Respiratory Distress
List the early and late signs of hypoxia.
What is:
Early signs- restlessness, anxiety, tachycardia, tachypnea
Late signs- bradycardia, extreme restlessness, dyspnea
What is a pneumothorax?
What is:
-accumulation of air within the pleural space, producing increased intrathoracic pressure and decreasing vital capacity
-based on % of how collapsed the affected lung is
Explain the term Acute Respiratory Distress Syndrome and its defining characteristics
What is:
-the most deadly form of acute lung injury
-aka adult respiratory distress syndrome, acute respiratory dysfunction syndrome, stiff lung, shock lung
-characterized by: refractory hypoxemia, decreased pulmonary compliance (acute onset of respiratory distress), dyspnea, noncardiogenic associated pulmonary edema, and dense pulmonary infiltrates on x-ray
-Dx: BNP should be <100 with no signs of cardiomegaly or EKG abnormalities
List the normal lab values for ABGs and coag studies.
Hgb: 12-15.2
Hct: 37-46%
WBC: 4.1-10.9
PT: 12-14 secs
PTT: 18-28 secs
pH: 7.35-7.45
PCO2: 35-45
PO2: 35-45
HCO3: 22-26
O2 Sat: 95-100%
Describe the ventilator settings on mechanical ventilation.
What is:
-RR: total number of breaths the vent is ordered to give per minute (10-14 breaths/min)
-VT (tidal volume): volume of air the vent is ordered to give during each breath
-PIP (peak inspiratory pressure): pressure recorded inside alveoli at end of inspiration
-FIO2: % fraction of inspired O2 to be delivered
21-100%
-PEEP (positive end expiratory pressure): positive pressure given by vent during expiration to keep alveoli open
Describe a tracheostomy and the complications of insertion.
What is:
-indicated for long term mechanical ventilation, exceeds 2 weeks
-complications: infection, bleeding, tube obstruction, and development of fistulas
-RN is responsible for providing trach care
Describe hypoxemia and the levels associated with this deficiency.
What is:
Hypoxemia- partial pressure of O2 in arterial blood <80mmHg
Mild hypoxemia: 60-80mmHg
Moderate hypoxemia: 40-60mmHg
Severe hypoxemia: <40mmHg
Explain what a tension pneumothorax is.
What is:
-develops rapidly, life-threatening
-Caused by blunt chest trauma. Can occur from a mechanical vent and resuscitative efforts
-Intrathoracic pressure increases from accumulation of air in the pleural space. The lung collapses and the trachea deviates away from the side with tension
-Tx: needle decompression, must be performed by a doctor
List the labs drawn for ARDS.
What is:
-sputum culture: if they are on a vent, use deep suction to obtain sample
-CBC: increased WBC, monitor RBC, Hgb, Hct
-CXR: shows infiltrate
-EKG: shows no signs of cardiac abnormality
-Lactic acid: >2 means sepsis
Describe PaO2 and the manifestations of abnormal levels.
What is:
-partial pressure of O2 in blood, how much O2 is dissolved in blood
-Normal values: 80-100
-<normal: hypoventilation
->normal: hyperventilation
Describe the ventilator modes.
What is:
-AC (assist control): based on ABGs, delivers breath and constant volume
-SIMV (synchronized intermittent mechanical volume): set volume pressure and rate, allows patient to breathe spontaneously, used for weaning of vent
-CPAP (continuous positive airway pressure): used for sleep apnea
-PS (pressure support): for additional help
Describe the interventions needed for extubation.
What is:
-have the patient cough when removing and prepare for increased secretions
-provide O2 via NC or face mask
-observe every 5 mins for signs of upper airway obstruction: dyspnea, coughing, inability to expectorate secretions
-use incentive spirometer
-suction at bedside, nonrebreather
-listen for stridor, patient should be reintubated
Explain the clinical manifestations of respiratory distress.
What is:
-airway that is open without support
-tachypnea, tachycardia
-increased respiratory effort
-clear lung sounds
-agitation
-pallor
-slow, delayed cap refill
List the symptoms of a patient with a tension pneumothorax.
What is:
-asymmetry of the thorax
-tracheal deviation to the unaffected side
-absent breath sounds on one side
-distended neck veins
-respiratory distress
-cyanosis
-crepitus
Explain the drugs administered for ARDS.
What is:
-O2, watch for O2 toxicity
-bronchodilators
-vasopressors
-antibiotics
-conservative fluid therapy (low fluid volume and diuretics)
Describe PaCO2 and the manifestations of abnormal values.
What is:
-partial pressure of CO2 in blood, how much CO2 is dissolved
-35-45
-<normal: alkaline
->normal: acidic
-compensation starts within 3-5 mins
Describe the nursing management necessary for patient on a ventilator.
What is:
-monitor patient response, determine if they are tolerating or fighting the ventilator
-suction for presence of secretions, rhonchi, increased peak airway pressure, decreased breath sounds
-assess area around site every 2 hours
-provide oral care via chlorhexadine rinses
-prone position
-apply high/low pressure alarms
What are the nursing assessments required for intubation?
What is:
-tube is marked at level it touches teeth
-always tape tube to upper lip
-be sure cuff is adequately inflated to ensure tidal volume 20-30cm H2O
-restraint is last resort
Explain the clinical manifestations of respiratory failure.
What is:
-decreased HR, decreased BP, decreased RR
-decreased peripheral perfusion and delayed cap refill
-decreased urine output
-acidosis, increased lactate on ABGs
-airway possibly obstructed
-abnormal breath sounds
-cyanosis
-failure to respond
Describe what is meant by a hemothorax.
What is:
-accumulation of blood within the pleural space caused by blunt or penetrating trauma
-Tx: chest tube insertion, monitor drainage
Describe the phases of ARDS.
