Grand Rounds: Acute Respiratory Failure

1
Grand Rounds Acute Respiratory Failure

• Ashley Hazelwood

2
Demographics

• 78 year old African American Female
• Widowed
• Baptist
• Never employed

• One Daughter
• Height 64 inches
• Weight 84.9 Kg
• Allergy Tetanus
• Full Code

3
Events Leading to Hospitalization

• Total hysterectomy late February
• Sent to rehab facility after surgery
• Found her unresponsive
• Experiencing agonal respirations
• Taken to hospital and intubated on 3/21

4
Risk Factors

• Age
• Ovarian Cancer stage III
• Total hysterectomy (abdominal incision)
• Hypertension
• Diabetes
• Anemia

5
Past Medical History

• Right sided hydronephrosis secondary to ovarian
  cancer
• Pyelonephritis
• Gout
• Hyperlipidemia

• Diabetes
• Hypertension
• Anemia
• Osteoarthritis

6
Medical Diagnosis

• Acute Respiratory Failure
• MRSA

7
Acute Respiratory Failure

• Classified as blood gas abnormalities
• Occurs rapidly
• Gives little time for body to compensate
• Three types Failure of oxygenation, failure of
  ventilation, and failure of both

8
Failure of Oxygenation

• Thoracic pressures are normal
• Pulmonary blood not adequately oxygenated
• 4 Mechanisms
• Hypoventilation
• Intrapulmonary shunting
• Ventilation/perfusion mismatch
• Diffusion defects

9
Failure of Oxygenation

• Ventilation/Perfusion mismatch
• Degree of a shunt
• Degree of dead space
• Most common cause of hypoxemia
• Diffusion
• Distance between alveoli and capillaries is
  increased

• Hypoventilation
• Buildup of CO2 displaces O2 (abdominal surgery)
• Intrapulmonary shunting
• Blood is shunted past lungs
• Unoxygenated blood sent back to left side of
  heart (atelectasis)

10
Failure of Ventilation

• Perfusion is normal
• Ventilation inadequate
• Little oxygen reaches alveoli
• Carbon dioxide is retained
• Hypoxemia develops
• 2 mechanisms
• Hypoventilation
• Ventilation/Perfusion mismatch

11
Failure of Ventilation

• Hypoventilation
• CO2 accumulates in alveoli
• CO2 is not blown off

• Ventilation/Perfusion mismatch
• Increase in volume of dead space
• Area no longer participates in gas exchange

12
Symptoms

• Hallmark Dyspnea
• Hypoxemia
• Hypercapnia
• Release of lactic acid

• Decreased level of consciousness
• Tachycardia
• Increased blood pressure
• Peripheral vasoconstriction

13
Complications

• Immobility
• Medication side effects
• Fluid and electrolyte imbalance
• Hazards of mechanical ventilation

• Hazards of mechanical ventilation
• Aspiration
• Volutrauma
• Oxygen toxicity
• Ventilator associated pneumonia

14
MRSA-Methicillin Resistant Staphylococcus Aureus

• Bacteria resistant to certain antibiotics.
• Frequently found in
• Immunocompromised patients
• Hospitalized patients

15
Collaboration of Care

• Nurses
• Nursing Students
• Nursing Instructor
• Physicians
• Respiratory Therapists
• Family

