NGN Respiratory EAQ Case Study Questions and Answers

NGN Respiratory EAQ Case Study Questions and Answers The nurse reviews clinical documents in the electronic health record. Complete the following sentence by choosing from the lists of options. The assessment findings requiring immediate follow-up include ___________, ______________, and ______________. 1st blank: weak dorsalis pedis and posterior tibial pulses delayed eye opening disorientation x1 2nd blank: oxygen (O2) saturation: 70% heart rate: 108 bpm temperature: 100.9° F (38.3° C) 3rd blank: PaCO2 70 mmHg bicarbonate 20 mEq/L hemoglobin 9 g/dL The assessment findings requiring immediate follow-up include delayed eye opening, oxygen (O2) saturation: 70%, and PaCO2 70 mmHG. Rationale: The client is experiencing acute hypoxemic respiratory failure associated with acute respiratory distress syndrome (ARDS). A key clinical finding of ARDS is respiratory distress with dyspnea, tachypnea, and hypoxemia not responding to supplemental O2 therapy (refractory hypoxemia). The client has a partial pressure of arterial oxygen (PaO2) of 70% despite receiving oxygen at 12 L/min. Hypoxemia triggers hyperventilation, resulting in respiratory alkalosis. Initial signs of ARDS may also include fine crackles, restlessness, disorientation, and change in the level of consciousness (LOC). Characteristics of ventilation failure, also known as hypercapnic or type 2 acute respiratory failure (ARF), include a partial pressure of arterial carbon dioxide (PaCO2) greater than 50 mmHg. Hypercapnia (increased PaCO2) significantly increases cerebral blood flow, causing the patient to appear restless and anxious. As intracranial pressure rises, the LOC decreases, progressing to coma if effective treatment does not occur. The nurse should address the assessment findings related to the client's hypoxemia first; those include the client's change in LOC, the decreased O2 saturation, and the increased PaCO2. The weak pulses are a result of decreased oxygenation and are not likely to improve until interventions to increase the oxygenation are implemented. The client not being oriented to location is not an immediate concern. The slightly tachycardic heart rate and the elevated temperature are not immediate concerns. The decreased bicarbonate does not require immediate intervention. The client is experiencing moderate anemia (a hemoglobin level of 7.0-9.9 g/dL). Severe anemia corresponds to a level The nurse reviews the client's electronic health record. Drag the potential complications from the choices below to fill in each blank in the following sentences. Based on the client's condition and mechanical ventilation, the nurse recognizes the client is most likely at risk for complications, especially ____________, ____________, and ______________. Potential Complications barotrauma volutrauma oxygen toxicity bronchiectasis pneumoconiosis idiopathic pulmonary fibrosis barotrauma volutrauma oxygen toxicity Rationale: Medical management of a client with acute respiratory distress syndrome (ARDS) involves a multifaceted approach. This strategy includes treating the underlying cause, promoting gas exchange, supporting tissue oxygenation, and preventing complications. Given the severity of hypoxemia, the client is intubated and mechanically ventilated to facilitate adequate gas exchange. Repeated opening and closing of the alveoli cause injury to the lung units (atelectrauma), resulting in inhibited surfactant production and increased inflammation (biotrauma), which then results in the release of mediators and an increase in pulmonary capillary membrane permeability. In addition, excessive pressure in the alveoli (barotrauma) or excessive volume in the alveoli (volutrauma) leads to excessive alveolar wall stress and damage to the alveolar-capillary membrane, resulting in air escaping into the surrounding spaces. Healthcare providers base selection of ventilator settings on lung-protective strategies that attempt to achieve adequate oxygenation while minimizing the risks of ventilator-associated complications such as oxygen toxicity, barotrauma, and volutrauma. Bronchiectasis, pneumoconiosis, and idiopathic pulmonary fibrosis (IPF) are not complications associated with mechanical