Pangpangdeo Shanne Delle B. - Worksheet 5 Ards

Vision: A PREMIER UNIVERSITY delivering
“Excellent nursing education that

world-class education that promotes
provides graduates with self-
sustainable development amidst climate
change.
Benguet State University direction, competence and
compassion.”
Mission: To provide quality education to COLLEGE OF NURSING
enhance food security, sustainable La Trinidad, Benguet “The College of Nursing is committed
communities, industry innovation, climate to provide a strong academic and
resilience, gender equality, institutional
www.bsu.edu.ph/ 422- 2127 professional foundation for the
development and partnerships. practice of nursing.”
NCM 112
Care of clients with problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory
and immunologic response, Cellular Aberrations, Acute and Chronic.
ACUTE RESPIRATORY DISTRESS SYNDROME

Occurs after an acute lung injury (ALI) as a traumatic event in people who have no pulmonary disease
Key Features:
Hypoxemia that persists even with 100% oxygen
Decreased pulmonary compliance (elasticity) risk to develop alveolar collapse (flat alveoli)
Dyspnea
Non-cardiac associated bilateral pulmonary edema
Dense pulmonary infiltrates on x-ray (ground class appearance)
RISK FACTORS: Common Causes of Acute Lung Injury (ALI)
A -Aspiration of gastric contents (gastric contents enter in the airways or respiratory system)
-Anaphylaxis (antigen-antibody reaction related to food or drug reaction)
R
-Respiratory trauma (common cause) (ex. Pulmonary embolism, fat embolism))
-Radiation
D
-Drowning
-Disseminated intravascular coagulation (DIC)
-Drug overdose (heroin, opioids, aspirin)
S
-Smoke inhalation/ inhalation of hot steam during fire/ Inhalation of toxic gases
-Sepsis (most common cause)
-Shock
Main site of injury: Alveolar-Capillary membrane

(normally this membrane is permeable [allowing] only to small molecules)
Damage to the Alveolar-Capillary membrane Damage Type II pneumocytes

(Despite different causes of acute lung injury (Normally: These cells produce surfactant
(ALI), the result is systemic inflammatory disease. Surfactant: substance that increases lung
ARDS manifestations are similar regardless of the compliance (elasticity) and prevents alveolar
cause. collapse ([flattening])
Activation of inflammatory response

Surfactant activity is reduced due to:
(Release of chemical mediators:
1. Type II pneumocytes are damaged.
histamine, bradykinin, prostaglandin)
2. Surfactant is diluted by excess lung
fluids (fluid shifting related to
inflammatory response)
Increased permeability of pulmonary blood
vessels -closely packed endothelial cells that
lines blood vessels become loosely packed
(gap formation) where fluid from intravascular Alveoli becomes:
(inside blood vessels) shifts to the alveoli. 1. Collapsed (due to decreased lung
surfactant)
2. Fluid-filled (due to fluid shifting)
Fluid shifting (allows large molecules such as
proteins and fluids to leak out from the blood
vessels into the interstitium and alveoli) Fluid continues to leak in more lung areas and in
the spaces between the alveoli.
Pulmonary edema
Hypoxemia (Low O2 in the blood)
(Lung tissue normally remains relatively dry)
Patients with ARDS: lung fluid increases and to hypoxia (Low O2 in the tissues)
contains more proteins (fluid shifting secondary
to inflammatory response) pulling the water into
the alveoli.
Read chapter review and search for images to understand this
pathophysiology. ACUTE RESPIRATORY DISTRESS
change.
compassion.”
SELF-REFLECTIVE ACTIVITIES
DECISION MAKING CHALLENGE

Case scenario
The patient is a 21-year-old college student who went swimming in his apartment complex
swimming pool after drinking 10 cans of beer. He hit his head on the side of the pool and was
under water for about 2 minutes before his friends pulled him out.
During CPR, he vomited a large amount of gastric fluids before the emergency squad came
to the scene.
In the emergency department, he is unconscious and breathing on his own. Oral, nasal, and
tracheal suctioning has produced stomach contents and fluid that smells strongly of chlorine.
On auscultation, wheezes and mild crackles are present.

