Case Study: Acute Respiratory Distress Syndrome (ARDS), Exams of Nursing

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Syndrome (ARDS)

Patient Profile Mr. S. is a 54-year-old African American man who was admitted 72 hours ago to a general surgical unit after surgery for a bowel obstruction. The surgical procedure involved extensive abdominal surgery to repair a perforated colon, irrigate the abdominal cavity, and provide hemostasis. During surgery his systolic blood pressure dropped to 70 mm Hg. Seven units of packed red blood cells and 4 L of normal saline were administered intravenously to restore blood loss and circulating volume. He is receiving 60% O 2 through an aerosol face mask. He is being monitored with a cardiac monitor and pulse oximeter. He has a central intravenous catheter in place and is receiving 0.9% normal saline IV at 125 ml per hour. A urinary catheter is in place. Subjective Data ● Complains of shortness of breath, inability to lie flat, and diffuse abdominal pain Objective Data Physical Assessment ● General: alert, well-nourished man who appears restless and anxious; head of bed elevated 45 degrees; skin cool with moderate diaphoresis ● Respiratory: no accessory muscle use, retractions, or paradoxic breathing; respiratory rate 28 breaths/min; SpO2 88%; fine crackles at lung bases. The nurse also assessed the patient’s chest and abdominal wall excursion as well as depth and pattern of respiration. ● Cardiovascular: blood pressure 100/60 mm Hg; cardiac monitor shows sinus tachycardia at 120 beats/min, with equal apical-radial pulse; temperature 101° F (38° C) orally. ● Gastrointestinal: surgical dressing dry and intact; sharp

Case Study: Acute Respiratory Distress

Syndrome (ARDS)

pain on palpation over incisional area ● Urologic: urinary catheter draining concentrated urine, less than 30 mL per hour Diagnostic Findings ● ABG results: pH 7.35, PaO 2 59 mm Hg, PaCO 2 27 mm Hg, bicarbonate 16 mEq/L, O 2 sat 89%. ● Chest x-ray shows new scattered interstitial infiltrates compatible with an ARDS pattern as interpreted by the radiologist.

Critical Thinking Questions

1. How does the pathophysiology of ARDS predispose to the development of refractory hypoxemia? - Alveolar injury causes the release of proinflammatory cytokines that pull neutrophils into the lungs. These neutrophils become activated and release toxic mediators - The released toxic mediators damage both the capillary and alveolar endothelium - The permeability of the alveolocapillary membranes is increased which allows fluid to start to accumulate within the lung interstitial, alveolar spaces and the small airways - This buildup of fluid causes the lung to stiffen - This stiffening of the lung causes ventilation to become impaired, which reduces the oxygenation of pulmonary capillary blood - Capillary pressure becomes elevated leading to an increase in interstitial and alveolar edema - Alveolar closing pressure exceeds pulmonary

Case Study: Acute Respiratory Distress

Syndrome (ARDS)

pressures causing alveoli to close and collapse

• Supplemental oxygen is not able to correct this oxygen problem 2. What clinical manifestations does Mr. S. exhibit that support a diagnosis of ARDS?
• Heart rate of 120 bpm (sinus tachycardia)
• Moderate diaphoresis
• Appears restless and anxious
• Complaints of being short of breath
• Fine crackles in the lung base
• O2 sat 89%
• ABG results show hypoxemia and respiratory alkalosis (PaO2 of 59 mm Hg and PaCO2 of 27 mm Hg)
• Chest x-ray shows new scattered intestinal infiltrates 3. What are the possible causes of ARDS in Mr. S.?
• Massive blood transfusion
• Trauma to abdomen
• Possible shock from losing excess amount of blood
• Extensive surgery
• Prolonged inhalation of high flow oxygen 4. What are the possible complications Mr. S. is at risk for developing secondary to ARDS?
• Oxygen toxicity
• Permanent lung disease
• Nosocomial pneumonia
• Respiratory failure
• Ventilator-assisted pneumonia
• Superinfection
• Death
• Delirium
• Venous thromboembolism
• Pneumothorax
• Scarred lungs