ventilation. Bronchiectasis is a condition in which patients develop abnormally dilated bronchial tubes. This reaction allows mucus to pool, causing frequent respiratory tract infections, wheezing, and shortness of breath. Pneumoconiosis is a category of conditions caused by inhaling something that injures the lungs. Examples include black lung disease from coal dust and asbestosis from asbestos dust. Most healthcare providers do not know what causes IPF. Clinicians suspect there is a correlation between IPF and The nurse reviews the client's electronic health record. Based on the client's condition and interventions, priority needs include preventing which 5 conditions? Dislodgement of tubes Facial edema Cardiac tamponade Pressure ulcers Corneal ulceration Aspiration Hypocapnia Dislodgement of tubes Facial edema Pressure ulcers Corneal ulceration Aspiration Rationale: Clients with severe acute respiratory distress syndrome (ARDS) may benefit from prone positioning when used earl and along with other protective ventilation strategies. Evidence indicates placing clients in the prone position for more than 12 hours decreases mortality in those with moderate to severe ARDS when used with lower tidal volume (VT) ventilation. Turning the client to the prone position (proning) alters the V/Q ratio by maintaining posterior perfusion while allowing optimal ventilation in the larger, dorsal portion of the lungs. Prone positioning removes the weight of the heart and abdomen from the lungs, facilitates removal of secretions, improves oxygenation, and enhances recruitment of airways. Potential complications from the prone position are accidental dislodgement of tubes and lines, gastric aspiration, peripheral nerve injury, pressure ulcers, corneal ulceration, facial edema, and agitation. Cardiac tamponade is not an associated complication of proning. Cardiac tamponade occurs when blood or fluid builds up in the space between the heart muscle and the outer covering sac of the heart and causes the increased pressures exerted on the heart. Hypocapnia, also known as hypocarbia, is a state of reduced carbon dioxide in the blood. Hypocapnia usually results from shallow or rapid breathing (hyperventilation). Proning improves ventilation; therefore, hypocapnia is not an associated complication. The nurse reviews the client's electronic health record. Which action would the nurse include in the plan of care at this time? Select all that apply. Maintain tidal volume (VT) of 6 mL/kg. Maintain end-inspiratory plateau pressure of 30 cm H2O. Continuous infusion of cisatracurium 0.5 mg/kg/hr. Enteral feeding: OSMOLITE 1.2 Cal via NG tube. Start at 20mL/hr, increasing by 10 mL every 4 hours: Dietary consult for continued feedings. Furosemide IV push 40 mg b.i.d. (2 x day). Extracorporeal membrane oxygenation (ECMO). Reposition at least every 2 hrs. 650 mg Tylenol suppository or PO every 4 hours PRN to maintain temperature 101°F (38.3°C). Maintain tidal volume (VT) of 6 mL/kg. Maintain end-inspiratory plateau pressure of 30 cm H2O. Continuous infusion of cisatracurium 0.5 mg/kg/hr. Enteral feeding: OSMOLITE 1.2 Cal via NG tube. Start at 20mL/hr, increasing by 10 mL every 4 hours: Dietary consult for continued feedings. Furosemide IV push 40 mg b.i.d. (2 x day). Reposition at least every 2 hrs. 650 mg Tylenol suppository or PO every 4 hours PRN to maintain temperature 101°F (38.3°C). Rationale: Lung-protective strategies consist of low VT (4 to 8 mL/kg of predicted ideal body weight [IBW]), low end-inspiratory plateau pressure ( 30 cm H2O), fraction of inspired oxygen (FiO2) at nontoxic levels (0.60), and positive end-expiratory pressure (PEEP). Actual body weight should not be used to calculate VT. The body weight may change secondary to accumulation of body fluid, but the size of the lungs does not change. Low VT ventilation uses smaller VT (6 mL/kg) to ventilate the patient in an attempt to limit the effects of barotrauma and volutrauma. The goal is to provide the maximum VT possible, while maintaining end-inspiratory plateau pressure less than 30 cm H2O. Current clinical practice guidelines for use of neuromuscular blockade suggest an early course of a continuous infusion of cisatracurium for 48 hours in severe acute respiratory distress syndrome (ARDS). The enteral route is the preferred method of nutrition administration. If the client cannot tolerate enteral feedings or cannot receive enough nutrients enterally, the provider should prescribe parenteral nutrition. OSMOLITE 1.2 CAL is high-protein therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding for patients who may benefit from increased protein and calories. Adequate tissue perfusion depends on an adequate supply of oxygen being tra The nurse reviews the client's electronic health record. