Module 2 ARDS Online CASE Study PDF

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8-2 Acute Respiratory Distress Syndrome (ARDS) CRITICAL CARE/HIGH ACUITY MEDICAL-SURGICAL STANDARD FORMS These templates are included in the Appendix; copy before each use.

LEARNING OUTCOMES Cognitive The participant will be able to: 1. Describe signs and symptoms of ARDS. 2. Correlate signs and symptoms of ARDS to the pathphysiology of ARDS. 3. Identify factors in a patient’s history that increase risk for ARDS. 4. Explain factors in a patient’s current condition that increase risk for ARDS. 5. Relate appropriate interventions for the patient with ARDS. 6. Differentiate the roles of team members in response to a patient with ARDS.

Psychomotor The participant will be able to: 1. Demonstrate appropriate assessment for a patient with ARDS. 2. Initiate appropriate interventions (respiratory assessment, gather appropriate assessment data and notify physician, prioritize physician orders, demonstrate appropriate collection of specimens, accurately calculate and administer medications) for a patient with ARDS. 3. Work collaboratively as part of the healthcare team in the care of a patient with ARDS.

Affective The participant will be able to: 1. Reflect upon performance in the care of a patient with ARDS. 2. Identify personal feelings in delivering care to a patient with ARDS. 3. Discuss feelings related to working as a member of a team in the care of a patient with ARDS. 4. Identify factors that worked well during the simulation of care of a patient with ARDS. 5. Identify factors that needed improvement during the simulation of care of a patient with ARDS. 6. Develop self-confidence in the care of a patient with ARDS.

Communication The participant will be able to: 1. Communicate effectively with healthcare team members in the care of a patient with ARDS. 2. Communicate effectively with the patient and family in the care of a patient with ARDS. 3. Utilize effective cross-cultural communication techniques with a client and family of Vietnamese descent. 4. Model family responses to hospitalization for the client with ARDS (family member). 5. Use SBAR format when communicating with team members in the care of a patient with ARDS. 6. Practice Transparent Thinking (thinking out loud) to facilitate group problem solving. 7. Use Directed Communication (directing a message to specific individual) when delegating tasks. 8. Employ Closed-Loop Communication (acknowledgment of receipt of the message and status) to acknowledge communications from others.

Safety The participant will be able to: Administer and maintain specific protecting interventions with attention to safety of the client and healthcare professional. 1. Demonstrate a safe environment with attention to hazards to healthcare providers, visitors, and the client. Includes body mechanics, tripping hazards, and equipment issues. 2. Demonstrate attention to national patient safety goals. Includes patient identification standards, effective communication among healthcare providers, and safe medication administration. 3. Demonstrate attention to standard precautions. Includes hand washing, infection control measures, and use of personal protective equipment (PPE) as needed.

Leadership and Management/Delegation The participant will be able to: 1. Identify and prioritize patient’s needs in care of a patient with ARDS. 2. Identify tasks that can be legally, ethically, and safely delegated to unlicensed assistive personnel (UAP) or licensed practical nurse (LPN) in the care of a patient with ARDS.

OVERVIEW OF THE PROBLEM Definition ARDS is characterized by noncardiogenic pulmonary infiltrations resulting in stiff wet lungs and refractory hypoxemia in an adult who was previously healthy. Acute hypoxemic respiratory failure occurs without hypercapnia.

Pathophysiology ■ Damage to alveolar capillary membrane ■ Increased vascular permeability creating noncardiac pulmonary edema and impaired gas exchange ■ Decreased surfactant production ■ Atelectasis ■ Severe hypoxia refractory to decreased FiO2 ■ Possible death

Risk Factors Primary ■ Shock, multiple trauma ■ Infections ■ Aspiration, inhalation of chemical toxins ■ Drug overdose ■ Disseminated intravascular coagulation (DIC) ■ Emboli, especially fat emboli

Secondary ■ Overaggressive fluid administration ■ Oxygen toxicity

Assessment Subjective ■ Restlessness, anxiety ■ History of risk factors ■ Severe dyspnea