Case Study: Acute Respiratory Distress

Syndrome (ARDS)

• Hypovolemia 5. What respiratory care interventions might be implemented to improve Mr. S’s hypoxemia?
• Medications: o Corticosteroids o Antibiotics
• Oxygen therapy
• Bronchoscopy
• Thoracentesis
• Chest tube insertion
• Artificial ventilation o Invasive ▪ Nasogastric tube ▪ Endotracheal tube ▪ Mechanical ventilator o Non-invasive ▪ BiPAP ▪ CPAP
• Maintain patent airway
• Perform tracheal suctioning
• Chest physiotherapy
• Perform passive range of motion exercises 6. Based on the assessment data presented, write two or more appropriate complete nursing diagnoses.
• Impaired gas exchange r/t abdominal surgery (extensive loss of blood) AEB abnormal arterial blood gasses (pH 7.35, PaO2 59 mm Hg, PaCO 2 27 mm Hg, bicarbonate 16 mEq/L), increased respiratory rate (28), diaphoresis, hypoxia (O2 89%), tachycardia (120 bpm), and complaints of being short of breath
• Risk for infection r/t invasive procedure and impaired

Case Study: Acute Respiratory Distress

Syndrome (ARDS)

skin integrity

• Anxiety r/t surgery and complications AEB tachycardia, restlessness, decreased urinary output, diaphoresis, temperature (101 degrees F), BP (100/60) 7. Discuss any collaborative problems that might apply to this patient.
• Respiratory therapy – due to pt. not responding to supplemental oxygen it is likely he will need to be put on some form on ventilator
• Physical therapy – due to surgery, pt. will be stuck in bed for a while and unable to move, PT will have to help him with ROM exercises so that he maintains some strength and joint mobility
• Occupational therapy – since pt. will be unable to perform daily tasks because of surgery and the complications he will likely lose some of his normal abilities to perform tasks. OT can work with him to meet his goals and get back to his abilities prior to surgery
• Nutrition – a pt. needs to maintain a good diet after surgery to promote healing. Since he had complications and since it was abdominal surgery there is a chance he may not want to eat or will need other forms of nutrition to meet his needs. Dietary/nutritionist will be able to figure out the correct way to keep the pts. Nutrition balanced
• Spiritual care – surgery itself can be a stressful thing and can be even more stressful when there are complications. Spiritual care will allow for the pt. to have his spiritual or religious needs met. This may help with his coping and help him heal emotionally as well as physically.
• Physician – since the pt. is having continual problems

Case Study: Acute Respiratory Distress

Syndrome (ARDS)

there will likely be a lot of communication with the physician about what they would like to do next. The physician is the one that will generally be making all of the calls about the treatment and care that will be given to the pt.

8. Mr. S. needs to be placed on a mechanical ventilator. Explain mechanical ventilation and indication for use. - There are two different types of mechanical ventilation: non-invasive and invasive. The two types of non-invasive options include BiPAP (provides 2 levels of airway pressure) and CPAP (provides 1 level of airway pressure). Both BiPAP and CPAP use air pressure as a splint in order to keep the airway open and they also prevent the body from obstructing itself. Invasive mechanical ventilation involves the usage of an endotracheal tube, a nasogastric tube and a mechanical ventilator. This option involves the control of inspiratory and expiratory pressure. - The usage of mechanical ventilation may come about for multiple different reasons. Some of these include, during surgery to control respirations, to oxygenate the blood when a patients ventilatory efforts are not adequate and to give the respiratory muscles a break and time to rest. - Mechanical ventilation is generally indicated when a patient has a compromised airway or respiratory failure. A patients arterial blood gas levels are a good indicator of when these measures are indicated. 9. What are the classification of ventilators and explain each one? - There are two different classifications of ventilators, including positive- pressure ventilators

Case Study: Acute Respiratory Distress

Syndrome (ARDS)

and negative-pressure ventilators.