The chest x-ray is normal, and these are the ABG values:
pH = 7.28
PaO2 = 88 mm Hg
PaCO2 = 58 mm Hg.
PART 1: CRITICAL THINKING ASSESSMENT
1. What factors could contribute to an acute lung injury in this patient?

The factors that contributed to an acute lung injury of the patient is being submereged in the water or
drowning and aspiration of gastric contents.
2. Is this patient at risk for TRALI? Why or why not?

The patient is not at risk for TRALI because their is no indication that the patient has undergone
blood transfusion since TRALI is associated with the activation of inflammatory response due to
recent transfusion of plasma-containing products and usually occurs within 6 hours of transfusion.
3. What is your interpretation of the ABG results?

Based from the ABG results, having a pH 7.28 and an PaCO2 of 58 mmHg results to respiratory
acidosis. Respiratory acidosis occurs during emergency situations such as acute respiratory
distress syndrome. Since the patient suffered from acute lung injury that led to ARDS, this is
a data that suports the interpretation of the ABG results.
change.
compassion.”
4. Why does the current chest x-ray show no abnormalities?

During the CPR, the patient vomited large gastric contents which means that there is a mistake
during the CPR wherein his stomach was compressed since the one who did the CPR was one
of the patient's friend and not the rescue team. Usually when you do CPR on a patient
who drowned they are supposed to cough out water and not gastric contents. The gastric contents
in the patients stomach has more likely higher acidity since he drank 10 cans of beer before
drowning. Due to gastric contents are acidic, there is a tendency that it will damage the lungs
because the patient vomited large amounts of it. However, since the patient drowned, there is
automatically water on his lungs which prevents the gastric contents from burning the lungs which
is reason why the chest x-ray shows no abnormalities.
5. Should this patient be intubated and mechanically ventilated at this time? Why or
why not?
Yes, the patient needs to be intubated and mechanically ventialyed at this time since he is
suffering from ARDS. The patient with ARDS often needs intubation and mechanical ventilation
with positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP).
This is a standard therapy in order to maintain adequate gas exchange during ARDS.
6. What are your care priorities for this patient at this time?
The care priorities for this patient at this time is the early recognition if the patient is high at risk for the
syndrome since the patient aspirated gastric contents and this indicates that patients who aspirate
gastric contents are at great risk.
PART 2: PATIENT-CENTERED COLLABORATIVE CARE

ASSESSMENT AND NURSING DIAGNOSIS
1. What are the clinical manifestations of patient with ARDS? Enumerate at least 7 physical
assessment finds.
1. Hyperpnea
2. Noisy respirations
3. Pallor
4. Cyanotic
5. Hypotention
6. Tachycardia
7. Dysrythmias
2. Enumerate at least 3 nursing diagnosis of patient with ARDS:

change.
compassion.”
a. 2 actual nursing diagnosis

Ineffective breathing pattern
i. ___________________________________________
Impaired gas exchange
ii. ___________________________________________
b. 1 potential nursing diagnosis

Anxiety
i. ___________________________________________
3. What are the common drugs used in patient with ARDS?

1. Human recombinant interleukin-1 receptor antagonist
2. Neutrophil inhibitors
3. Pulmonary-specific vasodilators
4. Surfactant replacement therapy
5. Antisepsis agents
6. Antioxidant therapy
4. What is the usual diet?