What is:
PHASE 1 REPRESENTATIVE INITIATING EVENTS:
-inflammatory response caused by sepsis, may have clear lung sounds
-s/s: cough, fever, tachycardia, SOB, tachypnea
-Tx: High Fowler's, O2, incentive spirometer, cough/deep breathing
2ND PHASE EXECUTIVE PHASE
-damage to alveoli, edema develops
-days 4-7
-s/s: tachypnea, SOB, use of accessory muscles, anxiety, cannot lay flat b/c of edema in lungs, crackles on auscultation
3RD PHASE PROLIFERATIVE PHASE
-fluid causes alveoli to collapse, interstitial area becomes inflamed
-decreased PaO2 and surfactant, atelectasis, and weight gain, signs of pulmonary edema
4TH PHASE FIBROSING PHASE
-lungs become fibrotic, harden and stop workingn
->21 days
-pulmonary HTN, decreased gas exchange, MODS
Describe HCO3 and manifestations of abnormal levels.
What is:
-recipient of H ions, amount of HCO3 in blood
-<normal: acidic
->normal: alkaline
-22-28
-kidneys can take hours to days to correct/compensate
Explain the measures taken to prevent VAP.
What is:
-keep HOB 30 degrees
-perform oral care
-ulcer prophylaxis
-chest physiotherapy
-postural drainage
-turning/positioning
Explain the nursing assessments for a client with a chest tube.
What is:
-signs of distress, trachea deviation
-occlusive dressing
-tubing: kinks, dependent loops, connections taped, clots present
-drainage system: intact, proper placement
-collection chamber: amount, type of drainage
-water-seal chamber: correct water level on 2cm line; bubbling means air leak
-suction control chamber: set level
List the signs of inadequate respiratory effort in pediatric patients.
What is:
-head bobbing
-grunting on expiration
-nasal flaring
-retractions
-poor feeding
List the symptoms of a patient with a hemothorax.
What is:
-decreased breath sounds
-dull sound on percussion
-decreased chest expansion
-blood visible on chest x-ray
List the direct and indirect injuries that can cause ARDS.
What is:
-Indirect injury: pancreatitis, multiple transfusions, sepsis, anything causing a cytokine storm, fat/amniotic embolism
-Direct injury: aspiration of gastric content, pneumonia, near drowning, blunt trauma, toxic inhalation injury
Describe pH and the manifestations of abnormal levels.
What is:
-number of hydrogen ions in blood
-7.35-7.45
-<normal: acidic, has more H
->normal: alkaline, has less H
Explain DOPE for trouble-shooting vents.
What is:
-Dislodged: ET tube not connected to trachea
-Obstructed: blockage is present
-Pneumothorax: tension pneumothorax
-Equipment: interruption in O2 supply
Describe the preparation needed for intubation.
What is:
-maintain a patent airway through positioning until patient is intubated
-keep HOB 30 degrees
-monitor vitals, signs of hypoxemia or hypoxia, dysrhythmias, and aspiration
-each intubation attempt should last <30 seconds. If longer, oxygenate via ambubag
-listen to lung sounds when placed
-check placement every time patient moves
Describe acute respiratory failure and the ABGs associated with this condition.
What is:
-failure of the pulmonary system to provide sufficient exchange of O2 to supply the body's demands. (Ventilation or perfusion is mismatched with the other in a lung)
-PaO2 <60 (hypoxia, O2 failure)
-PaCO2 >45 (acidosis)
-pH <7.35 (ventilatory failure, hypercapnic)
-SaO2 <90%
Describe the nursing interventions needed for a patient with a pneumothorax.
What is:
-maintain ABCs
-administer O2
-open pneumothorax, use a 3-sided dressing with 4x4 gauze
-prepare patient for chest tube insertion
-administer pain meds
-monitor vitals, RR, and PSO2
Explain the collaborative management of ARDS.
What is:
-endotracheal intubations and mechanical ventilation with PEEP or CPAP
-prone position
-sedatives, paralytics, analgesics, and breathing treatments
-check sedation holiday, spontaneous awakening, and breathing trials
-tube feedings (monitor for fluid overload)
-monitor gag reflex and ability to swallow
-perform proper hand hygeine, catheter care, and wound care to prevent infection
List the acid-base imbalances and symptoms of each.
What is:
-Respiratory Acidosis: decreased pH, increased PaCO2, hypoventilation, rapid shallow RR, hypoxemia, hyperkalemia, H/A, muscle weakness, increased cardiac output, disorientation
-Respiratory Alkalosis: increased pH, decreased PaCO2, seizures, deep rapid breathing, hyperventilation, confusion, hypokalemia, lightheadedness, tingling extremities
-Metabolic Acidosis: decreased pH, decreased HCO3, H/A, disorientation, decreased LOC, hyperkalemia, muscle twitching, Kussmaul RR, fruity breath
-Metabolic Alkalosis: increased pH, increased HCO3, restlessness, followed by lethargy, dysrhythmias, diarrhea, hypokalemia, decreased RR, N/V
List the complications of mechanical ventilators.
What is:
-hypotension, fluid retention
-Barotrauma: damage to lungs by positive pressure
-Volutrauma: damage to lungs by excess volume
-Atelectrauma: shear injury to alveoli opening/closing
-acid-base imbalance
-decreased surfactant, increased inflammation, fluid leakage, noncardiac PE causing lung injury
Describe the measures taken to verify tube placement.
What is:
-check CO2 concentration
-chest x-ray
-bilateral and equal breath sounds and chest expansion
-air emerging from ET tube may cause condensation
-auscultate over stomach to rule out esophageal intubation, which you will hear louder breath sounds over stomach and may cause abdominal distention
-priority is to maintain airway