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Complex Exam 2 Module 5 biology test
Hypoxemic Failure (basic) PaO2<60 on 60% O Hypercapnic Failure (basic) PaCO2> pH<7. *Acute respiratory failure is Not a disease but a _____ symptom Hypoxemic/Oxygenation Failure is Caused by V/Q mismatch, Shunting, or Impaired diffusion Diseases/ disorders that can cause that: -Pneumonia -Pulmonary Embolism -Pulmonary Edema -ARDS Hypercapnic/Ventilatory Failure is Caused by -Impaired ventilation, Impaired chest wall movement (decreased volume of breaths) -Diseases/ disorders that can cause that: --Asthma --COPD -Pain (cant take a deep breath because it hurts) -Drug overdose -Neurological disorders --MG - Myasthenia Gravis --GB - Guillain-Barre --MS - Multiple sclerosis Failure of Oxygenation -- Hypoxemic Failure -Ventilation-perfusion mismatch (V/Q mismatch) --Intrapulmonary shunting --Increased dead space ventilation -Diffusion defects -Low cardiac output -Low hemoglobin level Ventilation Perfusion Mismatch (Hypoxemic Failure) -We should have adequate perfusion (blood flow) and ventilation (O2) to all the alveoli -V/Q Mismatch can cause hypoxemic respiratory failure Low V/Q Mismatch Ex: we have adequate air coming in, but there's a blockage so we don't continue to get adequate air flow to alveoli, but we are getting adequate blood flow (perfusion) = Low V/Q Mismatch -Low ventilation, also called a shunt -- we are shunting blood passed a non-aerated alveoli High V/Q Mismatch Ex2: We have air coming in and we have an adequately ventilated alveoli, but we have a blockage of blood flow = High V/Q Mismatch -Adequate ventilation but poor perfusion -Also called dead space ventilation
-Often with Pulmonary embolism Shunt (Hypoxemic Failure) - Anatomic -Blood passes through an anatomic channel in the heart bypassing the lungs -Ex: Ventricular septal defect --The blood goes right from the Rโ L ventricle without going through the lungs and having O2/CO2 gas exchange Shunt (Hypoxemic Failure) - Physiologic -Blood flows through the pulmonary capillaries without participating in gas exchange -Causes: --Pneumonia --ARDS --These cause problems with ventilation of the alveoli Another Cause of Hypoxemic Failure: Diffusion Limitations Thickened alveolar/capillary membrane impairs gas exchange Failure of Ventilation -- Hypercapnic Failure -Disorders that will cause this Alveolar hypoventilation: --Respiratory muscle fatigue --CNS depressants --Head injury --Chest wall abnormalities --Neuromuscular conditions ---MG, GB, MS *Without treatment this will also result in hypoxemic failure too Manifestations of HypoxemiaTachycardic/Tachypneic Increased BP Restless * Confusion * Anxiety Manifestations of Hypercapnia Tachycardic/Tachypneic Headache Decreased LOC Increased somnolence * Dizzy Flushed Manifestations of Hypoxia and Hypercapnia -Pursed-lip breathing -Retractions -Orthopnea -Tripod position - increases AP diameter - decreases work of breathing -Inability to speak in full sentences Diagnosis -History --Figure out what is causing this, do they have a history of COPD, etc? -Chest x-ray -Blood work -Pulse oximetry Diagnosis - Blood work -Arterial blood gases --pH to see acid/base balance
-Neurological assessment --Gives us info about PaCO -Breath sounds --Adventitious sounds? Secretions cleared? -Cardiac monitoring --Dysrhythmias can occur from hypoxemia and hypercapnia Nursing Actions - Oxygen management -As ordered -We can put on a 100% non-rebreather before the order if it is emergent but you need to follow up after with provider and get an order for it Nursing Actions - Secretion management -Chest physical therapy -Airway suctioning / effective coughing -Positioning - Increase HOB, OOB to decrease work of breathing Secretion management - Chest PT -Physically positioning a patient in a way that the secretions can be drained out of the lungs and out of the alveoli into the bigger airway so they can be coughed up -Ex: if a pt has secretions or pneumonia in right lower lobe, we're gonna turn them to their left side with their head down, right lower lobe up and we're gonna tap on the side of their chest to try and knock the secretions out of the lungs into the major airway to be coughed or suctioned up Secretion management - Airway suctioning / effective coughing Airway suctioning is typically done when a patient has an artificial airway in, but we can also put a tube down into the nasal airway or an oral airway and physically suction down through the nose or mouth to remove the secretions Secretion management - Positioning -Increase HOB, OOB to decrease work of breathing --Good lung down -- to decrease V/Q Mismatch ---To optimize ventilation/perfusion of the good lung since gravity will also go down to the good lung --Ambulation is very