ARDS

Question 1

ARDS definition

Answer 1

Rapid onset of noncardiac pulmonary edema

Progressive refractory hypoxemia

Extensive lung tissue inflammation

Small blood vessel injury

Multisystem organ failure

Question 2

Pathophysiology of ARDS

Answer 2

Acute lung injury

Unregulated systemic inflammatory response

Damaged capillary membranes leak

Damage alveolar membrane

Fluid enters alveoli

Significant tissue hypoxia results

Metabolic acidosis

Question 3

Risk Factors for ARDS

Direct Insults

Answer 3

Direct insults

Aspiration of gastric contents
Inhalation injuries
Smoke inhalation
Salt water inhalation

Question 4

Risk Factors for ARDS

Indirect Insults

Answer 4

Indirect insults

Overall body sepsis
Trauma
Gastrointestinal infections

Question 5

The greatest risk factor for ARDS is

Answer 5

Aspiration

Question 6

Initial manifestations of ARDS begin

Answer 6

24–48 hours post insult

Question 7

Early signs of ARDS

Answer 7

Dyspnea and tachypnea are early signs

Question 8

S/S of ARDS

Answer 8

Progressive respiratory distress
Hypoxia
Hypercapnia
Agitation, confusion, and lethargy

Question 9

Diagnostic Tests for ARDS

Answer 9

ABG analysis to determine oxygen levels

Chest x-ray to determine fluid in lungs

Blood tests such as CBC, blood chemistry, and blood cultures

Sputum culture to determine cause of infection

Question 10

Pharmacological Therapy

Answer 10

No definitive drug therapy

Nitric oxide

• Reduces intrapulmonary shunting
• Improves oxygenation

Surfactant therapy

NSAIDS and corticosteroids are being studied

Question 11

Nonpharmacologic Therapy

Answer 11

Mechanical ventilation
Artificial airways
Proper nutrition
Adequate amounts of fluids
Other clinical therapies

Question 12

The mainstay of ARDS management is

Answer 12

Mechanical Ventilation

Question 13

Types of ventilators
Negative vs Positive pressure
Noninvasive

Answer 13

Negative-pressure ventilators
*Create negative pressure externally to draw chest outward and air into lungs

Positive-pressure ventilators
*Push air into lungs

Noninvasive ventilation (NIV)

• Uses face mask
• Sleep apnea

Question 14

ARDS

What is happening?

Answer 14

A: Atelectasis
R: Refractory hypoxemia (hallmark sign)
D: Decreased lung compliance
S: Decreased surfactant

Question 15

Complications of Mechanical Ventilation
Why?
HAP
Barotrauma, pneumothorax
Cardiovascular effects
GI effects

Answer 15

Hospital-acquired pneumonia (HAP): loss of humidity and filtering from upper airway
Barotrauma: PEEP
Pneumothorax: PEEP
Cardiovascular effects: Increased pressure in the chest decreases cardiac output
Gastrointestinal effects: Misplacement of tube (monitor for abdominal distention)

Question 16

Artificial Airways
What do they do?
Oropharangeal vs Naropharangeal

Answer 16

Inserted to maintain patent air passage

Oropharyngeal airways
*Stimulate gag reflex

Nasopharyngeal airways

• Better tolerated by alert clients
• Frequent oral care important

Question 17

Artificial Airways

Endotracheal tubes

Answer 17

General anesthesia, emergency situations
Specialized education to insert
Guided by laryngoscope
Client unable to speak while tube in place

Question 18

Artificial Airways

Tracheostomies

Answer 18

Long-term airway support
Opening to trachea through neck
Percutaneous or surgical insertion

Question 19

Nursing Considerations

Fluids and Nutrition

Answer 19

Monitor I & O
Renal perfusion
Catheter
Arterial line

Question 20

What effect does Mechanical Ventilation have on Cardiac Output?

Answer 20

increased intrathoracic pressure can decrease CO sec return of blood to the heart. Urine Output is an early sign.

Question 21

Other Clinical Therapies for ARDS
Position?
Medications?
I/O?
Swan Ganz?

