Transcript ards
ACUTE RESPIRATORY DISTRESS SYNDROM PREPARED BY: TINTU VARGHESE ICU DEPARTMENT CASE NO: 195937 NAME: XYZ AGE:25YRS SEX: MALE DIAGNOSIS: ACUTE RESPIRATORY DISTRESS SYNDROM, SEPTECEMIA DOA:05/02/2013 The patient is 25 years of age, male, approximately weighs 80kg He is unconscious with ET tube with ventilator support and patient is sedated. GCS3/15,with the following vital signs. BP=130/80, PR=70bpm, RR=24mts Temp= 38.2, SPO2= 93% SKIN HEAD Patient unconscious On fully sedation On ventilator EYES EARS No unusual discharge No tenderness in sinus MOUTH NECK AND THROAT CHEST AND LUNGS HEART ABDOMEN GENITALS Pulse full and equal No lesions noted No past medical history 25yres male patient came in ER with complaints of tachypnea, agitated, SOB, fever, productive cough which was started one week ago and became worse. From ER patient was confused, SPO2 was low 85%,CXR showed patchy opacities are seen in the middle and lower zone of both lung . Hilar shadows and vascular markings are prominent in both lungs. Mild to moderate pleural effusion in both lungs Patient was shifted to surgery ward, patient was desaturated and developed tachypnea and shifted to ICU for further treatment and observation. Patient was intubated and on ventilator and fully sedated .patient developed hypotension and started inotropic support for two days. After all management patient was extubated and fully conscious and oriented. Patient shifted to surgery ward. DRUG DOSE ROUTE ACTION INJ. COLOMYCIN 1MILLION IV INJ.TAVANIC 750MG IV INJ. MEROPENEM 1GM IV INJ. NEXIUM 40MG IV ANTIBIOTICS(generat ion3cephalosporin) ANTIBIOTICS (generation2 fluoroquinilone) ANTIBIIOTICS(generation 3 cephalosporines) H2RECEPTOR INJ. PERFALGAN 1GM IV ANTIPYRETICS TAB TAMIFLUE 75MG NGT ANTIVIRAL TEST WBC PATIENT VALUE NORMAL VALUES 42.25% 4.23-9.07% HGB 13.2(G/DL) 13.7-17.5(G/DL) PLT 346(10^3/UL) 163-337(10^3/UL) UREA 8.7mmol/L 1.8-8.3 mmol/L CREATININE 113.7 mmol/L 58-110 mmol/L SODIUM 142 mmol/L 135-150 mmol/L POTTASIUM 3.8 mmol/L 3.5-5 mmol/L PT 13.6SEC INR 1.31% 10.9 TO 16.3 SEC 2 -4% APTT 29.6SEC 27-39SEC PH 7.13 7.35-7.45 PO2 88.8 80-100 PCO2 58.5 35-45 CHCO3 19.4 mmol/L 22-26 mmol/L Patchy ( air space) opacities are seen in the middle and lower zone of the both lungs. Hilar shadows and vascular markings are prominent in both lungs. Mild to moderate plural effusion in both lungs. BIilateral pleral effusion ( large amount)with opacity is seen in lower area of both lungs A distinct type of hypoxemic respiratory failure characterized by acute abnormality of both lungs was first recognized during the 1960s. Military clinicians working in surgical hospitals in Vietnam called it shock. Then referred to it as adult respiratory distress syndrome . Subsequent recognition that individuals of any age could be afflicted led to the current term, acute respiratory distress syndrome (ARDS). ARDS is an acute, diffuse, inflammatory lung injury that leads to increased pulmonary vascular permeability, increased lung weight, and a loss of aerated tissue . Clinical hallmarks of ARDS are hypoxemia and bilateral radiographic opacities, while the pathological hallmark is diffuse alveolar damage (ie, alveolar edema with or without focal hemorrhage, acute inflammation of the alveolar walls, and hyaline membranes). Acute respiratory distress syndrome (ARDS) is a sudden and progressive form of acute respiratory failure in which the alveolar capillary membrane becomes damaged and more permeable to intravascular fluid resulting in severe dyspnea, hypoxemia and diffuse pulmonary infiltrates. superior lobe inferior lobe Direct Lung Injury ◦Common causes Aspiration of gastric contents or other substances. Viral/bacterial pneumonia Chest trauma Embolism: fat, air, amniotic fluid Inhalation of toxic substances Near-drowning O2 toxicity Radiation pneumonitis ◦Common causes Sepsis Severe traumatic injury ◦ Less common causes Acute pancreatitis Anaphylaxis Prolonged Cardiopulmonary