important too Nursing Actions - Hydration and humidification -Adequate fluid intake - so secretions don't dry out so we don't get a mucus plug -IV hydration/humidification -Humidification devices Acute Respiratory Distress Syndrome (ARDS) X-ray appearance -Called a Ground Glass Appearance --Bilateral infiltrates --Adequate hydration of the lungs --The lung fields look black -When we are not adequately aerating out lungs, we get this whitish appearance ARDS Epidemiology -190,000 new cases annually -15-18% of all mechanically ventilated patients -Mortality 30-70%; average 40% --ARDS is deadly -We need to diagnose and treat quickly Causes of ARDS -Alveolar capillary interface becomes damaged and more permeable to intravascular fluid --The Alveoli fill with fluid
--ARDS is the most extreme form of hypoxemic failure Causes of that^ (ARDS) -Sepsis -Pneumonia -Aspiration -Trauma --Causes a systemic inflammatory response that can lead to extreme inflammation which can cause ARDS -Massive transfusions -Pancreatitis -Shock states -Inflammation is the main cause and is a result of most of these above ^ ARDS -- Failure of Oxygenation -Acute onset -Bilateral infiltrates (both lungs affected) -Severe, refractory hypoxemia --PaO2/FiO2 ratio ---200 - 300 - mild ARDS ---100-200 - moderate ARDS ---<100 - severe ARDS *all of this is in the absence of isolated cardiogenic pulmonary edema Severe V/Q mismatch and shunting of pulmonary capillary blood result in refractory hypoxemia -Unresponsive to increasing O2 concentrations --Ex: putting the 100% nonrebreather on them does not help ---No matter how much oxygen we give them, we cannot get it into the lungs -Lungs become less compliant --This means it takes more pressure into the lung to deliver the adequate amounts of air into the lungs --Because of the fluid -Increased airway pressures must be generated --To give them the volume of air that they need to keep their oxygen levels up, to keep their alveoli aerated 3 Phases of ARDS: 1. Exudative Phase (early)
- Proliferative Phase
- Fibrotic Phase ARDS - Exudative Phase (early) - Changes -Inflammatory mediators released -Disruption of alveolar capillary membrane -Fluid in the alveoli -V/Q mismatch -Loss of surfactant = alveolar collapse --This is why providing O2 does not work ARDS - Exudative Phase (early) - Manifestations -Tachypnea and tachycardia -Mild hypoxemia and respiratory alkalosis caused by hyperventilation --Because the patient is breathing faster -Dyspnea, tachypnea, cough, restlessness -Chest auscultation may be normal or may reveal fine, scattered crackles -Increased CO
--A popular mode is the low tidal volume at higher respiratory rates; still needing higher levels of PEEP -Requires advanced airway --Have tube in their mouth (endotracheal tubes) -- if it lasts longer than 2 weeks then we will remove the airway and place a trach instead ARDS - Positive End Expiratory Pressure (PEEP) -- the same as CPAP -PEEP vs CPAP --This is different from CPAP because PEEP is only used when the patient is also getting respiratory support through a ventilator -PEEP Increase functional residual capacity (FRC) and opens up collapsed alveoli -Higher levels of PEEP are often needed to maintain PaO2 at 60 mm Hg or greater -High levels of PEEP can compromise venous return --Because we have an increased intrathoracic pressure --โ Preload, CO, and BP ARDS Nursing - Optimize O2 delivery -Frequent assessment - hemodynamic and ventilatory --Vital signs (VS); sats, ScvO2/SvO2, etc. -Keep the airways clear ARDS Nursing - Minimize O2 Demand -We need to Minimize O2 demand - Decrease O consumption --Comfort --Provide Sedation --Provide Pain relief --Neuromuscular blockade - medical paralysis ---So the patient does not fight the ventilator and get out of sync ---These patients also need sedation and pain relief because paralysis is terrifying ---We try to minimize the use of this ARDS Nursing - Positioning -Prone positioning --For patients who are always on their back, all their secretions will start to pool on the posterior sections of the lungs -- this causes bad lung down which worsens V/Q Mismatch --We turn the patient to make them lying on their stomach (Prone) ---This minimizes the V/Q mismatch -Elevate HOB to decrease work of breathing -Frequent changes Which assessment findings would the nurse expect to observe in a client diagnosed with acute respiratory distress syndrome in the exudative phase? Select all that apply. Decreased heart rate Increased respiratory rate Respiratory alkalosis Increased cardiac output Productive cough Increased respiratory rate Respiratory alkalosis Increased cardiac output Which finding in the client's history should the nurse rule out as a contributing factor in the development of acute respiratory distress syndrome?