16
Respiratory Alkalosis
ABGs 3/22/08 Result High/Low Rationale
pH 7.54 High Normal7.35-7.45 Mechanical ventilation
PCO2 34.0 mmHg Low Normal 35-45 Increased respiratory rate
PO2 109 mmHg High Normal 80-100 Hyperventilation
HCO3 20 mmol/L Low Normal 22-26 Compensating for alkalosis
17
Laboratory Results
Lab Result High/Low Rationale
Serum Protein Prealbumin 3/25/2008 lt5.0 mg/dL Low Normal 18-25 Inflammation r/t acute respiratory failure
Coagulation PTT 3/25/2008 70.9 Sec. High Normal 22-35 Prolonged clotting time r/t Lovenox therapy
MRSA swab 3/27/2008 Positive for MRSA Abnormal Normal negative swab MRSA infection
18
Laboratory Results
Hematology 3/27/2008 Results High/Low Rationale
WBC 28.7x103/mm3 High Normal4.3-10.0 Infection, stress, inflammation
RBC 3.37x106/mm3 Low Normal4.0-5.40 History of Anemia
Hemoglobin 9.3g/dl Low Normal12.0-16.0 History of Anemia
Hematocrit 29.6 Low Normal35-47 History of Anemia
19
Laboratory Results
Hematology 3/27/2008 Results High/Low Rationale
Platelets 15.3 High Normal11.5-14.5 History of Anemia
Glucose 175 High mg/dL Normal70-110 Diabetes
20
Diagnostics X-Rays
Diagnostic Date Findings
X-Ray Placement of ET tube 3/21 Above Canna(1-2cm) No infiltrates or infusions
X-Ray Abdomen Flexi flow placement 3/22 Tip in transport position in duodenal flap
X-Ray Chest, post procedure of thoracentesis 3/25 No pneumothorax, mild volume loss right lung, no pulmonary edema
X-Ray portable chest PICC placement 3/26 Right Upper Extremity, tip in mid-SVC
X-Ray Chest 3/27 Atelectasis in lower left base
21
Diagnostics CT and US
Diagnostics Date Findings
CT Head 3/21 Negative for injury
Lower Extremity Doppler Exam 3/22 No deep vein thrombosis present
CT Chest with IV Contrast, Pulmonary embolism protocol 3/24 Right Pleural effusion, no evidence of pulmonary embolism.
US Right thoracentesis for right pleural effusion 3/25 200cc straw colored fluid aspirated from right pleural space
22
Medications
Medication Class Dose Route Frequency Rationale
Insulin Regular Short acting insulin BG-100/20 U SubQ QID,AC, Bedtime Diabetes
Insulin Lantus Long acting insulin 15 Units SubQ Qday Diabetes
Pulmocare Tube Feeding Nutrition supplement 40mL/h Per Tube Continuous Feeding Q24 hours Respiratory failure
Benazepril (Lotensin) ACE inhibitor 10mg Per Tube BID HTN Hold if SBPlt100
Diltiazem (Cardizem) Ca channel blocker 60mg Per Tube Q6h tachycardia, HTN
Amlodipine (Norvasc) Ca channel blocker 10mg Per Tube Qday HTN, Tachycardia
23
Medications
Medication Class Dose Route Frequency Rationale
Esomaprazole (nexium) Proton pump inhibitor 40mg Per Tube add 15 mL of water Qday Prevent stress ulcers
Albuterol Broncho-dilator 4 puffs Inhalation By RT Q4h Respiratory Failure
Potassium Chloride Electrolyte 40 mEq Per Tube TID Prevent hypokalemia
Enoxaparin (Lovenox) Anticoagulant, low molecular weight heparin 40mg SubQ abdomen Q24h Prevent Deep vein thrombosis
24
Medications
Medication Class Dose Route Frequency Rationale
Piperacillin-Tazobactum (Zosyn) Extended Spectrum penicillin 3.375 gm IV solution 100mL/h Q6H MRSA, Respiratory Failure
Linezolid (Zyvox) Oxazolidinone 600mg IV solution 300mL/h BID MRSA
Furosemide (Lasix) Loop Diuretic 40mg Per Tube BID Peripheral Edema
Loperamide (Immodium) Piperidine Derivative 2-4mg Per Tube PRN for diarrhea Diarrhea Several soft stools a day
25
Assessment

• Intake
• D5W with 40 Potassium at 30mL/h
• Output
• 3 to 4 stools a day
• Zossi Placed
• Urine average of 40-60 mL/h

