Grand Rounds: Acute Respiratory Failure

1. Grand Rounds: Acute Respiratory Failure Ashley Hazelwood

2. 78 year old African American Female Widowed Baptist Never employed One Daughter Height: 64 inches Weight: 84.9 Kg Allergy: Tetanus Full Code Demographics

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. Right sided hydronephrosis secondary to ovarian cancer Pyelonephritis Gout Hyperlipidemia Diabetes Hypertension Anemia Osteoarthritis Past Medical History

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. 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) Ventilation/Perfusion mismatch: Degree of a shunt Degree of dead space Most common cause of hypoxemia Diffusion: Distance between alveoli and capillaries is increased Failure of Oxygenation

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. 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 Failure of Ventilation

12. Hallmark: Dyspnea Hypoxemia Hypercapnia Release of lactic acid Decreased level of consciousness Tachycardia Increased blood pressure Peripheral vasoconstriction Symptoms

13. Immobility Medication side effects Fluid and electrolyte imbalance Hazards of mechanical ventilation Hazards of mechanical ventilation: Aspiration Volutrauma Oxygen toxicity Ventilator associated pneumonia Complications

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

17. Laboratory Results

18. Laboratory Results

19. Laboratory Results

20. Diagnostics: X-Rays

21. Diagnostics: CT and US

22. Medications

23. Medications

24. Medications

25. Vital Signs: BP:158/62 HR: 101 RR: 29 O2 sat: 99 Temp: 98.4 Pain: 0 Intake: D5W with 40 Potassium at 30mL/h Output: 3 to 4 stools a day Zossi Placed Urine average of 40-60 mL/h Assessment

26. 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 Assessment: Neurological

27. Head: No lumps, lesions or tenderness Symmetrical Face: Symmetrical No weakness No involuntary movements Eyes: Brows and lashes present No ptosis Conjunctiva clear Sclera white No lesions Ears: No masses, or lesions No tenderness or discharge Assessment: HEENT

28. 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 Assessment: HEENT

29. 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 Assessment: Musculoskeletal

30. Normal heart sounds, S1 and S2 noted Telemetry: Normal sinus rhythm with premature atrial beats No jugular vein distention Capillary Refill <3 seconds Right and left dorsalis pedis weak Right and left radial 2+ 2+ edema in lower extremities 1+ edema in hands Assessment: Cardiovascular

31. 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 Assessment: Respiratory

32. Bowel sounds in all four quadrants Abdomen Soft and distended Healed abdominal incision from hysterectomy (midline) Impaired swallowing: mechanical ventilation NPO Flexi Flow NGT Continuous feeding: Pulmacore at 40mL/h Several loose, yellow stools a day Zossi Placed Assessment: Gastrointestinal

33. Assessment: Genitourinary • Urine clear • Color: pale yellow • Urine output > 30mL/h • Foley catheter in place and patent

34. Excoriated skin on buttocks and perineum Stage 2 breakdown 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 Assessment: Integumentary

35. Other areas of skin dry, warm, and intact No clubbing PICC on right upper forearm: No infiltration or inflammation Dressing dry and intact Patent Assessment: Integumentary

36. 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 Assessment: Psychosocial

37. Related toaltered oxygen supply secondary to acute respiratory failure. As Evidenced By: abnormal ABGs (pH:7.54, CO2:34.0mmHg, O2:109mmHg, HCO3:29.2mmol/L) tachypnea (varying from 29-33) tachycardia (101) anxiety dyspnea mechanical ventilation decreased RBCs (3.37x10^6/mm3), Hgb (9.3g/dl), Hct (29.6%) Impaired Gas Exchange

38. Goal: Patient will not experience discomfort in maintaining air exchange Interventions: Monitor VS and I&O 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 Goals and Interventions

39. Vital signs and I&O 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 Evaluation

40. Related to immobility secondary to mechanical ventilation As Evidenced By: Excoriated buttocks and perineum, stage 2 Braden score of 13 Inflammation Diarrhea Increased WBC (28.7x10^3/mm3) Low pre albumin (<5.0mg/dL) Decreased RBCs (3.37x10^6/mm3), Hgb (9.3g/dl), Hct (29.6%) Impaired Skin Integrity

41. Goal: Patient will not exhibit any further breakdown. 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 Goals and Interventions

42. 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 Evaluation

43. Related to artificial airway and mechanical ventilation secondary to respiratory failure As Evidenced By: ET tube Anxiety Few episodes of crying Frustration Impaired Verbal Communication

44. Goal: Patient will be able to communicate her needs to the best of her ability Interventions Establish method that is appropriate for her Attempt reading gestures Speak slowly and clearly Explain procedures Expect frustration Involve family Goals and Interventions

45. 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. Evaluation

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: 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 Methods and Sample Size

49. 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 Results

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