ARDS Nursing – Flashcards
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What is ARDS characterized by
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sudden, progressive pulmonary edema, increasing bilateral infiltrates on x-ray, hypoxemia unresponseive to O2 supplementation regardless of the amount of PEEP
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What do pts. demonstrate
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reduced lung compliance
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What is the major cause of death in ARDS
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non pulmonary multiple system organ failure, often with sepsis
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Patho of ARDS
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alveolar damage, inflammation, ventilation perfusion mismatch, alveolar collapse, small airways narrow, marked decrease in lung compliance=decreased functional residual capacity and severe hypoxemia
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Patho in a nutshell
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blood is interfacing with non functioning alveoli and gas exchange is markedly impaired, resulting in severe refractory (hard to treat) hypoxemia
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ARDS inhalation etiology
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ASPIRATION such as gastric secretions, drowning, hydrocarbons, DRUGS ingestion & OD, PROLONGED INHALATION of high concentrations of O2. smoke or corrosive substances
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are inhalation/aspiration injuries direct or indirect
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Direct
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Other examples of direct
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pulmonary contusion, fat embolims o Direct moves directly to the lung
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ARDS infection & metabolic etiology
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LOCALIZED INFECTION like bacterial, fungal, viral pneumonia, METABOLIC DISORDERS like pancreatitis, & uremia
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ARDS hematologic etiology
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HEMATOLOGIC DISORDERS like DIC, massive transfusions, cardiopulmonary bypass MAJOR SURGERY
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ARDS trauma etiology
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any kind of SHOCK TRAUMA- pulmonary contusion, multiple fractures, head injury FAT/AIR EMBOLISM, SYSTEMIC SEPSIS
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What are examples of indirect injury
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overall body, sepsis, trauma, GI infection, pancreatitis, overall body sepsis most common cause
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How does ARDS develop
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acute event develops over 4-48 hours
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What does ARDS initially resemble
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severe hemodynamic pulmonary edema aeb bilateral infiltrates in xray
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What are early manifestation
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As early as 4 hours after initital insults, Rapid on set severe dyspnea, tachypnea Progressive respiratory distress- shallow breath, access muscle use, crackle, rhonchi, wheezes, dry cough, mottled skin with our without cyanosis, agitation, confusion, restlessness, hypoxia refractory to supplemental oxygen
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Acute phase of ARDS
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marked by rapid onset of severe dyspnea occurs 12-48 hrs after initiating event
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What is characteristic
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arterial hypoxemia that doesn't respond to supplemental O2
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How does it progress
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acute lung injury progresses to fibrosing alvolitis with persistent severe hypoxemia
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The patient also has
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increased alveolar dead space & decreased pulmonary compliance
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What's increased alveolar dead space
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ventilation to alveoli but poor perfusion
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What's decreased pulmonary compliance
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stiff lungs which are difficult to ventilate
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Clinically when is pt thought to be in recovery phase
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hypoxemia gradually resolves, c-xray improves and the lungs become more compliant
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Physical assessment
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intercostal retractions and crackles may be present as fluid begins to leak into the alveolar interstitial space
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ARDS diagnostic tests
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PLASMA BNP to distinguish ARDS from hemodynamic pulmonary edema, TRANSTHORACIC ECHOCARDIOGRAPHY may be used if BNP isn't conclusive and PULMONARY ARTERY CATH to distinguish between HF & ARDS
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How do we treat ARDS
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treat the underlying condition, supportive care to compensate for respiratory dysfunction
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What kind of supportive therapy
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intubation, mechanical vent, circulatory support, adequate fluid volume, nutritional support, supplemental O2
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How are O2 and vent settings determined
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patient response via ABG, pulse ox, bedside pulmonary function testing
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What's a critical part of treatment
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PEEP improves oxygenation but doesn't influence natural history of the syndrome
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PEEP ventilation definition
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airway pressure is maintained above atmospheric pressure at the end of exhalation by means of a mechanical impedance, usually a valve, within the circuit.
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How does PEEP work
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The purpose of PEEP is to increase the volume of gas remaining in the lungs at the end of expiration in order to decrease the shunting of blood through the lungs and improve gas exchange. PEEP is done in ARDS (acute respiratory failure syndrome) to allow reduction in the level of oxygen being given.
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How does PEEP help
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increase functional residual capacity and reverse alveolar collapse by keeping alveoli open, this reduced severity of ventilation perfusion imbalance
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PEEP goals
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PAo2 > 60 or an O2 sat >90% at the lowest FIO2 or fraction of inspired oxygen
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What is something else that becomes imbalanced
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hypovolemia from leakage of fluid into the interstitial spaces and depressed CO from high levels of PEEP therapy
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What does hypovolemia cause
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orthostatic hypotension, treat carefully without causing further overload
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Pharmacological treatments for orthostatic hypotension
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inotropic or vasopressor agents
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How do inotropic agents work
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affect the contraction of the heart muscle. Positive stimulate and increase the strength of heart muscle contraction causing the heart rate to increase. Negative agents weaken the force of muscular contractions.
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Postitive inotropic agent names?
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Digoxin
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Negative inotropic agent?
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Beta blockers Calcium channel blockers Centrally acting sympatholytics
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How are negative inotrope beta blockers used
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•Beta-blockers are usually used for treating high blood pressure, heart attack, chest pain, and irregular heart rhythm.