• Vital Signs
• BP158/62
• HR 101
• RR 29
• O2 sat 99
• Temp 98.4
• Pain 0

26
Assessment Neurological

• LOC
• easily aroused
• alert responds to verbal stimuli
• calm, nods to questions
• Pupils are PERRLA

• Coma Score
• Eyes Open Spont. 4
• Best Verbal Response T (Trach)
• Best Motor Response Obeys Commands 6
• Total 10T

27
Assessment HEENT

• Eyes
• Brows and lashes present
• No ptosis
• Conjunctiva clear
• Sclera white
• No lesions
• Ears
• No masses, or lesions
• No tenderness or discharge

• Head
• No lumps, lesions or tenderness
• Symmetrical
• Face
• Symmetrical
• No weakness
• No involuntary movements

28
Assessment HEENT

• Nose
• Symmetrical
• No drainage
• Flexi Flow in left nostril
• No skin breakdown

• Throat
• Endotracheal tube in place
• Trachea midline
• No pain
• Teeth missing
• Mucosa pink and dry

29
Assessment Musculoskeletal

• Nonambulatory
• Limited range of motion
• Assist with all activities of daily living

• Minimal equal weakness upper extremities
• General weakness left lower extremity
• Greater weakness right lower extremity

30
Assessment Cardiovascular

• Normal heart sounds, S1 and S2 noted
• Telemetry Normal sinus rhythm with premature
  atrial beats
• No jugular vein distention
• Capillary Refill lt3 seconds

• Right and left dorsalis pedis weak
• Right and left radial 2
• 2 edema in lower extremities
• 1 edema in hands

31
Assessment Respiratory

• Clear lung sounds
• Diminished lung sounds in bases bilaterally
• Sputum thick and white

• Mechanical Ventilation Settings
• CPAP
• PEEP 5
• FiO2 30
• Pressure Support 20
• Vt 600

32
Assessment Gastrointestinal

• Impaired swallowing mechanical ventilation
• NPO
• Flexi Flow NGT
• Continuous feeding Pulmacore at 40mL/h
• Several loose, yellow stools a day
• Zossi Placed

• Bowel sounds in all four quadrants
• Abdomen Soft and distended
• Healed abdominal incision from hysterectomy
  (midline)

33
Assessment Genitourinary

• Urine clear
• Color pale yellow
• Urine output gt 30mL/h
• Foley catheter in place and patent

34
Assessment Integumentary

• Braden Score
• Sensory Perception no impairment 4
• Moisture very moist 2
• Activity bedfast 1
• Mobility very limited 2
• Nutrition adequate 3
• Friction Shear problem 1
• Total 13 interventions in place

• Excoriated skin on buttocks and perineum
• Stage 2 breakdown

35
Assessment Integumentary

• Other areas of skin dry, warm, and intact
• No clubbing

• PICC on right upper forearm
• No infiltration or inflammation
• Dressing dry and intact
• Patent

36
Assessment Psychosocial

• Patient cried a few times from impaired
  communication and several accidents
• Most of the time was calm and resting

• Had family support at bedside
• Daughter visited everyday
• Was there by 0800 every morning

37
Impaired Gas Exchange

• Related to altered oxygen supply secondary to
  acute respiratory failure.

• As Evidenced By
• abnormal ABGs (pH7.54, CO234.0mmHg, O2109mmHg,
  HCO329.2mmol/L)
• tachypnea (varying from 29-33)
• tachycardia (101)
• anxiety
• dyspnea
• mechanical ventilation
• decreased RBCs (3.37x106/mm3), Hgb (9.3g/dl),
  Hct (29.6)

38
Goals and Interventions

• Goal Patient will not experience discomfort in
  maintaining air exchange

• Interventions
• Monitor VS and IO every hour
• Position every 2 hours
• Suction as needed
• Elevate HOB
• Assess lung sounds every assessment
• Assess for restlessness and change in LOC
• Provide ADLs, rest

39
Evaluation

• Vital signs and IO recorded every hour
• Positioned every two hours to promote gas
  exchange
• No further ABGs were drawn
• Suctioned twice a day