Adequate nutritional support us vital in the treatment of ARDS. Patients with ARDS requires
35-45 kcal/kg per day to meet caloric requirements. Enteral feeding is the first
consideration; howver, parenteral nutrition may also be required.
MEDICAL AND NURSING INTERVENTIONS

The patient with ARDS often needs intubation and conventional mechanical ventilation with
positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP). This
intervention will improve oxygenation and ventilation in patients with moderate to severe
ARDS.
PART 3: MECHANICAL VENTILATION

1. Which assessment finding in a client with an endotracheal tube most strongly indicates to
the nurse that the tube remains correctly in the trachea and is not in the esophagus?
A. Stomach contents cannot be aspirated.
B. Oxygen saturation is greater than 50%.
C. End-tidal carbon dioxide level is 38 mm Hg.
D. No air is heard in the stomach when auscultated with a stethoscope.
change.
compassion.”
2. What is the purpose of mechanical ventilator during an acute lung injury?

Mechanical ventilator is used during an acute lung injury in order to improve gas exchange and to
decrease the work needed for effective breathing. It is used to support the patient until the patient
can resume the process of breathing on his or her own.
3. Positioning is important in promoting gas exchange in patient receiving mechanical

ventilation after an acute lung injury. What is the best position for patient in mechanical
ventilation?
Thes best position for patient in mechanical ventilation is "good lung down" postition. It is used
to optimize ventilation-perfusion matching. In this position, the majority of blood flow will go
to the lungs and result in best oxygenation.
5. What are your independent nursing interventions when caring for a patient receiving
mechanical ventilation? List at least 5 independent nursing interventions with rationale.
Take vital signs atleast every 4 hours in order to determine if there are any changes with the patient.
a. _________________________________________________________________________
Maintain head of the bed more than 30 degrees when patient is supine to prevent aspiration and ventilator-associated pneumonia.
b. _________________________________________________________________________
Check at least every 8 hours to be sure the ventilator setting is as prescribed
c. _________________________________________________________________________
Maintain accurate intake and output records to monitor fluid balance.
d. _________________________________________________________________________
Turn the patient at least every 2 hours, and get the patient out of bed as
e. _________________________________________________________________________
prescribed to promote pulmonary hygiene and prevent complications of immobility.
PART 4: MODES OF VENTILATION
INSTRUCTION: Define the following terms and explain in 3 sentences using your own words
MODE DEFINITION
Assist-control Assist-control ventilation is one of the mode mechanical ventilation.
The patient's breathing pattern may cause the ventilator to
deliver a certain volume of air that is inhaled and exhaled each
breath. When there is an absence of consecutive breathings, the
ventilator delivers a certain tidal volume.
Synchronized intermittent Synchronized intermetten mandatory ventilation allows the

mandatory ventilation (SIMV) patient to breathe at the same time. While allowing the
patient to breathe at the same time, it also provides certain
number of breaths. This ensures the adequate ventilation.
change.
compassion.”
Bi-level Positive airway pressure It is a type of ventilator that can help push air into the lungs.
(BiPAP) The patient will wear a mask or nasal plugs that is connected
to the ventilator. It supplies pressurized air into your
aiways.
DEFINITION OF TERMS
INSTRUCTION: Define the following
VENTILATOR CONTROLS AND

SETTINGS
1. Tidal Volume (VT) The volume of air inhaled and exhaled with each breath.
2. Rate or breaths/minute The number of movements indicative of inspiration and expiration

per unit time.
3. Fraction of Inspired Concentration of oxygen delivered (1.0=100% oxygen)

Oxygen (FiO2)
4. Peak airway (inspiratory) Highest level pressure applied to the lungs during inhalation.
pressure (PIP)
5. Continuous positive A respiratory treatment that improves obstructive sleep

airway pressure (CPAP) apnea in patients with heart failure.
6. Positive end-expiratory Positive end-expiratory pressure maintained by the ventilator at

pressure (PEEP) the end of exhalation to increase functional residual capacity and
open collapsed alveoli
7. Flow rate The volume of fluid which passes per unit time.
change.
compassion.”
PART 5: COMPLICATIONS OF MECHANICAL VENTILATION