bypass surgery Disseminated intravascular coagulation Multiple blood transfusions Narcotic drug overdose (e.g., heroin) Non pulmonary systemic diseases restlessness Dyspnea Low blood pressure Confusion Extreme tiredness Change in patient’s behavior Mood swing Disorientation Change in LOC ◦ If pneumonia is causing ARDS then client may have Cough Fever ◦ ◦ ◦ ◦ ◦ ◦ Shortness of breath. Tachycardia Cyanosis (blue skin, lips and nails) Think frothy sputum Metabolic acidosis Abnormal breath sounds, like crackles Increased PaCo2 with respiratory alkalosis. Severe difficulty in breathing i.e., labored, rapid breathing. ◦ Decreased PaO2 ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Lung injury Release of Vasoactive substances (serotonin, histamine, bradykinin) Damaged Type II alveolar cell Surfactant production Alveolocapillary membrane permeability Alveolar Compliance and recoil Vascular narrowing & obstruction Bronchoconstriction Outward migration of blood cells & fluids from capillaries Atelectasis Hyaline membrane formation Pulmonary Edema Lung compliance Impairment in gas exchange ARDS Pulmonary hypertension 24 hours vital signs observed will be monitored and documented. Monitor for exhaustion and signs of reduced lung compliance eg: use of accessory muscles for respiration. Evaluate effectiveness of respiratory function like rate, rhythm and depth. Suction airway hourly or as necessary to remove secretion. Administer prescribed inhalations or bronchodilators mucolytic as ordered. Institute safety of the patient. Fall prevention. Side rails up low bed position. Prevent infection and potential complication. Provide patient and family education about treatment and recovery of the patient. Persons with ARDS are hospitalized and require treatment in an intensive care unit. No specific therapy for ARDS exists. Supportive measures : ◦ Supplemental oxygen ◦ Mechanical respirator ◦ Positioning strategies . –Fluid Administration – The patient should be aggressively fluid resuscitated for any signs /symptoms of shock in order to optimize end organ perfusion. Once hemodynamic stability is achieved, fluid administration should be minimized to decrease the alveolar-capillary leak and pulmonary edema. Aggressive diuresis should also be considered once hemodynamic stability is achieved. Nutritional support should be initiated as early as possible.– .Prone Positioning – Has been used since mid 1970’s in an effort to improve lung perfusion and oxygenation. Prone position or bed that provides continuous lateral position helps mobilize pulmonary secretions and improve ventilation/ perfusion matching. In prone position patient face down improves ventilation in posterior lung, where edema settles when patient in supine position . Risks are mainly logistical, i.e. dislodgement of endotracheal tube or vascular lines, increased intraabdominal pressure, feeding intolerance, and edema (facial). The greatest effects are achieved when patients are maintained prone for 12 hours or longer and oxygenation improves in 60-70% of patients. ◦ Antibiotics ◦ Anti-inflammatory drugs; such as corticosteroids ◦ Diuretics ◦ Drugs to raise blood pressure ◦ Anti-anxiety ◦ Muscle relaxers ◦ Inhaled drugs (Bronchodilators) RECRUITMENT MANEUVER Patients with ARDS require support with mechanical ventilator. Utilizing a CPAP mode and providing PEEP 35 to 40 for 40 second. In ventilator PEEP used to prevent alveolar derecruitment at end-expiration. In patients with ARDS, PEEP is used primarily to improve arterial oxygenation. Increased end-expiratory pressure increases mean airway and intra thoracic pressure. When applied correctly, this prevents alveolar collapse, increasing the volume of aerated lung by preventing alveolar de-recruitment at end-expiration The beneficial effects of PEEP include improved total lung compliance, and decrease in the work of breathing for spontaneously breathing patients, and improved gas exchange through a reduction