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How are negative inotrope calcium channel blockers used
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•Calcium-channel blockers are used for treating high blood pressure, chest pain, and irregular heart rhythm.
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How are negative inotrope centrally acting sympatholytics used
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•Centrally acting sympatholytics are used for treating high blood pressure.
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Vasopressor or antihypotensive agents
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epi, isoproterenol, phenylephrine, norepinephrine, dobutamine, phenylephrine
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If hypoTN is a problem how do we accurately monitor
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pulmonary artery pressure catheters monitor fluid status and severe & progressive pulmonary hypertension sometimes observes in ARDS
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Pharm therapy to treat ARDS
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treat symptoms and complications from ARDS, Inhale nitric oxide, reduces intrapulmonary shunting, improves oxygenation by dilating blood vessels in better ventilated areas of the lungs
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Nutritional therapy
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35-45 cal/kg/day is needed, enteral tube feeding is first consideration, parenteral or IV nutrition may also be required
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What are enteral routes
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Nasogastric, nasoduodenal or nasojejunal tube feedings
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What respiratory modalities are used
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O2 admin, nebulizer, chest physiotherapy, ET intubation, tracheostomy, mechanical vent, suctioning, bronchoscopy= frequent assessment of pt status is needed
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What other needs should nurse consider
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Turning improves pt. ventilation and perfusion in lungs and will enhance secretion drainage
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What should I look out for when turning the patient
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When change position monitor closely for deterioration in O2 status
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What particular position can improve pts. O2 status
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frequent position changes, prone up to 6 hours, improves o2, ventilation and perfusion, IF PT hemodynamic status, skin breakdown etc would change time in prone position but would
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How will the patient feel
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extremely agitated and anxious because of increasing hypoxemia & dyspnea
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Why do we need to decrease pt. anxiety
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Because it increases O2 consumption and worsens hypoxemia, prevents rest
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Ventilator & mechanical vent with PEEP nursing considerations
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it causes increased en expiratory pressure, this feels unnatural to patients and they may fight the vent and have anxiety reaction
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What problems that may cause anxiety reaction
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tube may be blocked due to kinkage or secretions, other respiratory problems such as pneumothorax or pain, vent malfunction or sudden decrease in O2 level
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How might this be managed if can't get it under control
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sedatives like lorazepam (Ativan), midazolam (Versed), dexmedetomidine (Precedex), propofol (Diprivan) and short acting barbituates.
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What if sedatives don't work?
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problems that may cause anxiety reaction may be used to paralyze the patient such as pancuronium (Pavulon), vecuronium (Norcuron), atracurium (Tracruim), rocuronium (Zemuron)
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What should the nurse remember if a patient is paralyed
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they appear to be unconscious, lose motor function, can't blink etc, increases risk of corneal abrasion but can hear and is awake, they retain sensation, give pain meds
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How does this affect how the nurse should work with the patient
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Reassure them that paralysis is a result of the medication and is temporary, paralyze shortest time possible
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How can this treatment be dangerous for the patient
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is disconnected from vent the respiratory muscles are paralyzed, pt will become apneic (won't breath), vent alarms must be on at all times and watch pt closely
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What are some vent complications
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predispose the patient to DVT, muscle atrophy and skin breakdown,
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What are some lung vent complications
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Nosocomial pneumonia, barotrauma lung injury rt alveolar over distention may cause pneumothorax
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What are some vent complications with heart & circulation
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o Pos increases intrathoracic pressure, interfere w/venous return to heart and ventricular filling
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What are some GI complications from the vent
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GI- stress ulcer, leads to gi hemorrhage, air leaks lead to gastric distension, constipation
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What else may the pt experience
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discomfort or pain, but they can't communicate this, analgesia is usually administered along with neuromuscular blocking agent
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How else can the nurse ensure patient comfort
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check pt position, ensure normal alignment, talk to the patient, not about them while in the pts presence
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How might a paralyzed vent pt. effect their family and loved ones
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family needs to know that they're paralyzed and why so they won't think the pts. condition is deteriorating
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Difference between ARDS and ARF per allnurses
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ARDS, because of the lack of O2 to major organs and the high levels of thoracic pressure needed to provide oxygen generally leads to multi-organ failure. These patients have low blood flow to "unimportant" organs like the gut, kidneys, extremities and bones. It's the body's way of trying to save itself, but organs fail as a result.
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Difference between ARDS and ARF per allnurses
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Acute respiratory failure is a CHF, pneumonia, non compliant dialysis patient, COPD'er that can be turned around with BIPAP, or a few days on the vent, that does NOT get the inflammatory response that initiates capillary leak in the alveoli that starts the whole cascade I just mentioned.
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What do ABG's reflect with ARDS?
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respiratory acidosis, pCO2 >45 and pH lower than 7.35
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ARDS assessment findings for HESI
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diminished breath sounds, deteriorating blood gas levels, and hypoxemia despite a high concentration of delivered oxygen.
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ARDS Interventions HESI
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Restriction of fluid intake may be prescribed. Diuretics, anticoagulants, or corticosteroids intubation and mechanical ventilation with PEEP
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ARDS Gas levels
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pH less than 7.25, a PaCO2 greater than 50, and a PaO2 under 50
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How do we wean vent patient
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recondition muscle so take off for brief period of time
