NCM 118 Midterms PDF

NCM 118: CRITICAL CARE NURSING S.Y. ‘24 - ‘25 | SEM #1# | SIR ERVIN ROI CABIBIL & SIR MICHAEL ANGELO AMAUT MIDTERMS -SEM #1#MIDTERMS#- and alveoli, the pulmonary circulati...

NCM 118: CRITICAL CARE NURSING S.Y. ‘24 - ‘25 | SEM #1# | SIR ERVIN ROI CABIBIL & SIR MICHAEL ANGELO AMAUT MIDTERMS -SEM #1#MIDTERMS#- and alveoli, the pulmonary circulation, 3.0 PULMONARY ALTERATIONS and the alveolar-capillary membrane. Acute Lung Failure Acute Respiratory Distress Pneumonia Aspiration Pneumonitis 3.1 Acute Lung Failure Description and Etiology - Acute lung failure (ALF), also known as acute respiratory failure, is a clinical condition in which the pulmonary system fails to maintain adequate gas exchange. - It is the most common type of organ failure seen in the critical care unit, with approximately 56% of the patients in the critical care unit experiencing it. - ALF results from a deficiency in the performance of the pulmonary system. It usually occurs secondary to another disorder that has altered the normal function of the pulmonary system in such a way as to decrease the ventilatory drive, decrease muscle strength, decrease chest wall elasticity, decrease the lung’s capacity for gas exchange, increase airway resistance, or increase metabolic oxygen requirements. - ALF can be classified as hypoxemic normocapnic respiratory failure (type I) or hypoxemic hypercapnic respiratory failure (type II), depending on analysis of the patient’s arterial blood gases (ABGs). Pathophysiology - In type I respiratory failure, the patient - Alveolar Hypoventilation presents with a low arterial oxygen a. Alveolar hypoventilation pressure (PaO2) and a normal arterial occurs when the amount of carbon dioxide pressure (PaCO2) oxygen being brought into the - In type II respiratory failure, the patient alveoli is insufficient to meet presents with a low PaO2 and a high the metabolic needs of the PaCO2. body. This can be the result of - The causes of ALF may be classified increasing metabolic oxygen as extrapulmonary or intrapulmonary, needs or decreasing depending on the origin of the ventilation. Hypoxemia caused patient’s primary disorder. by alveolar hypoventilation is - Extrapulmonary causes include associated with hypercapnia disorders that affect the brain, the and commonly results from spinal cord, the neuromuscular extrapulmonary disorders. system, the thorax, the pleura, and the - Ventilation/Perfusion Mismatching upper airways. a. V/Q mismatching occurs - Intrapulmonary causes include when ventilation and blood disorders that affect the lower airways flow are mismatched in NCM 118: CRITICAL CARE NURSING NCM 119 REVIEWER PAGE 24 template by: @wonrika | transcribed by: @go7dss  NCM 118: CRITICAL CARE NURSING S.Y. ‘24 - ‘25 | SEM #1# | SIR ERVIN ROI CABIBIL & SIR MICHAEL ANGELO AMAUT MIDTERMS various regions of the lung in Medical Management excess of what is normal. - Oxygenation Blood passes through alveoli - Actions to improve that are under ventilated for oxygenation include the given amount of perfusion, supplemental oxygen leaving these areas with a administration, with either a lower than normal amount of low-flow system or a high-flow oxygen. V/Q mismatching is system, and the use of the most common cause of positive pressure ventilation hypoxemia and is usually the - The purpose of oxygen result of alveoli that are therapy is to correct partially collapsed or partially hypoxemia; although the filled with fluid. absolute level of hypoxemia - Intrapulmonary Shunting varies in each patient, most a. Intrapulmonary shunting, the treatment approaches aim to extreme form of V/Q keep the arterial hemoglobin mismatching, occurs when oxygen saturation greater than blood reaches the arterial 90% system without participating - The goal is to keep the in gas exchange. The mixing tissues’ needs satisfied but of unoxygenated (shunted) not produce hypoxemia or blood and oxygenated blood hyperoxemia. lowers the average level of - Supplemental oxygen oxygen present in the blood. administration is effective in Intrapulmonary shunting treating hypoxemia related to occurs when blood passes alveolar hypoventilation and through a portion of a lung V/Q mismatching. that is not ventilated. This - When intrapulmonary shunting may be the result of exists, supplemental oxygen (1) alveolar collapse alone is ineffective. In this secondary to atelectasis or situation, positive pressure is (2) alveolar flooding with pus, necessary to open collapsed blood, or fluid. or fluid-filled alveoli and Assessment and Diagnosis facilitate their participation in - Diagnosing and following the course gas exchange. of respiratory failure is best - Positive pressure is delivered accomplished by ABG analysis. ABG via invasive and noninvasive analysis confirms the level of PaCO2, mechanical ventilation. PaO2, and blood pH. ALF is generally - To avoid intubation, positive accepted as being present when the pressure is usually PaO2 is less than 60 mm