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The nurse would first ____________ to ____________. 1st blank: prepare for chest tube insertion administer an opioid medication request a stat electrocardiogram (ECG) 2nd blank: determine if the client is having a myocardial infarction treat the client's pain treat the pneumothorax The nurse would first prepare for chest tube insertion to treat the pneumothorax. Rationale: The client is evidencing signs of a tension pneumothorax. If the pneumothorax is large, decreased respiratory excursion on the affected side may be noticed, along with bulging intercostal muscles. The trachea may deviate away from the affected side. Percussion reveals hyperresonance with decreased or absent breath sounds over the affected area. Arterial blood gas (ABG) analysis demonstrates hypoxemia and hypercapnia. Treatment of a pneumothorax requires prompt insertion of a chest tube. When using high levels of positive end-expiratory pressure (PEEP), assess for potential adverse effects. PEEP increases intrathoracic pressure, potentially leading to decreased cardiac output. Excessive pressure in stiff lungs increases peak inspiratory and plateau pressures, which may result in barotrauma and pneumothorax. Regardless of the cause of a pneumothorax, the entry of air into the pleural space compresses the affected lung. As the lung collapses, the alveoli become underventilated, causing V/Q mismatching and intrapulmonary shunting. A pneumothorax greater than 15% requires intervention to evacuate the air from the pleural space and facilitate reexpansion of the collapsed lung. Interventions include placement of a chest tube. Chest tubes are inserted into the pleural space to remove fluid or air, reinstate the negative intrapleural pressure, and reexpand a collapsed lung. The new onset of pain most likely relates to the tension pneumothorax. If the air is removed, the pain will probably diminish or disappear; the priority is to manage the client's ability to breathe. The signs and symptoms are consistent with a tension pneumothorax and not likely indicative of a myocardial infarction. The nurse reviews the client's electronic health record. For each client finding, click to specify if interventions were effective (helped to meet expected outcomes), ineffective (did not help to meet expected outcomes), or unrelated (not related to expected outcomes). Client Finding Potassium 4.9 mEq/L Hemoglobin 14 g/dL Partial pressure of arterial carbon dioxide (PaCO2) 42 mmHg Breathing dyssynchrony V/Q matching Arterial oxygen saturation (SaO2) 91% Effective: Hemoglobin 14 g/dL Partial pressure of arterial carbon dioxide (PaCO2) 42 mmHg V/Q matching Arterial oxygen saturation (SaO2) 91% Ineffective: Breathing dyssynchrony Unrelated: Potassium 4.9 mEq/L Rationale: A normal potassium level is not related to management of acute respiratory failure related to acute respiratory distress syndrome (ARDS). An adequate cardiac output and hemoglobin level are critical to oxygen transport. A low hemoglobin level may result in tissue hypoxia. A PaCO2 value of 42 mmHg is a normal finding. The hypercapnia the client experienced has been treated. Breathing dyssynchrony causes inadequate gas exchange and increases the risk for ventilator-induced lung injury. V/Q (ventilation perfusion) matching refers to the coordination of blood flow and gas flow into a lung unit. Ventilation perfusion mismatch or "V/Q defects" are defects in total lung ventilation perfusion ratio. The condition occurs when one or more areas of the lung receive oxygen but no blood flow, or the lungs receive blood flow but no oxygen due to some diseases and disorders. A goal of treatment is to maintain a SaO2 higher than 90%.