PE, ARF, and ARDs Flashcards
A patient presents with dyspnea, chest pain, a cough, minor fever, and seems anxious.
What diagnostic tests do you expect they will undergo? What are your nursing priorities?
They probably have a PE.
-Dx: CT scan, D-dimer test, ABGs. CXR and ECG to determine cause.
-Nurse mgmt: give O2, cough/deep breathing, long term anticoagulant therapy if d/t thrombus
A patient w/ recent pelvic surgery presents with cyanosis, hypotension, and confusion. They say that they feel like ‘something really bad is happening’.
What are your next steps?
This is probably a massive/saddle PE and the beginning of ARF.
-administer o2
-administer alteplase/tPA to break up the clot (if d/t thrombus)
-administer heparin
-bridge to long term therapy (warfarin, apixaban)
A patient with a saddle PE (thrombus) received a IVC yesterday.
They report sudden chest pain.
Vitals: RR 22, BP 140/90.
What are your next steps?
Since they had a thrombus, they probably are on heparin and are at risk for HIT.
-check platelets–if low, that confirms HIT
-stop heparin admin immediately
-this patient is at high risk for bleeding out
Warfarin considerations/patient education
-takes a few days to work, will need to use heparin/LWMH to bridge
-needs regular labs for monitoring of INR (range 2-3)
-Vit K antidote–don’t eat too many leaf greens
-be careful when shaving, flossing (bleeding risk)
Based on these labs:
-PaO2 45 on 60% O2
-PaCO2 32
-pH 7.4
determine the type of ARF
hypoxemic respiratory failure
Based on these labs:
-PaO2 68 on 60% O2
-PaCO2 69
-pH 7.2
determine the type of ARF
hypercapnic respiratory failure
Based on these labs:
-PaO2 78 on 30% O2
-PaCO2 58
-pH 7.3
determine the type of ARF
hypercapnic respiratory failure
Based on these labs:
-PaO2 53 on 70% O2
-PaCO2 45
-pH 7.35
determine the type of ARF
hypoxemic respiratory failure
Based on these labs:
-PaO2 61 on 20% O2
-PaCO2 70
-pH 7.34
determine the type of ARF
hypercapnic respiratory failure
Ventilatory failure vs oxygenation failure: main differences
Ventilatory: not ‘blowing off’ enough CO2–hypercapnic
Oxygenation: not getting enough O2
A patient in the ER with a history of substance use disorder presents as lethargic and confused with the following labs:
PaO2 50 on 40% O2
PaCO2 63
pH 7.2
What type of respiratory failure is this? What are your next steps? What is your primary concern?
Most likely hypercapnic RF d/t overdose.
-administer narcan/naloxone
-monitor closely: papilledema
-apply O2, encourage cough/deep breathing–if this isn’t working, may have progressed to ARDs (primary concern)
A 72 y/o man w/ a history of COPD presents with confusion, paradoxical breathing, and severe anxiety.
Vitals: RR 21, BP 140/76, temp 99F
What are your next steps? What diagnostic tests do you expect to be ordered?
An hour later, the patient’s vitals are RR 26, BP 90/70. How do you respond?
This is probably hypoxemic respiratory failure–worried about possible infection
-administer O2
-administer bronchodilators
-administer antibiotics if infection is present
-administer benzo r/t anxiety
-coach deep breathing/cough
-Dx tests: ABGs, CXR, CBC, sputum culture
An hour later–worried about progression to ARDs
-increase O2
-call provider–intubation
A patient undergoing chemotherapy for lung adenocarcinoma calls the clinic and reports difficulty breathing when they walk or go up stairs and a severe headache.
What class of cancer do they have?
What type of respiratory failure might they have? What nursing interventions would you implement?
Adenocarcinoma a form of non small cell–NSCLC (most common type)
They likely have hypoxic respiratory failure
-assess/monitor–especially mental status
-hospital immediately (administer O2)
A patient with a history of A-fib and angina presents in the ER with chest pain, edema to BLE, and a ‘feeling of doom’.