Objective ■ Cyanosis ■ Tachycardia ■ Hypotension ■ Hypoxemia, acidosis

■ Crackles ■ X-ray: bilateral patchy infiltrates ■ Death if untreated

Diagnostic Tests ■ ABG ■ Chest x-ray ■ CBC ■ Metabolic panel

Treatment ■ Oxygen ■ Antibiotics ■ Sedation/analgesics ■ Bronchodilators ■ Low molecular weight heparin (DVT prophylaxis) ■ Steroids ■ Diuretics

Nursing Management Goal: Assist in respirations. ■ Intensive care unit ■ Mechanical ventilation ■ Positive end expiratory pressure (PEEP) ■ Oxygen ■ Monitor blood gases ■ Suctioning ■ Cough and deep breathe ■ Rotation therapy and/or prone position Goal: Prevent complications ■ Monitor for and prevent gastrointestinal bleeding ■ Monitor for and correct acidosis ■ Monitor for dysrhythmias ■ Decrease anxiety, conserve energy, calm atmosphere, comfort, and emotional support

■ Hemodynamic monitoring (central venous and pulmonary artery pressures) ■ Maintain fluid balance ■ Accurate I&O: Assess for bleeding tendencies (potential for disseminated intravascular coagulation) ■ Protect from infection (aseptic technique, DVT prophylaxis) ■ Maintain nutrition ■ Skin care Goal: Health teaching. ■ Procedures ■ Follow-up care ■ Risk factors

Evaluation/Outcome Criteria ■ Alert and oriented ■ Skin warm to touch ■ Respiratory rate and other assessments within normal limits ■ Urine output >30 mL/hr

REVIEW QUESTIONS 1. Describe the pathophysiology of ARDS. Answer: ■ Damage to alveolar capillary membrane ■ Increased vascular permeability creating noncardiac pulmonary edema and impaired gas exchange ■ Decreased surfactant production ■ Atelectasis ■ Severe hypoxia refractory to decreased FiO2 ■ Possible death 2. Identify five potential causes of ARDS. Answer: ■ Shock, multiple trauma ■ Infections ■ Aspiration, inhalation of chemical toxins ■ Drug overdose

■ Disseminated intravascular coagulation (DIC) 3. Describe the progression sequence of ARDS (onset/exudative phase, progression/fibroproliferative phase, resolution) with associated clinical manifestations, and laboratory/diagnostic findings of each phase. Answer: Complete the table on page 339.

Phase

Clinical Manifestations

Onset/Exudative

The exudative phase occurs typically within 24 to 48 hours after injury.

Laboratory/Diagnostic Findings

Arterial blood gasses reveal a respiratory alkalosis. Cardiac output increases in an attempt to increase blood flow through the lungs. The chest x-ray reveals the The alveolar and interstitial edema results in a increased alveolar fluid as bilateral infiltrates and is severe V/Q mismatch; inadequate ventilation referred to as pulmonary edema. Unlike the pulmonary occurring in the face of adequate perfusion or edema associated with a heart failure exacerbation blood flow, which results in hypoxemia; blood there is no evidence of increased left atrial or ventricular is shunted past the fluid-filled alveoli without pressure, which would indicate left heart failure. being oxygenated. This is referred to as noncardiogenic pulmonary edema. In addition to the alveolar and interstitial edema, there is damage to the alveolar cells that produce surfactant. Clinical manifestations in this phase include tachypnea and tachycardia as a compensatory response to hypoxemia.

hypercarbia and worsening hypoxemia

Progression/Fibroproliferative Clinical manifestations in this phase include hypercarbia and worsening hypoxemia.

The chest x-ray reveals the

As the process continues, PaCO2 begins to rise increased alveolar fluid as bilateral infiltrates despite hyperventilation. Increases in delivered oxygen do not alleviate the dropping PaO2 caused by the increasingly impaired oxygen exchange across the fluid-filled and damaged ACM. This is refractory hypoxemia.