• Negative-pressure ventilators: o Older methods of ventilatory support and are generally not used anymore
• Positive-pressure ventilators: o Inflate the lungs by exerting positive pressure on the airway, pushing air in, and forces the alveoli to expand during inspiration o Expiration occurs on its own (passively) o A tracheostomy or endotracheal intubation may be needed o Three types classified by the method of ending the inspiratory phase of respiration ▪ Volume cycled - Deliver a preset volume of air with each inspiration - After the preset volume is delivered, the ventilator turns off and exhalation occurs on its own - Volume of air delivered is constant and consistent with adequate breaths ▪ Pressure cycled - Delivers a flow of air (inspiration) until it reaches a preset pressure, cycles off and expiration occurs - Volume of air or oxygen can vary with resistance or compliance changes - Volume of air delivered may be inconsistent ▪ High-frequency oscillatory support - Deliver very high respiratory rates (180-900 breaths per minute) along with very low tidal volumes and high airway pressures

Case Study: Acute Respiratory Distress

Syndrome (ARDS)

• Small pulses of oxygen enriched air go down through the center of airways, giving the alveolar air to exit the lungs around the outer part of the airway
• Used in situations with closed small airways o One type that does not require intubation ▪ Noninvasive positive-pressure ventilation (NIPPV)
• Given via facemasks that cover the nose and mouth
• Endotracheal intubation or tracheostomy are not needed
• Indicated in acute or chronic respiratory failure, acute pulmonary edema, COPD, chronic heart failure or a sleep-related breathing disorder
• CPAP – most effective treatment for obstructive sleep apnea o Positive pressure acts like a splint which keeps the upper airway and trachea open while a person is sleeping
• BiPAP – offers independent control of inspiratory and expiratory pressures while providing pressure support ventilation o Delivers two levels of positive airway pressure o Inspirations can either by initiated by the patient or the machine – backup of the machine ensures that the patient receives a set number of breaths every minute 10. Explain each of the ventilator modes
• Continuous mandatory ventilation (CMV) – full ventilatory support by delivering a preset tidal

Case Study: Acute Respiratory Distress

Syndrome (ARDS)

volume and respiratory rate, used for apneic patients

• Assist-control (A/C) ventilation – ventilator delivers preset tidal volume at preset rate like CMV but if the patient takes a breath between the breaths given by the machine, the ventilator will deliver at the preset volume
• Intermittent mandatory ventilation (IMV) – combination of mechanically assisted breaths and spontaneous breaths. Mechanical breaths are given at preset times and preselected volumes. Patient is allowed to use their own muscles during ventilation
• Synchronized intermittent mandatory ventilation (SIMV) – delivers a preset tidal volume and number of breaths per minute. Patient is able to breathe on their own during delivered breaths. As patient breaths independently more often, the preset amount of breaths is decreased and the patient does more work.
• Pressure support ventilation (PSV) – applies pressure plateau to the airway during patient-triggered inspiration in order to decrease resistance within the tracheal tube and ventilation tube. As the patient’s strength increases the pressure support is decreased
• Airway pressure release ventilation (APRV) – time triggered, pressure- limited, time-cycled mode of mechanical ventilation that allows for spontaneous breathing. Allows alveolar gas to be expelled through lungs natural recoil
• Proportional assist ventilation (PAV) – provides partial ventilatory support where the ventilatory generates pressure in proportion to the patient’s inspiratory efforts. As the patient breaths, the ventilatory synchronizes. As the inspiratory pressure the patient generates increases the more pressure the ventilator generates.