• Lung sounds remained clear
• Remained alert and oriented
• Mouth care and bathing was performed
• Head of bed elevated
• O2 oximetry stayed above 90
• No signs of respiratory distress

40
Impaired Skin Integrity

• Related to immobility secondary to mechanical
  ventilation

• As Evidenced By
• Excoriated buttocks and perineum, stage 2
• Braden score of 13
• Inflammation
• Diarrhea
• Increased WBC (28.7x103/mm3)
• Low pre albumin (lt5.0mg/dL)
• Decreased RBCs (3.37x106/mm3), Hgb (9.3g/dl),
  Hct (29.6)

41
Goals and Interventions

• Interventions
• Assess skin every shift assessment
• Keep skin dry and clean
• Turn and position every two hours
• Clean accidents promptly, make sure zossi is
  draining with no leaks.
• Apply skin cream
• Consult with wound care nurse

• Goal Patient will not exhibit any further
  breakdown.

42
Evaluation

• Skin assessed and documented every eight hours.
• Patient cleaned promptly when had accident

• Patient was bathed and skin dried
• Turned and positioned every two hours
• No further breakdown occurred

43
Impaired Verbal Communication

• Related to artificial airway and mechanical
  ventilation secondary to respiratory failure

• As Evidenced By
• ET tube
• Anxiety
• Few episodes of crying
• Frustration

44
Goals and Interventions

• Interventions
• Establish method that is appropriate for her
• Attempt reading gestures
• Speak slowly and clearly
• Explain procedures
• Expect frustration
• Involve family

• Goal Patient will be able to communicate her
  needs to the best of her ability

45
Evaluation

• I used yes/no questions to communicate with N.M.
• Able to nod to answer my questions
• Every procedure was explained in a clear slow
  manner

• Frustration and anxiety were decreased when she
  used the yes/no responses
• Family was involved in trying to communicate with
  N.M.

46
Research Article

• A Prospective, Randomized Study of
  Ventilator-Associated Pneumonia in Patients Using
  a Closed vs. Open Suction System

47
Purpose

• Verify incidence of nosocomial pneumonia in
  mechanically ventilated patients having
  suctioning by open vs. closed suction method

48
Methods and Sample Size

• Methods
• Randomized assay
• Parallel groups
• Approval was given

• Sample
• Forty seven patients
• Twenty-four received open suction
• Twenty-three received closed suction
• All older than thirteen
• Mechanical ventilation greater than forty eight
  hours

49
Results

• Of 24 receiving open suctioning
• 11 developed ventilator-associated pneumonia
• Of 23 receiving closed suctioning
• 7 developed ventilator-associated pneumonia

• Use of a closed suction system did not decrease
  the incidence compared with the open system

50
Relation to patient

• On mechanical ventilation
• At risk for developing ventilator-associated
  pneumonia
• Receiving closed system suctioning
• Did not acquire pneumonia during my care

51
References

• Ignatavicius, D., and Workman, JL (2006).
  Medical-surgical nursing Critical thinking for
  collaborative care. 5th ed. Philadelphia WB
  Saunders.
• MRSA Infection (2008). MayoClinic.com
  http//www.mayoclinic.com/print/mrsa/DS00735/METHO
  DprintDSECTIONall
• Zeitoun, S., Barros, A., Diccini, S. (2003). A
  prospective, randomized study of
  ventilator-associated pneumonia in patients using
  a closed vs. open suction system. Journal of
  Clinical Nursing, 12, 484-489.
• Pagan, K. and Pagana T. Mosbys Diagnostic and
  Laboratory Test Reference. 7th edition. Elsvier
  Mosby Inc. Philadelphia, PA, 2005.
• Skidmore-Roth, L. (2007). Mosbys drug guide for
  nurses, 7th edition. St. Louis Mosby Elsevier.
• Sole, ML, Klein, D, and Moseley, M (2004).
  Introduction to critical care nursing. 4th
  edition. Philadelphia WB Saunders.
•