control ventilation (PCV)
Ventilator settings
Rate, tidal volume, oxygen concentration
12–15 ventilator breaths per minute initially
Symptoms of Barotrauma
*Pneumothorax
Tracheal Deviation
Asymmetrical Chest Rise
Absent Lung Sounds
Rice Crispies from air trapped
Aspirating secretions through a catheter
When to suction?
Effects on patient?
Sterile technique
Open-tipped, whistle-tipped
Yankauer device for oral suctioning
Nursing decision to suction
- Based on clinical need, not fixed schedule
- Suctioning irritates mucous membranes
Uncomfortable for patient
Patient may feel panicked by loss of oxygen
Nursing diagnoses may include:
Risk for \_\_\_\_\_ Ineffective \_\_\_\_\_ Ineffective \_\_\_\_\_ Impaired \_\_\_\_\_ Decreased \_\_\_\_\_ Dysfunctional \_\_\_\_\_ Imbalanced \_\_\_\_\_ Acute \_\_\_\_\_
Nursing diagnoses may include:
Risk for Acute Confusion Ineffective Airway Clearance Ineffective Breathing Pattern Impaired Gas Exchange Decreased Cardiac output Dysfunctional Ventilator Weaning Response Risk for Imbalanced Fluid Volume Imbalanced Nutrition: Less Than Body Requirements Risk for Infection Acute Pain Anxiety
Client Goals with Planning
Be oriented \_\_\_\_\_ Receive adequate \_\_\_\_\_ Be free of \_\_\_\_\_\_ Maintain \_\_\_\_\_ Maintain \_\_\_\_\_ Receive adequate \_\_\_\_\_ Be free of \_\_\_\_\_ Have no development of \_\_\_\_\_ Manage \_\_\_\_\_ Cope with or be free from \_\_\_\_\_
Goals may include that client will:
Be oriented with each interaction Receive adequate ventilatory support Be free of pulmonary tissue damage Maintain patent airways Maintain adequate cardiac output Receive adequate nutrition Be free of signs, symptoms of infection Have no development of thrombosis Manage pain successfully Cope with or be free from anxiety
Common Interventions
Monitor-
Lab work and specimens
Suction airways as needed
Monitor
- Vital signs hourly
- Oxygenation status
- Neurological status
- Lung and heart sounds
Position Interventions
Maintain HOB at 30° or higher
Prone position as tolerated 3–4x/day
Common Medication Interventions
Provide analgesia, anxiolytics, sedation
Beta-agonist to maintain patent airways
Common Interventions
Fluid balance?
Glucose levels?
Pulses?
Monitor hemodynamic status
Monitor renal function
Place Foley catheter
IV fluids as needed
Monitor glucose levels
Assess peripheral pulses
Interventions
Maintain patent airway
Maintain patent airway
- Suction as needed
- Obtain sputum for culture
- Chest physiotherapy as ordered
- Secure endotracheal or tracheostomy tube
- Maintain adequate hydration
Interventions
Promote spontaneous ventilation
Promote spontaneous ventilation
Assess, document
Respiratory rate, VS, O2 saturation every 15–30 minutes
Promptly report worsening data
Administer O2 as ordered, monitor response
Place in Fowler or high-Fowler
Minimize activity, energy expenditures
ARDS Pneumonic
A- atelectasis
R- refractory hypoxemia
D- decreased lung compliance
S- surfactant (damaged)