Case Study: Acute Respiratory Distress

Syndrome (ARDS)

11. Fill out the table on the medications used to treat ARDS. Medic atio n Indica tion s Classifi catio n Adve rse reacti ons Contraindi cation s Nursing consideratio ns DOBU Tamin Mainta in Inotrop es Asthma attack, Hx. Of sulfite Continuous e adequ ate anaphyla xis, sensitivity, hx. Of monitoring of ECG, hydroc hlori cardia c chest pain, hypertensi on, BP, cardiac output de output palpitation s after acute MI and urine output. Correct hypovolemi a before therapy. Monitor electrolyte levels. Nitric oxide Impro ve Vasodila tor Anaphyla xis, Hx. Of heart Do not stop using oxyge natio cyanosis, chest problems, heart suddenly. Monitor n and pain, dizziness failure, lung or labs pulmo nary breathing vascul ar problems resista nce Loraze pam Depre ss Anxiolyt ic Amnesia, Hypersensi tivities, Monitor hepatic, the CNS insomnia, use cautiously in renal, and nausea, dizziness pt. with hematopoiet ic pulmonary, renal function. Don’t stop or hepatic abruptly impairment of hx. Of substance abuse Hepari Prophy anticoa Hemorrha Active Measure

Case Study: Acute Respiratory Distress

Syndrome (ARDS)

n laxi gulant ge, bleeding, PTT s for VTE prolonged hypersensi tivities, carefully and clotting time, bleeding regularly. Monitor thrombocy topeni tendencie s platelet count, a, hyperkale mia monitor vitals, inspect for bleeding gums, bruises, petechiae Omepr azol Preven t Antiulce r Back pain, Use cautiously Assess for e ulcers flatulence, with hypokalem ia osteoporosis , gastrin nausea, and respiratory level rises in first 2 vomiting, alkalosis weeks of therapy, abdominal pain, drug increases its constipati on bioavailabilit y with repeated doses Albuter ol Relax es broncho dilato Bronchos pasm,

CV

disorders, Monitor for sulfate bronch ial r hypokale mia, hyperthyr oidism effectivenes s and tachycardi a, or diabetes vascul ar epistaxis mellitus smoot h muscl e Sodiu m Metab olic antacid Hypokale mia, Metabolic or Obtain blood pH, bicarb onat acidos is metabolic respiratory PaO2, PaCO2 and e alkalosis, alkalosis, electrolyte levels hypernatr emia hypocalce mia, hypertensi on, seizures or heart

Case Study: Acute Respiratory Distress

Syndrome (ARDS)

failure Morphi ne Pain Opioid Bradycardi a,

GI

obstruction , Monitor vitals, pain sulfate analges ic cardiac arrest, head injury, level, respiratory shock, increased ICP, status and sedation thrombocy topeni seizures, level. Reassess level a, apnea, hypothyroi dism, of pain 15- 30 respirator y circulatory shock, minutes after depressio n

CNS

depressio n parenteral administrati on and 30 minutes after oral Cisatra curi Mainta in Skeletal Bradycardi a, Hypersensi tive to Don’t give IM, um neuro musc muscle bronchos pasm, drug or other monitor besyla te ular relaxant prolonged apnea benzylisoq uinolini neuromusc ular blocka de um drugs or function, monitor during benzyl alcohol acid-base balance mech anica and electrolyte l levels ventila tion Penicilli n infecti on Antibioti c Leukopeni a, thrombocy topeni a, anaphylax is Cautiousl y with hx. Of allergies or asthma Monitor for diarrhea Predni sone Inflam mati corticos teroid Seizures, Recent MI, GI Always adjust to on arrhythmi as, ulcer, renal lowest effective pancreatiti s, disease, dose, give once- hypokale mia, hypertensi on, daily dose in hypoglyce mia osteoporos is, morning, monitor diabetes mellitus, BP, sleep patterns

Case Study: Acute Respiratory Distress

Syndrome (ARDS)

hypothyroi dism, and potassium level. cirrhosis, active Weight daily. Monitor hepatitis, for signs and diverticuliti s, symptoms of seizures. Pt. more infection, if therapy susceptible to lasts longer than 6 infection weeks monitor IOP epinep hrin Anaph ylaxi vasopre ssor Cerebral Angle- closure Observe closely for e s hemorrha ge, glaucoma, shock, adverse reactions. If stroke, organic brain

BP

increases subarach noid damage, HF, sharply, give rapid- hemorrha ge, cardiac dilation, acting vasodilators ventricular arrhythmia s or fibrillation, shock cerebral arterioscler osis.