The following items are complications of mechanical ventilation. Explain the following items briefly using
3-4 sentences only.
1. Cardiac problems
 What is the cause of hypotension if the patient is hooked to mechanical ventilator?
Hypotension is caused by possitive pressure that increases chest pressure and prevents
the blood return to the heart. The decreased blood return is the one causing hypotension.
In order to avoid hypotention, teach the patient to avoid bearing down while holding
their breath.
 What is the reason why patients develop fluid retention during mechanical ventilation?
Fluid is being retained due to decreased cardiac output. The kidney receive less blood
flow which stimulates the renin-angiotensin-aldosterone system to retain fluid. The
humidifier air in the ventilator also contributes in fluid retention.
2. Lung problems
 What is the cause of barotrauma during mechanical ventilation?
Barotrauma is the damage to the lungs by positive pressure. The cause of borotrauma during
mechanical ventilation is due to the requirement of high pressure to ventilate the lungs since
it shows that patient with ARDS has stiff lungs.
 Why do patients hooked to ventilators develop pneumonia?

Infections are a threat for the patient using a ventilator, especially ventilator-associated
pneumonia (VAP). The ventilator provides a direct access for the bacteria to enter the
lower respiratory system. The artificial airway is being colonized by bacteria within 48
hours which promotes pneumonia.
3. Gastrointestinal problems
 Explain why patients develop stress ulcer or gastric ulcer when they receive mechanical
ventilation.
Gastrointestinal problems result from the stress of mechanical ventilation. Stress ulcers occur
in many patients receiving mechanical ventilation. These ulcers complicate the nutrition
status and, because the mucosa are not intact, increase the risk for systemic infection.
4. Ventilator dependence
 Why do patients develop ventilator dependence?
Ventilator dependence is the inability to break off from ventilator. The longer a patient uses a
ventilator, the more difficult the weaning process is because the respiratory muscles fatigue
and cannot assume breathing. Weaning is the process of going from ventilatory dependence to
spontaneous breathing.

Pangpangdeo Shanne Delle B. - Worksheet 5 Ards

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Pangpangdeo Shanne Delle B. - Worksheet 5 Ards

Uploaded by

Copyright:

Available Formats

Vision: A PREMIER UNIVERSITY delivering

“Excellent nursing education that

ACUTE RESPIRATORY DISTRESS SYNDROME

RISK FACTORS: Common Causes of Acute Lung Injury (ALI)

Main site of injury: Alveolar-Capillary membrane

Damage to the Alveolar-Capillary membrane Damage Type II pneumocytes

Activation of inflammatory response

DECISION MAKING CHALLENGE

On auscultation, wheezes and mild crackles are present.

PART 1: CRITICAL THINKING ASSESSMENT

1. What factors could contribute to an acute lung injury in this patient?

2. Is this patient at risk for TRALI? Why or why not?

3. What is your interpretation of the ABG results?

4. Why does the current chest x-ray show no abnormalities?

PART 2: PATIENT-CENTERED COLLABORATIVE CARE

2. Enumerate at least 3 nursing diagnosis of patient with ARDS:

a. 2 actual nursing diagnosis

b. 1 potential nursing diagnosis

3. What are the common drugs used in patient with ARDS?

4. What is the usual diet?

MEDICAL AND NURSING INTERVENTIONS

PART 3: MECHANICAL VENTILATION

2. What is the purpose of mechanical ventilator during an acute lung injury?

3. Positioning is important in promoting gas exchange in patient receiving mechanical

Synchronized intermittent Synchronized intermetten mandatory ventilation allows the

VENTILATOR CONTROLS AND

2. Rate or breaths/minute The number of movements indicative of inspiration and expiration

3. Fraction of Inspired Concentration of oxygen delivered (1.0=100% oxygen)

5. Continuous positive A respiratory treatment that improves obstructive sleep

6. Positive end-expiratory Positive end-expiratory pressure maintained by the ventilator at

PART 5: COMPLICATIONS OF MECHANICAL VENTILATION

 Why do patients hooked to ventilators develop pneumonia?

You might also like