Hg. If the administered initially patient is also experiencing noninvasively via a mask. hypercapnia, the PaCO2 will be greater - High-flow oxygen therapy and than 45 mm Hg. In patients with noninvasive ventilation were chronically elevated PaCO2 levels, superior to low-flow oxygen these criteria must be broadened to therapy in the treatment of include a pH less than 7.35 hypoxemia. - Various additional tests are performed - High-flow oxygen therapy is depending on the patient’s underlying better tolerated and more condition. These include comfortable than noninvasive bronchoscopy for airway surveillance ventilation. or specimen retrieval, chest - Ventilation radiography, thoracic ultrasound, - Interventions to improve thoracic computed tomography (CT), ventilation include the use of and selected lung function studies noninvasive and invasive mechanical ventilation. - Depending on the underlying NCM 118: CRITICAL CARE NURSING NCM 119 REVIEWER PAGE 25 template by: @wonrika | transcribed by: @go7dss  NCM 118: CRITICAL CARE NURSING S.Y. ‘24 - ‘25 | SEM #1# | SIR ERVIN ROI CABIBIL & SIR MICHAEL ANGELO AMAUT MIDTERMS cause and the severity of the - Impaired ventilation leads to ALF, the patient may be the accumulation of carbon treated initially with dioxide and the development noninvasive ventilation. of respiratory acidosis. Once - Pharmacology the patient is adequately - Bronchodilators, such as oxygenated and ventilated, the beta-2 agonists and acidosis should correct itself. anticholinergic agents, aid in - The use of sodium smooth muscle relaxation and bicarbonate to correct are of particular benefit to metabolic acidosis has been patients with airflow shown to be of minimal limitations. benefit to the patient and is no - Methylxanthines, such as longer recommended as aminophylline, are no longer first-line treatment. recommended because of - Bicarbonate therapy shifts the their negative side effects. oxygen-hemoglobin - Steroids also are often dissociation curve to the left administered to decrease and can worsen tissue airway inflammation and hypoxia. enhance the effects of the - Sodium bicarbonate may be beta-2 agonists. used if metabolic acidosis is - Mucolytics and expectorants severe (pH less than 7.2), are also no longer used refractory to therapy, and because they have been found causing dysrhythmias or to be of no benefit in this hemodynamic instability. patient population. - NUTRITION SUPPORT - Sedation is necessary in many - The goals of nutrition support patients to assist with are to meet the overall maintaining adequate nutrition needs of the patient ventilation. Sedation can be while avoiding overfeeding, to used to comfort the patient prevent nutrition delivery and decrease the work of related complications, and to breathing, particularly if the improve patient outcomes. patient is fighting the - Failure to provide the patient ventilator. with adequate nutrition - Analgesics are administered support leads to the for pain control. development of malnutrition. - In some patients, sedation - Both malnutrition and does not decrease over-feeding can interfere with spontaneous respiratory the performance of the efforts enough to allow pulmonary system, further adequate ventilation. perpetuating ALF. - Neuromuscular paralysis may - Malnutrition decreases the be necessary to facilitate patient’s ventilatory drive and optimal ventilation. muscle strength, whereas - Paralysis also may be over-feeding increases carbon necessary to decrease oxygen dioxide production, which consumption in severely increases the patient’s compromised patients. ventilatory demand, resulting - Acidosis in respiratory muscle fatigue. - Acidosis may occur in a - The enteral route is the patient for many reasons. preferred method of nutrition - Hypoxemia causes impaired administration. If the patient tissue perfusion, which leads cannot tolerate enteral to the production of lactic acid feedings or cannot receive and the development of enough nutrients enterally, he metabolic acidosis. or she will be started on NCM 118: CRITICAL CARE NURSING NCM 119 REVIEWER PAGE 26 template by: @wonrika | transcribed by: @go7dss  NCM 118: CRITICAL CARE NURSING S.Y. ‘24 - ‘25 | SEM #1# | SIR ERVIN ROI CABIBIL & SIR MICHAEL ANGELO AMAUT MIDTERMS parenteral nutrition. matching of ventilation with - Nutrition support is initiated perfusion to optimize gas before the third day of exchange. mechanical ventilation for - Because gravity normally well-nourished patients and facilitates preferential within 24 hours for ventilation and perfusion to malnourished patients. the dependent areas of the - COMPLICATIONS lungs, the best gas exchange - Patients with ALF may would take place in the experience many dependent areas of the lung. complications, including - Thus the goal of positioning is ischemic-anoxic to place the least affected encephalopathy, cardiac area of the patient’s lung in dysrhythmias, venous the most dependent position. thromboembolism (VTE), and - Patients with diffuse lung stress ulcers. disease may benefit from - Ischemic-anoxic being positioned with the encephalopathy results from right lung down, because it is hypoxemia, hypercapnia, and larger and more vascular than acidosis. the left lung. - Dysrhythmias are precipitated - For patients with alveolar by hypoxemia, acidosis, hypoventilation, the goal of electrolyte imbalances, and positioning is to facilitate the administration of beta-2 ventilation. These patients agonists. benefit from non recumbent - VTE is precipitated by venous positions such as sitting or a stasis resulting from semi erect position. immobility and can be - Elevating the head of the bed prevented through the use of 30 to 45 degrees has also intermittent pneumatic been shown to decrease the compression devices and risk of aspiration; however, it low-dose unfractionated also has been shown to heparin or low increase the risk of pressure molecular-weight heparin injuries. (LMWH). - Frequent repositioning (at - Stress ulcers can be least every 2 hours) is prevented through the use of beneficial in optimizing the histamine receptor patient’s ventilatory pattern antagonists and proton pump and V/Q matching. inhibitors. The use of stress - Preventing desaturation. ulcer prophylaxis has been - Hyperoxygenating the patient associated with an increased before suctioning, providing risk of ventilator-associated adequate rest and recovery pneumonia. time between procedures, and Nursing Management minimizing oxygen - Nursing interventions to optimize consumption. oxygenation and ventilation include - Interventions to minimize positioning, preventing desaturation, oxygen consumption include and promoting secretion clearance. limiting the patient’s physical - POSITIONING activity, administering - Positioning of a patient with sedation to control anxiety, ALF depends on the type of and providing measures to lung injury and the underlying control fever. cause of hypoxemia. - The patient is continuously - For patients with V/Q monitored with a pulse mismatching, positioning is oximeter to warn of signs of used to facilitate better desaturation. NCM 118: CRITICAL CARE NURSING NCM 119 REVIEWER PAGE 27 template by: @wonrika | transcribed by: @go7dss  NCM 118: CRITICAL CARE NURSING S.Y. ‘24 - ‘25 | SEM #1# | SIR ERVIN ROI CABIBIL & SIR MICHAEL ANGELO AMAUT MIDTERMS - Promoting secretion clearance. equal to 200 mm Hg with - Interventions to promote PEEP greater than or equal to secretion clearance include 5 cm H2O); or severe providing adequate systemic (PaO2/FIO2 less than or equal hydration, humidifying to 100 mm Hg with PEEP supplemental oxygen, greater than or equal to 5 cm coughing, and suctioning. H2O). - Postural drainage and chest - A wide variety of clinical conditions is percussion and vibration have associated with the development of been found to be of little ARDS. These are categorized as direct benefit in critically ill patients or indirect, depending on the primary site of injury - Direct injuries are injuries in which the 3.2 Acute Respiratory Distress lung epithelium sustains a direct Description and Etiology insult. The recent coronavirus - Acute respiratory distress syndrome pandemic is an example of a virus (ARDS) is a systemic process that is causing direct injury to the lung considered to be the pulmonary epithelium. manifestation of multiple-organ - Indirect injuries are injuries in which dysfunction syndrome. the insult occurs elsewhere in the - It is characterized by noncardiac body and mediators are transmitted pulmonary edema and disruption of via the bloodstream to the lungs. the alveolar- capillary membrane as a Sepsis, aspiration of gastric contents, result of injury to either the pulmonary diffuse pneumonia, and trauma were vasculature or the airways. found to be major risk factors for the - Berlin Definition: This definition development of ARDS. eliminated the term “acute lung injury” and proposed three distinct categories (mild, moderate, and severe) of ARDS based on the severity of hypoxemia. The Berlin Definition of ARDS is as follows: 1. Timing: Within 1 week of known clinical insult or new or worsening respiratory symptoms 2. Chest imaging: Bilateral opacities not fully explained Pathophysiology by effusions, lobar/lung - The progression of ARDS can be collapse, or nodules described in three phases: exudative, 3. Origin of edema: Respiratory fibroproliferative, and resolution. failure not fully explained by - ARDS is initiated with stimulation of heart failure or fluid overload; the inflammatory-immune system as a objective assessment needed result of a direct or indirect injury to exclude hydrostatic edema - Exudative Phase if no risk factor present a. In the first 72 hours following 4. Oxygenation: Mild (200 mm an injury, the exudative or Hg less than PaO2/fraction of acute phase begins, inspired oxygen [FIO2] less characterized by increased than or equal to 300 mm Hg permeability of pulmonary with