Vitals: RR 20, BP 140/82
What meds would you expect to administer?
-nitroglycerin
-diuretic to reduce load on heart
-morphine for anxiety/reduce cardiac demand
-supplemental O2
A patient hospitalized and intubated for pneumonia is recovering well. Their intubation was successfully discontinued last night. When you bring them breakfast, they refuse, saying their throat hurts.
How do you respond?
Nutrition is really important for ARF/ARD recovery–suggest soft foods, high calorie drinks
A patient is recovering after a bowel resection. Upon auscultation, bowel sounds are absent and lungs are crackly.
Vitals: RR 22, HR 119
Labs: PaCO2 30, PaO2 86
What is your priority concern?
sepsis-induced ARDS (exudative/early stage)
What differentiates ARDS from ARF?
ARDs = severe ARF that includes damage to alveolar-capillary membrane –> increased permeability of alveoli –> atelectasis.
Big difference: refractory to O2 therapy (does not respond to O2 therapy)
Severe signs/symptoms (cyanosis, hypotension, loss of consciousness)
More likely to be intubated, require PEEP, mech vent, ECMO
More complications (hypotension, delirium, GI bleed, anemia, AKI)
For a diagnosis of ARDS, the causative factor must have occurred less than ____________ before symptom onset.
1 week
How might complications of ARDS manifest in:
-cardiac system
-GI system
-hematologic system
-renal system
-cardiac: increased output, dysrhythmias, RSHF, hypotension
-GI: hypermetabolic state (nutrition), ileus, ulcers, GI bleed
-hematologic: anemia, DIC, thrombocytopenia (low platelets)
-renal: acute kidney failure
Basically, hypoperfusion related damage
People between the ages of ___-____ with a history of __________ are the most at risk for developing lung cancer, and should get a ___ _______ every year.
-ages 50-80
-history of smoking
-they should get a low-dose CT scan every year
While _________ is the most common risk factor for lung cancer, others include:
-smoking most common
also:
-exposure to airborne carcinogens (eg, asbestos, secondhand smoke)
-chronic lung disease
Diagnostic tests for lung cancer and reasoning
-CXR, CT, MRI (identify/stage)
-Bone scans, full body scans (check for metastasis)
-sputum cytology/biopsy (identify)
TNM staging is based on:
-Tumor size
-Node (lymph) involvement
-Metastasis
Describe the three types of lung surgery for NSCLC:
-wedge resection
-pneumonectomy
-lobectomy
-wedge resection: tiny chunk of lung removed
-pneumonectomy: entire lung removed
-lobectomy: one lobe of lung removed
Chest tubes are often placed after ____ _________ because of the risk for _________ and _________.
Chest tubes are often placed after lung surgery because of the risk for hemothorax and pneumothorax.
Three days after a diagnosis of pneumonia, a patient’s chest x-ray shows bilateral opacities in the lungs. They likely have:
ARDS
Lung cancer most commonly metastasizes to (4):
Bones, brain, liver, adrenal glands
Why is PEEP of 10+ used in ARDS?
PEEP–positive end-expiratory pressure–of 10 is pretty high. It’s used to keep alveoli open at the end of expiration to improve gas exchange, especially b/c atelectasis is characteristic of ARDS
Describe the 4 Ps of mechanical ventilation management in ARDS. (plus two more)
PPPP-NW
- Prone Positioning
- Paralytics (propofol)
- Protection–low tidal volume and appropriate PEEP
- Pneumothorax risk – make sure lung sounds are present
N - nutrition
W - daily weights
Why might a patient on mechanical ventilation develop barotrauma? How would you know?
Barotrauma: ‘rice-krispy-feeling chest’
PEEP/fiO2 too high, causing damage
The ______ is a system often most seriously affected during chemotherapy/radiation treatment.
skin (mouth ulcers, hair loss)
Immunologics work to…
boost a compromised immune system
_________ is a common LMWH used for short term anticoagulation management/bridging.
enoxaparin (Lovenox)
Most common cause of PE
DVT