12. Devise a detailed educational plan for a patient with ARDS. Include the family in the plan as well. - Disorder: ARDS is an abbreviate for acute respiratory distress syndrome – it is a serious lung problem that keeps you from getting enough oxygen into your blood. Fluid builds up within the lungs causing increased pressure making it more difficult to breath. This lack of oxygen to your blood means you are unable to get enough oxygen to the rest of your body. There is many different reason ARDS can develop, in your case it is likely from the blood transfusion you received due to your surgery complications. When not treated

Case Study: Acute Respiratory Distress

Syndrome (ARDS)

promptly, this can be life threatening.

• Medications: o Analgesic – pain medication may be used in order to help relieve some discomfort. Take medication before pain becomes severe. The medication may cause dizziness, ask for help when needed and do not drive. o Antibiotic – to help fight/prevent infection caused by bacteria. Take the prescribed dose and do not stop taking them even if you start to feel better.
• Breathing exercises: due to the fluid build-up in the lungs, while active you may become short of breath. Practicing deep breathing can help with this. Breathe using your diaphragm and with pursed or puckered lips.
• Complications: o Pneumothorax o Respiratory failure o Blood clot o Pneumonia o Lung scarring
• Mechanical ventilation: Since the supplemental oxygen was not helping you the way your doctor would have liked to see, we had to start you on a mechanical ventilator to help you breathe. This machine allowed for adequate oxygen to be delivered to your body and helped you to breathe efficiently. While beneficial this machine does come with some risks. It increased your chance for an infection as well as a pneumothorax (collapse of a lung). If you suddenly become short of breath with chest pain seek immediate care.
• Exercise: since you were laid up for a while it is important that you start to exercise. This is something that you are gradually going to have to work at and work up too. Do things progressively and as tolerated. Exercise will strengthen your hard and build your strength back up.

Case Study: Acute Respiratory Distress

Syndrome (ARDS)

• Diet: It is important that you maintain a healthy diet in order to promote healing. This includes eating your fruits and vegetables and limiting your fat intake. Eat food high in fiber and drink plenty of fluids.
• Wound care: it is important to keep your wounds as clean as possible. This means practicing aseptic technique. We will send your home with directions on how to clean and to care for your wounds.
• Infection: You have multiple wounds that you will be going home with. These wounds increase your chance for an infection. Make sure to practice meticulous hand washing and to avoid places/people where you are more likely to become sick.
• When to seek help: o If you have a fever o If you are coughing up bloody sputum o If you have increased swelling in legs, feet or abdomen o If you are hearing a high-pitched noise as you breathe (wheezing) o If you become short of breath or have trouble breathing o If you experience chest pain and heart palpitations o If your lips, skin or nail beds become blue
• Follow up: Your doctor may want you to come back to see how you are doing. This will likely involve some tests. Your doctor will look and see how much air is in your lungs as you are breathing which will show how well your lungs are functioning. 13. Explain self-management strategies for a patient recovering from ARDS.
• Practice good hand washing with soap and water – prevent the spread of infection
• Keep a distance from others who are sick – prevent the spread of infection

Case Study: Acute Respiratory Distress

Syndrome (ARDS)

• Do not share anything with anyone who is sick – prevent the spread of infection
• Stay away from crowded places – prevent the spread of infection
• Do not smoke – causes the heart and lungs to have to work harder
• Get plenty of exercise – can decrease blood pressure and promote adequate oxygen exchange throughout the body
• Do not drink alcohol – causes the heart and lungs to have to work harder
• Breathing exercises – promotes expansion of lungs and allows for more oxygen to enter

Case Study: Acute Respiratory Distress