in intrapulmonary shunting and improved ventilation–perfusion matching. Improved gas exchange may allow for reduction in the fraction of inspired oxygen (FiO2) and oxygen toxicity. Furthermore, studies have suggested that PEEP can reduce the release of bioactive mediators by the lung and may reduce the incidence of secondary infections in the lungs Common complications are; ◦ Nosocomial pneumonia: ◦ Barotrauma ◦ Renal failure Other complications are : ◦ O2 toxicity, ◦ stress ulcers, ◦ Tracheal ulceration, ◦ Blood clots leading to deep vein thrombosis & ◦ pulmonary embolism. Ineffective breathing pattern related to decreased lung compliance, decreased energy as characterized by dyspnea, abnormal ABGs, cyanosis & use of accessory muscles Impaired gas exchange related to diffusion defect as characterized by hypoxia, & cyanosis. Risk for decreased Cardiac output related to positive pressure ventilation. Impaired physical mobility related to monitoring devices, mechanical ventilation & medications as characterized by imposed restrictions of movement, decreased muscle strength & limited range of motion. Knowledge deficit related to health condition, new equipment & hospitalization as characterized by increased frequency of questions posed by patient and significant others & immobility. Ineffective protection related to positive pressure ventilation, decreased pulmonary compliance & increased secretions as characterized by crepitus, altered chest excursion, abnormal ABGs & restlessness. Risk for impaired skin integrity related to prolonged bed rest, prolonged intubation NURSING DIAGNOSIS Impaired gas Objective data: exchange related patient is dyspenic to diffusion defect , restless, cyanosis as characterized and desaturated.. by hypoxia, & cyanosis ASSESSMENT PLANNING After 12 hours of nursing intervention patient will shows signs of improved ventilation and adequate oxygenation. IMPLIMENTATION/ RATIONALE Vital signs, →Evaluate breath sounds, the degree breathing of pattern and compensati level of on. consciousness. Checked hourly. →To →Evaluated evaluate o2 pulse oxymery. saturation. Shows 95% →Evaluated →Facilitate head of the bed adequate 35 degree. oxygen intake →Suctioned secretion as →To clear needed the airway →Administered bronchodilators, expectorance like syp:.mucolyte, as orders. →Blood gas analysis done 2 hourly . →To treat the underlying condition. →To check the gas level. EVALUATION After 12 hours of nursing intervention patient exhibited signs of improved ventilation like free of distress, ABG shows Paco2 between 35-45. Remain on modified bed rest Take medication prescribed. Follow up regularly. Take adequate nutrition. Maintain personal hygiene. Maintain skin care. Regularly checkup vitals This is the case of 25 years old male patient with the diagnosis of acute respiratory syndrome and septicemia. Acute respiratory distress syndrome (ARDS) is a sudden and progressive form of acute respiratory failure in which the alveolar capillary membrane becomes damaged and more permeable to intravascular fluid resulting in severe dyspnea, hypoxemia and diffuse pulmonary infiltrates. Criteria which are fulfilled by the patient, conservative management rendered such as investigations , Antibiotics, Anti-inflammatory drugs; such as corticosteroids, Diuretics, Drugs to raise blood pressure, Anti-anxiety Muscle relaxers, Inhaled drugs (Bronchodilators).. A conservative fluid management strategy has been shown to reduce duration of mechanical ventilation andICU stay. Patient was intubated and on ventilator and fully sedated .patient developed hypotension and started inotropic support for two days. After all management patient was extubated and fully conscious and oriented. Patient shifted to surgery ward. Wikipedia. Medical and surgical nursing book volume 1 and 2 of Brunner. Luck man and Sorensen’s MedicalSurgical Nursing a Physiologic Approach 4th edition Lippincott Manual of Nursing Practice 9th edit. tintu