Answer 21

Prone positioning

Antibiotics
Low-molecular-weight heparin

Careful fluid replacement
Attention to nutrition

Swan-Ganz line to monitor

• Pulmonary artery pressures
• Cardiac output

Question 22

Weaning from ventilator support
When to start?
Why wean?

Answer 22

When: Begins after underlying process corrected

T-piece, CPAP
SIMV, PSV

Why: Reconditioning respiratory muscles
Terminal weaning

Question 23

Modes with positive pressure ventilators

Answer 23

Continuous positive airway pressure (CPAP)
Bilevel ventilator (BiPAP)
Assist-control mode ventilation (ACMV)
Synchronized intermittent mandatory ventilation (SIMV)
Positive end-expiratory pressure (PEEP)
Pressure-support ventilation (PSV)
Pressure-control ventilation (PCV)

Question 24

Ventilator settings

Answer 24

Rate, tidal volume, oxygen concentration

12–15 ventilator breaths per minute initially

Question 25

Symptoms of Barotrauma | *Pneumothorax

Answer 25

Tracheal Deviation Asymmetrical Chest Rise Absent Lung Sounds Rice Crispies from air trapped

Question 26

Aspirating secretions through a catheter When to suction? Effects on patient?

Answer 26

Sterile technique Open-tipped, whistle-tipped Yankauer device for oral suctioning Nursing decision to suction * Based on clinical need, not fixed schedule * Suctioning irritates mucous membranes Uncomfortable for patient Patient may feel panicked by loss of oxygen

Question 27

Nursing diagnoses may include: ``` Risk for _____ Ineffective _____ Ineffective _____ Impaired _____ Decreased _____ Dysfunctional _____ Imbalanced _____ Acute _____ ```

Answer 27

Nursing diagnoses may include: ``` Risk for Acute Confusion Ineffective Airway Clearance Ineffective Breathing Pattern Impaired Gas Exchange Decreased Cardiac output Dysfunctional Ventilator Weaning Response Risk for Imbalanced Fluid Volume Imbalanced Nutrition: Less Than Body Requirements Risk for Infection Acute Pain Anxiety ```

Question 28

Client Goals with Planning ``` Be oriented _____ Receive adequate _____ Be free of ______ Maintain _____ Maintain _____ Receive adequate _____ Be free of _____ Have no development of _____ Manage _____ Cope with or be free from _____ ```

Answer 28

Goals may include that client will: ``` Be oriented with each interaction Receive adequate ventilatory support Be free of pulmonary tissue damage Maintain patent airways Maintain adequate cardiac output Receive adequate nutrition Be free of signs, symptoms of infection Have no development of thrombosis Manage pain successfully Cope with or be free from anxiety ```

Question 29

Common Interventions Monitor-

Answer 29

Lab work and specimens Suction airways as needed Monitor * Vital signs hourly * Oxygenation status * Neurological status * Lung and heart sounds

Question 30

Position Interventions

Answer 30

Maintain HOB at 30° or higher Prone position as tolerated 3–4x/day

Question 31

Common Medication Interventions

Answer 31

Provide analgesia, anxiolytics, sedation Beta-agonist to maintain patent airways

Question 32

Common Interventions Fluid balance? Glucose levels? Pulses?

Answer 32

Monitor hemodynamic status Monitor renal function Place Foley catheter IV fluids as needed Monitor glucose levels Assess peripheral pulses

Question 33

Interventions | Maintain patent airway

Answer 33

Maintain patent airway * Suction as needed * Obtain sputum for culture * Chest physiotherapy as ordered * Secure endotracheal or tracheostomy tube * Maintain adequate hydration

Question 34

Interventions | Promote spontaneous ventilation

Answer 34

Promote spontaneous ventilation Assess, document Respiratory rate, VS, O2 saturation every 15–30 minutes Promptly report worsening data Administer O2 as ordered, monitor response Place in Fowler or high-Fowler Minimize activity, energy expenditures

Question 35

ARDS Pneumonic

Answer 35

A- atelectasis R- refractory hypoxemia D- decreased lung compliance S- surfactant (damaged)