Pulmonary embolism Recurrent pneumonia Left-sided heart failure Drug/alcohol overdose Left-sided heart failure The nurse is caring for a client being treated for refractory hypoxemia for acute respiratory distress syndrome. Which intervention should the nurse anticipate next? Apply a non-rebreather mask Prepare for chest tube placement Place on mechanical ventilation The client will receive bedside bronchoscopy Place on mechanical ventilation A nurse is caring for a client diagnosed with acute respiratory distress syndrome on mechanical ventilation. Which ventilator setting should the nurse question? High tidal volume High positive-end expiratory pressure High-frequency oscillating ventilation Airway pressure release ventilation High tidal volume When caring for a client diagnosed with acute respiratory distress syndrome who is on mechanical ventilation, the nurse should place the client in what position to improve oxygenation? Fowler's Semi-Fowler's Trendelenburg Prone Prone Pneumothorax / Hemothorax -Collection of air / blood in the pleural space -Reduction in the negative thoracic pressure and poor lung expansion --We essentially have positive pressure in the thoracic space which makes it difficult to take in enough air and take a deep breath -- poor lung expansion -Reduction of gas exchange at the alveolar level resulting in hypoxemia Tension Pneumothorax -Worse case scenario with a pneumothorax is a tension pneumothorax --The lung parenchyma is completely collapsed and we start to see a shift over -- put pressure on the heart and have obstructive shock --We start to have impaired filling because the heart is being collapsed --Tension pneumothorax is a deadly complication of pneumothorax that needs to be treated right away Hemothorax -From the outside โ in, from a wound, rib fracture, or GSW, knife injury -We have blood that enters into the pleural space that collapses down the lung Manifestations (PTX/HTX) -Decreased oxygenation -Tachypnea = Respiratory alkalosis initially -Later - respiratory acidosis --Then metabolic acidosis -Very Painful -SOB
-Low Risk Massive PE -Profound hypotension -R & L ventricular dysfunction -Shock/cardiac arrest Submassive PE -Normotensive -R ventricular dysfunction -Elevated cardiac markers Low Risk PE -Normotensive -No ventricular dysfunction or elevation in cardiac markers -May present SOB and with pain that doesn't go away -Still must be treated quickly because it will get bigger PE Clinical Manifestations - Initial Dyspnea Chest pain Tachypnea Tachycardia PE Clinical Manifestations - Submassive/Massive -R heart failure with JVD -Hypotension -Anxious/restless/confused -Hypoxia -Poor peripheral perfusion -Hemoptysis with pulmonary infarction --Bloody pulmonary secretions PE Diagnosis - Imaging -CXR --Does not diagnose it --Used to rule out other causes of the respiratory distress (pneumonia, consolidation, atelectasis) -CT scan --Diagnosis --We can see the PE PE Diagnosis - Lab testing -D-dimer --Lab result we get when there is a breakdown of a clot occurring in the body --A positive D-dimer tells you that the patient has had clots and they are breaking them down now --They need a CT done ASAP -ABG -Cardiac markers PE Medical Management -Anticoagulation --Heparin helps prevent the clot from getting bigger -IVC filters - prevent recurrence --IVC filter - Vena Cava filter - would trap new clots that are formed before they get to the lungs -Cautious fluid management -Hemodynamically compromised --Thrombolytics --Embolectomy --Vasoactive/inotropic support PE Medical Management - Thrombolytics -Breaks down the clot
-Can be done systemically (risky) -Or we can put a line in up to the Pulmonary artery and deliver the thrombolytics directly to the area needed PE Medical Management - Vasoactive/inotropic support To maintain CO until we can effectively treat the PE and stabilize the pt hemodynamically PE Nursing Assessments -Oxygenation/Spo -Chest pain -VS -Labs --ABGs --Lactate --Coagulation studies ---If they're taking heparin or warfarin (coumadin) --Cardiac markers -Urine output --Good indicator of CO PE Nursing Actions -Provide O -Elevate HOB -Medication Management -Fluid management -Bleeding precautions A client with severe respiratory distress is intubated and placed on mechanical ventilation. Which intervention will help maintain patient ventilator synchrony? Providing adequate sedation Using a manual resuscitation bag Maintaining a proper head position Providing intermittent subglottic suction Providing adequate sedation What parameters are most beneficial in assessing the severity of respiratory distress in a newly admitted patient with an acute asthma exacerbation? Select all that apply Chest x-ray Pulse ox ABGs CT scan The ability to speak in full sentences Pulse ox ABGs The ability to speak in full sentences Which breath sound indicates an airway emergency in a patient newly extubated? Stridor Wheezing Crackles Rhonchi Stridor Which complication is the patient at risk for when on positive pressure mechanical ventilation?
