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RESPIRATORY FAILUREARDS

Highline Nursing ProgramN241

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Contents

� Definitions and defining characteristics

� Complications of S/S’s

� Interventions

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Respiratory Failure

� Any impairment in oxygenation or ventilation in the lungs

� PaO2, PaCO2, pH

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Causes for Hypoxic Resp. Failure

◦ Ventilation-perfusion mismatch

◦ Shunt

◦ Diffusion limitation

◦ Alveolar hypoventilation

◦ Combination

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Causes of Hypercapnic Resp. Failure

� Imbalance between ventilatory supply and demand

� Airways and alveoli� Central nervous system� Chest wall� Neuromuscular conditions

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Clinical Manifestations

� Sudden vs. Gradual� Hypoxemia vs. Hypercapnea◦ Hypoxemia: Dyspnea, neurological Sx, initial

tachycardia and HTN, may progress to dysrhythmia, hypotension, decreased CO

◦ Hypercapnea: Dyspnea and headache early, decreased LOC, pursed-lip breathing

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Diagnostic Studies

� History and physical assessment� ABG analysis� Chest x-ray � CBC, BMP � Sputum/Blood cultures� ECG� Urinalysis� V/Q lung scan� Pulmonary artery catheter

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Interventions

� Medications: • Bronchodilators, Corticosteroids • Diuretics, nitrates if heart failure present• IV antibiotics• Benzodiazepines, Narcotics� O2: � Airway management: Hydration,

humidification, Chest physical therapy, Airway suctioning, Effective coughing and positioning

� Mechanical ventilation: PPV, BiPAP, CPAP� Nutritional

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Augmented Cough

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Noninvasive PPV

� Bi-phasic positive airway pressure (BiPAP)

� Continuous positive airway pressure (CPAP): PEEP (positive end-expiratory pressure)

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Types of Ventilators

� Settings: rate, tidal volume, FiO2

� Negative pressure

� Positive pressure

◦ Endotracheal tube, tracheostomy

◦ In acute respiratory failure

◦ Trigger: ventilator-assisted breath vs. ventilator-controlled breath

◦ Cycle (duration of inspiration): volume controlled, pressure-cycled

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Complications of mechanical ventilation � Improper ET tube placement

� Nosocomial pneumonia

� Barotrauma

� Decreased cardiac output

� GI distress 12/5/2011 15

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Care of client on ventilator

� Monitoring of ventilator function

� Continuous assessment of O2 sat, lung

� Suction

� Sedation, emotional support

� Means of communication 12/5/2011 16

Weaning from the ventilator

� Underlying problem must be corrected or stabilized.

� Readiness for weaning:

� T-piece or CPAP

� SIMV, PSV

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Gerontologic Considerations

� Physiologic aging results in◦ ↓Ventilatory capacity◦ Alveolar dilation◦ Larger air spaces◦ Loss of surface area ◦ Diminished elastic recoil◦ Decreased respiratory muscle strength ◦ ↓ Chest wall compliance

� Lifelong smoking� Poor nutritional status� Less available physiologic reserve◦ Cardiovascular◦ Respiratory◦ Autonomic nervous system

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Nursing Diagnoses

◦ Impaired gas exchange◦ Ineffective airway clearance◦ Ineffective breathing pattern◦ Risk for fluid volume imbalance◦ Anxiety◦ Imbalanced nutrition: Less than body

requirements

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CASE � 75 YO male has a long history of COPD.� He develops a respiratory infection that is

unresponsive to treatment.� He is admitted to the ED in moderate

respiratory distress◦ RR of 32, shallow respirations, anxious,

can barely talk, uses his accessory muscles.◦ His wife is yelling at the health care team

to “do something or he will die”� ABG: pH 7.14, PaO2 58, PaCO2 60, O2 sat

85%

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1. What type of respiratory failure does he have?

2. What could have prevented this from happening?

3. What is his priority of care?

4. When he is stable, what teaching should be done for him and his wife?

5. What is his priority of care?

6. What may be needed for improved CO?

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ACUTE RESPIRATORY DISTRESS SYNDROME

(ARDS)

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Acute Respiratory Distress Syndrome

� Sudden progressive form of acute hypoxemic respiratory failure

� Alveolar capillary membrane becomes damaged and more permeable to intravascular fluid

� No pharmacologic therapeutic protocol

� Mortality > 50% 12/5/2011 23

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Definition

�

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Statistics

� 10%-15% of ICU

� 20% of mechanically ventilated

� $5 billions/year for healthcare costs

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CLINICAL DISORDERS COMMONLY ASSOCIATED WITH ARDS

Direct Lung Injury Indirect Lung Injury

PneumoniaAspiration of gastric contentsPulmonary contusionNear-drowningToxic inhalation injury

SepsisSevere traumaMultiple bone fracturesFlail chestHead traumaBurnsMultiple transfusionsDrug overdosePancreatitisPost-cardiopulmonary bypass

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Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.12/5/2011 28

PathophysiologyInjury or exudative phase:

• Neutrophils adhere to pulmonary microcirculation

• Damage to vascular endothelium

Reparative or proliferative phase

• Interstitial and alveolar edema: noncardiogenic

• Atelectasis resulting in V/Q mismatch

• refractory hypoxemia

Fibrotic or chronic/late phase

• ↓ Lung compliance, Pulmonary hypertension from

pulmonary vascular destruction and fibrosis12/5/2011 29

Clinical Manifestations: Early

� Subjective Sx:

� Assessment:

� Hx:

� Tests:

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Clinical Manifestations: Late

� Subjective Sx:

� Assessment:

� Tests:

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Chest X-Ray of Person with ARDS

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Interventions

� Goals:

� Oxygen

� Mechanical Ventilation

� Fluid management

� Positioning

� Treat underlying causes

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Positioning

� Proning

� Continuous lateral rotation

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Oxygen Toxicity

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Complications of ARDS

� Hospital-acquired pneumonia � Barotrauma � Volu-pressure trauma � High risk for stress ulcers � Renal failure

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Nursing Diagnoses

� Ineffective airway clearance� Ineffective breathing pattern� Risk for fluid volume imbalance� Anxiety� Impaired gas exchange� Imbalanced nutrition: Less than body

requirements

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CASE

� 82 Y female brought to the ED from a LTC.