The overall result is severe tissue hypoxia and lactic acidosis.

Resolution In the fibrotic phase, there is diffuse fibrosis and scarring, resulting in greatly impaired gas exchange and compliance. Pulmonary hypertension worsens, as does the accompanying right-sided heart failure. Clinical manifestations in this phase include a decreased left-heart preload due to the right heart failure and reduced capacity of the right ventricle to deliver blood to the lungs and on to the left side of the heart. This results in a decreased blood pressure and cardiac output. The severe V/Q mismatch, diffusion defects, and intrapulmonary shunting result in refractory hypoxemia. The overall result is severe tissue hypoxia and lactic acidosis.

4. List five anticipated medical/pharmacological interventions for the client with ARDS and give rationales for each. Answer: Intervention

Rationale

1. ■ Oxygen

As of result of fluid accumulation in the alveoli, pt is hypoxic and requires supplemental O2.

2. ■ Antibiotics

Antibiotics are required if the ARDS is a result of a infection or sepsis produced by infection.

3. ■ Bronchodilators

Bronchodilators are important for easier entrance of the oxygen and helps open up the bronchi So other inhaled medications are more effective.

4. ■ Steroids

Steroids are administered in order to decrease the inflammation and the over reactive immune Response.

5. ■ Diuretics

Diuretics are administered to reduce pulmonary edema.

Related Evidence-Based Practice Guidelines CDC

Pneumonia. https://www.cdc.gov/nchs/fastats/pneumonia.htm The Joint Commission National Patient Safety Goals Hospital Program. Retrieved from https://www.jointcommission.org/standards_information/npsgs.aspx National Guideline Clearing House Pneumonia in adults: diagnosis and management. 2014 https://www.guideline.gov/summaries/summary/50009/pneumonia-in-adultsdiagnosis-and-management?q=ARDS SBAR technique for communication: A situational briefing model. The Institute for Healthcare Improvement. Retrieved from http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniquefor CommunicationASituationalBriefingModel.htm

Topics to Review Prior to the Simulation ■ Acute medical-surgical nursing, ARDS. ■ Mechanical ventilation (SIMV, PEEP). ■ Arterial blood gas interpretation. ■ Trauma, pulmonary contusion. ■ Antibiotic administration. ■ Sputum specimen collection. ■ IV sedation administration (lorazepam [Ativan], morphine IV). The Richmond Agitation and Sedation Scale: The RASS http://www.icudelirium.org/docs/CAM_ICU_worksheet.pdf

SIMULATION Client Background Biographical Data ■ Age: 55 ■ Gender: male ■ Height: 5 ft 5 in ■ Weight:14l lb

Cultural Considerations ■ Language: English and Vietnamese ■ Ethnicity: Vietnamese ■ Nationality: American ■ Culture: Vietnamese

Demographic ■ Marital status: married ■ Educational level: 6th grade ■ Religion: Buddhist ■ Occupation: shrimper

Current Health Status ■ Acute respiratory failure

History ■ Psychosocial history ■ Social support: family ■ Past health history: not available ■ Medical ■ Surgical ■ Family History: not available Admission Sheet Name:

Ty Nguyen

Age:

55

Gender:

Male

Marital Status:

Married

Educational Level:

6th grade

Religion:

Buddhist

Ethnicity:

Vietnamese

Nationality:

American

Language:

Primarily Vietnamese, minimal English

Occupation:

Shrimper, owner of boat

Hospital

Patient’s Name: Ty Nguyen

Provider’s Orders

Allergies: NKDA

Diagnosis: Acute respiratory failure Date

Time

Order

Sign

Vital signs: q hr Diet: NPO Activity: Bed rest IV therapy: 0.9% NS at KVO Medications: Diagnostic studies: CBC and BMP in AM, ABG’s at 8 AM Treatments: Respiratory therapy assessment Vent settings: TV 550 Assist control 10, FiO2 55% Call if O2 saturation...