ARDS
Alveolar capillary membrane becomes damaged and more permeable to intravascular fluid causing the alveoli to fill with fluid.
What is Acute Respiratory Distress Syndrome (ARDS).
PaO2 <60 mmHg
PaCO2 WNL or Decreased
What is Hypoxemic respiratory failure.
Guidelines for preventing ventilator-associated pneumonia (VAP) ?
What is Elevate HOB 30 degrees, daily oral care, daily SBTs & sedation vacation, Minimize sedation, skin care, nutrition, ROM exercises, peptic ulcer prevention.
Signs of a tension pneumonthorax?
What is Clinical presentation of pneumothorax PLUS: Tachycardia (> 134 bpm), Hypotension, tracheal deviation (the trachea can deviate away from the affected lung and will result in hypoxemia), JVD, Cyanosis.
Normal fluctuation of water within the water-seal chamber.
What is Tiadaling.
Berlin Criteria for ARDS
What is Onset occurring within 7 days of injury, noncardiac in origin, bilateral lung infiltrates, PaO2/FiO2 ratio <300 mmHg.
Mild ARDS is less than 300
Moderate ARDS is less than 200
Severe ARDS is less than 100
What are some causes of Hypoxemic respiratory failure?
V/Q Mismatch
Pulmonary Edema
Heart Failure
COPD
Atelectasis
Emphysema
There is NOT enough oxygen to the tissues due to inadequate oxygen availability.
Your client pulls out their ETT. What should you do next?
What is manually ventilate the client with a bag valve mast and 100% o2 if needed.
Nursing Interventions for pneumothorax?
What is High Fowlers Position, Supplemental Oxygen, Sprinting, Cough/Deep Breathe, Analgesics, Prepare for Needle Decompression or Thoracentesis, Prepare for Chest Tube Insertion.
A nurse is caring for a client with a chest tube. What should the nurse do when the collection chamber is full?
What is change the unit. DO NOT try to empty it.
Common causes of ARDS?
Sepsis, Pneumonia, Aspiration.
PaCO2 > 50mmHg
What is Hypercapnic respiratory failure.
The low-pressure alarm sounds on the ventilator. The O2 sat dropped to 87%. What should the nurse do?
What is tighten ventilator tubing and connections and checking for a possible leak.
The non-fractured side of the chest will expand on inspiration while the injured side will sink inward on inspiration.
What is Flail Chest.
A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. What should the nurse do?
What is Immerse the end of the chest tube in a bottle of sterile water.
This allows air to escape and not enter the pleural space.
A client in ARDS who is hemodynamically stable is experiencing refractory hypoxemia. How should the nurse position the client?
What is Prone Positioning.
A client in Respiratory Failure is being given nebulized albuterol. What side effects is important for the nurse to monitor for?
What is Tachycardia.
A family member asks you what Assist control ventilation is. What do you tell them?
What is this mode will ensure that a set number of breaths are taken. This mode sets the ventilator to give a preset TV and RR. The ventilator will work even if the client is not breathing on their own.
Clinical manifestations of pulmonary embolism.
What is dyspnea, mild to moderate hypoxemia, tachypnea, cough, chest pain, hemoptysis, crackles, wheezing, fever, tachycardia, syncope, decreased LOC, hypotension, impending doom.
Methods for verifying correct placement of a tracheostomy?
End-tidal CO2 capnography, auscultating breath sounds bilaterally for air entry, chest x-ray, inspection of bilateral chest wall movement.
Nursing Interventions for ARDS?
What is
Treat the cause: sepsis, pneumonia, aspiration.
Gas Exchange: Ventilatory adjustments, Suctioning, Prone positioning.
Prevent Complications: DVT: Meds and ROM, VAP: Oral hygiene, HOB, SAT/SBT.
Education.
What are some causes of Hypercapnic respiratory failure?
Sedatives
Guillian-Barre
Spinal Cord Injury
Flail Chest
Obesity
Tachypnea
Sepsis
There is an INCREASE in CO2 due to poor ventilation or respiratory effort.
What does a client on pressure support ventilation (PSV) need to be able to do on their own?
What is be awake and alert to initiate a breath.
Treatment for Tension Pneumothorax?
What is urgent needle decompression followed by chest tube insertion.
A nurse is caring for a client with a chest tube placed 24 hours ago. The nurse notes the client had 150ml of drainage within the past hour. What action should the nurse take?
What is: Notify the provider.
During the first hour after insertion of a chest tube, notify the provider if the client drains > 1-1.5 L of fluid.
After the first hour, notify the provider if the client drains > 100 mL in an hour.