� 4 DA, aspirated her lunch and has been coughing ever since.

� 2 DA, diagnosed with aspiration pneumonia

� started on empiric antibiotic therapy of azithromycin (Zithromax)

� During the past 24 hours, has developed progressive dyspnea and restlessness

� On admission to the ED, confused and agitated, at times she is gasping for air.

� Chest x-ray shows diffuse infiltrates12/5/2011 38

1. Why was she at risk for ARDS?

2. What is her priority of care?

3. What is the goal of her treatment?

4. What are some possible complications that she could develop?

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Slide 40

Hypoxemic respiratory failure is most likely to occur in the patient who has

1. a massive pulmonary embolism.

2. slow, shallow respirations as a result of sedative overdose.

3. respiratory muscle paralysis.

4. thoracic trauma with flail chest.

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Slide 41

A patient with severe chronic lung disease is hospitalized in respiratory distress. The nurse suspects rapid decompensation of the patient upon finding

1. a SpO2 of 86%.

2. blood pH of 7.33.

3. agitation or confusion.

4. a change in PaCO2 level from 48 mm Hg to 55 mm Hg.

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Slide 42

A patient’s arterial blood gas (ABG) results include pH 7.31, PaCO2 50 mm Hg, PaO2 51 mm Hg, and HCO3

24 mEq/L. Oxygen at 2 L/min is administered and the patient is placed in high-Fowler’s position. An hour later the ABGs are repeated with results of pH 7.36, PaCO2 40 mm Hg, PaO2 60 mm Hg, and HCO3 24 mEq/L. It is most important for the nurse to take which of the following actions?

1. Increase the oxygen flow rate to 4 L/min.

2. Prepare the patient for endotracheal intubation and mechanical ventilation.

3. Document the findings in the patient’s record.

4. Reposition the patient in a semi-Fowler’s position. 12/5/2011

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Slide 43

When assessing a patient with sepsis which of the following findings would alert the nurse to the onset of acute respiratory distress syndrome (ARDS)?

1. Use of accessory muscles of respiration

2. Fine, scattered crackles on auscultation of the chest

3. SpO2 of 80%

4. ABGs of pH 7.33; PaCO2 48 mm Hg, and PaO2 80 mm Hg

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SIRS and MODSHighline Community College

Nursing Program

N241

Contents

� Review the definition of SIRS

� MODS- summarize the S/S’s, tests, and interventions of failing organs/systems.

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SIRS can be diagnosed when two or more of the following are present.

(1) Heart rate > 90/ min(2) Body temperature < 36 or > 38°C(3) Hyperventilation > 20/min or PaCO2 < 32 mm Hg(4) WBC count < 4000 cells/mm3 or > 12000 cells/mm3, or immature neutrophils > 10%

SIRS and MODS

SIRS (Systemic Inflammatory Response Syndrome) � Systemic inflammatory response to a variety

of insults� Generalized inflammation in organs remote

from the initial insult

MODS (Multiple organ dysfunction syndrome)� Results from SIRS� Failure of two or more organ systems� Homeostasis cannot be maintained without

intervention

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Causes for SIRS

◦ Mechanical tissue trauma: burns, crush injuries, surgical procedures◦ Abscess formation: intra-abdominal, extremities◦ Ischemic or necrotic tissue: pancreatitis, vascular

disease, myocardial infarction◦ Microbial invasion: Bacteria, viruses, fungi◦ Endotoxin release: Gram-negative bacteria◦ Global perfusion deficits: Post–cardiac

resuscitation, shock states◦ Regional perfusion deficits: Distal perfusion

deficits

Pathophysiology

� Inflammatory response◦ Release of mediators◦ Direct damage to the endothelium◦ Vasodilation leading to decreased SVR ◦ Increase in vascular permeability ◦ Activation of coagulation cascade

� Hypermetabolic state◦ Hyperglycemia–hypoglycemia◦ Catabolic state◦ Liver dysfunction◦ Lactic acidosis

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Interventions

� Vigilant assessment and detect early signs

� Maintenance of tissue oxygenation

� Enhance CO

� Nutritional and metabolic needs

� Support of failing organs

CASE

� 28 YO female, brought to the ED by her mother with confusion, fever, and “flu for past week”.

� She has been vomiting for the past 2 days and has noted generalized edema.

� BP 88/54, HR 112, Temp 103.5°F, RR 24� Chest x-ray shows bilateral infiltrates.� WBC and lactic acid elevated

� She is admitted to the ICU with R/O sepsis.

� Urine output: amber, 15 ml/2 hr.

1. Nurse notes petechiae and jaundiced skin. What do these signs indicate?

2. What are some treatments that you would anticipate being done for her?

3. How should she receive nutritional support? How would the blood glucose be affected?

4. What can you do to prevent further infections?

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.12/5/2011 28