ARDs
What Clinical Manifestations can a client with ARDS exhibit?
Tachypnea- in attempt to increase O2, tachycardia, restlessness/irritability, dyspnea-increased work of breathing, decreased lung expansion-decreased compliance
Breath sounds- initially no abn. d/t edema occurring first. LATER- crackles and decreased breathsounds and SpO2 despite supplemental O2
Flail chest treatment
Humidified O2, pain and anxiety management,
encourage deep breathing and coughing to clear secretions, possible administration of nerve block for severe pain, mechanical ventilation
Assessment
Evaluate placement of tube, document as XXcm at lips/gums/teeth, speech should not be heard
assess pt. response to ventilation ( appearance, VS, LOC)
Barotrauma - leads to air being introduced into the pleural space or other body cavity, results in pneumothorax, pneumoperitoneum, pneumomediastinum.
What is causes and s/s?
decreased/absent lung sounds on affected site, SQ emphysema/crepitus, respiratory distress
PH: 7.18
PCO2: 40
HCO3: 8
Uncompensated Metabolic Acidosis
Cause DKA
What are some Diagnostic findings of ARDs?
CXR-diffuse haziness " white out"
ABG-hypoxemia refractory to high levels of O2, respiratory and metabolic acidosis, CO2 retention and lactic acid build up from decreased O2 levels
Treatment of Pulmonary Contusion
Maintain O2 w/supplemental O2
Mechanical ventilation if respiratory failure develops
Suctioning
Perform when needed (coughing, gurgling, increased anxiety/restlessness)
Observe/document sputum & culture if necessary
Preoxygenate
VAP (Ventilator Associated Pneumonia)-
Cause: secretions pooling on tip of the balloon become infected then ooze down around the balloon into the lungs, silent gastric aspiration.
What are the prevention strategies?
Hand washing
mouth care q2h or more if needed, suction back of throat w/mouth care, suction deep secretions,
keep HOB >30 degrees
PH: 7.45
PCO2: 74.3
HCO3: 30.2
Compensated
Metabolic alkalosis
cause: unmonitored HCO3 infusion, excessive antacid use
What are the Mechanical Ventilation Goals for ARDs and complications to watch for?
Keep SpO2 88-95% or PaO2 55-80mmHg
Complications: For FiO2 up to 100% O2 toxicity
For PEEP hypotension or barotrauma
Treatment of Tension Pneumothorax
High flow O2-up to 100% if pos
Emergent needle compression
Chest tube placement following decompression
Mouth Care
Perform as often as needed q2h minimum d/t decreases VAP, mouth drying occurs, mouth secretions difficult to control
Endotracheal tube must be repositioned at least every shift to prevent skin breakdown esp. on lips
Observe for Cardiovascular complication- intrathoracic pressure decrease preload and activate RAA system.
What will we see?
Hypotension, s/s of fluid retention
PH:7.07
PCO2: 11.4
HCO3: 3.1
Partially compensated Metabolic acidosis
cause: DKA
60% of lung surface is dependent in supine position & 40% supine, fluid moves by gravity to dependent lung fields. Prone position allows for fluid shift and exposure of alveoli
Treatment of Pneumothorax & hemothorax
Pneumothorax -High flow O2
Chest tube- if 15% or greater lung area affected
Hemothorax- Chest tube
Reduce anxiety
Speak to not over pt. explain monitors, procedures, alarms. Encourage family interaction.
Let pt. and family know someone is always near
Follow Riker agitation scale for sedation medication titration.
Let's talk about pt. weaning off of Vent
When does it occur, what assessments and actions need completed?
Trials begin as soon as pt. is stable & underlying reason for vent has been addressed. Sedation needs to be decreased.
Ongoing assessment to ID s/s of poor pt. response
(tachycardia, tachypnea, decreased SpO2, increased BP, anxiety/restlessness, abdominal breathing
PH: 7.17
PCO2: 69.3
HCO3: 28
Partially compensated respiratory acidosis
Cause: COPD exacerbation/respiratory failure, Pneumonia
Pharmacologic treatments for ARDs
Versed, fentanyl, ativan, propofol- sedation/antianxiety
vecuronium, rocuronium- paralytics
ABX if infection present
Fluid management balance with diuretics
Dopamine, norepinephrine, vasopressin (vasopressors)- maintain CO and perfusion
Steroids (still controversial) only in early ARDs
ECMO- complication ; heparin induced thrombocytopenia
Nitric Oxide-dilate pulmonary blood vessels
Findings of pneumothorax
Findings of Hemothorax
Pneumothorax-Resp distress (tachypnea, tachycardia, hypoxia, cyanosis, dyspnea, increased work of breathing), decreased O2 sats, decreased or absent breath sounds on affected side, asymmetrical chest wall movement, pleuritic pain, subcutaneous emphysema/crepitus
Hemothorax- decreased breath sounds, respiratory distress, perhaps hemodynamically unstable (tachycardia, hypotensive -s/s of poor perfusion)
Nutrition
Pt. on ventilator need nutritional supplement, need strength to be weaned off of vent, feed gut if bowel sounds present, otherwise TPN/Lipids if no bowel sounds or contraindications
How do we conduct the post-extubation assessment?
VS and Respiratory q5minutes, then every hour
assess LOC, work of breathing, cardiac rhythm, voice and swallowing evaluation
COMPLICATIONS:
Decreased O2 levels , vocal cord damage, Bronchial/laryngeal spasm (life-threatening)
PH: 7.45
PCO2: 27
HCO3: 19.1
Compensated Respiratory alkalosis
cause: anxiety, hyperventilation, pain