positive end-expiratory capillaries. This leads to the airway pressure [PEEP] or leakage of fluid, proteins, and continuous positive airway cells into the pulmonary pressure [CPAP] greater than interstitium, causing or equal to 5 cm H2O); interstitial and alveolar moderate (100 mm Hg less edema. The accumulation of than PaO2/FIO2 less than or NCM 118: CRITICAL CARE NURSING NCM 119 REVIEWER PAGE 28 template by: @wonrika | transcribed by: @go7dss  NCM 118: CRITICAL CARE NURSING S.Y. ‘24 - ‘25 | SEM #1# | SIR ERVIN ROI CABIBIL & SIR MICHAEL ANGELO AMAUT MIDTERMS fluid compresses alveoli and cellular debris. small airways, damaging type I and type II alveolar cells, which impairs surfactant production and causes further alveolar collapse. b. As a result, hypoxemia develops due to intrapulmonary shunting and ventilation-perfusion (V/Q) mismatching. Increased airway resistance and decreased lung compliance elevate the work of breathing, leading to fatigue and alveolar hypoventilation. Additionally, damage to pulmonary capillaries and the formation of microthrombi contribute to pulmonary hypertension and increased right ventricular afterload, ultimately resulting in right ventricular dysfunction and decreased cardiac output. - Fibroproliferative Phase a. The fibroproliferative phase begins as disordered healing and starts in the lungs. b. Cellular granulation and collagen deposition occur within the alveolar-capillary membrane. The alveoli become enlarged and irregularly shaped (fibrotic), and the pulmonary capillaries become scarred and obliterated. c. This leads to further stiffening of the lungs, increasing Assessment and Diagnosis pulmonary hypertension, and - During the exudative phase, the continued hypoxemia. patient presents with tachypnea, - Resolution Phase restlessness, apprehension, and a. Recovery occurs over several moderate increase in accessory weeks as structural and muscle use. vascular remodeling take - During the fibroproliferative phase, the place to reestablish the patient’s signs and symptoms alveolar-capillary membrane. progress to agitation, dyspnea, fatigue, b. The hyaline membranes are excessive accessory muscle use, and cleared, and intra alveolar fluid fine crackles as respiratory failure is transported out of the develops. alveolus into the interstitium. - ABG analysis shows a low PaO2, c. The type II alveolar epithelial despite increases in supple- mental cells multiply, some of which oxygen administration (refractory differentiate to type I alveolar hypoxemia). epithelial cells, facilitating the - The PaCO2 initially is low as a result of restoration of the alveolus. hyperventilation but eventually - Alveolar macrophages remove increases as the patient fatigues. NCM 118: CRITICAL CARE NURSING NCM 119 REVIEWER PAGE 29 template by: @wonrika | transcribed by: @go7dss  NCM 118: CRITICAL CARE NURSING S.Y. ‘24 - ‘25 | SEM #1# | SIR ERVIN ROI CABIBIL & SIR MICHAEL ANGELO AMAUT MIDTERMS - The pH is high initially but decreases - Low tidal volume Low tidal as respiratory acidosis develops. volume ventilation uses - Initially the chest radiograph may be smaller tidal volumes (6 normal, because changes in the lungs mL/kg) to ventilate the patient do not become evident for up to 24 in an attempt to limit the hours. effects of barotrauma and - As the pulmonary edema becomes volutrauma. The goal is to apparent, diffuse, patchy interstitial provide the maximum tidal and alveolar infiltrates appear. This volume possible, while progresses to multifocal consolidation maintaining end-inspiratory of the lungs, which appears as a plateau pressure less than 30 “whiteout” on the chest radiograph. cm H2O. To allow for Medical Management adequate carbon dioxide - This strategy includes treating the elimination, the respiratory underlying cause, promoting gas rate is increased to 20 to 30 exchange, supporting tissue breaths/min. oxygenation and preventing - Permissive hypercapnia complications. Permissive hypercapnia uses - Given the severity of hypoxemia, the low tidal volume ventilation in patient is intubated and mechanically conjunction with normal ventilated to facilitate adequate gas respiratory rates in an attempt exchange. to limit the effects of - Ventilation atelectrauma and biotrauma. - Traditionally, patients with To maintain normocapnia, the ARDS were ventilated with a patient’s respiratory rate mode of volume ventilation, normally would have to be such as assist/control increased to compensate for ventilation or synchronized the small tidal volume. intermittent mandatory - Pressure control ventilation ventilation (SIMV), with tidal In pressure control ventilation volumes adjusted to deliver 10 mode, each breath is delivered to 15 mL/kg. or augmented with a preset - Current research indicates amount of inspiratory that this approach may have pressure as opposed to tidal actually led to further lung volume, which is used in injury. It is now known that volume ventilation. Thus the repeated opening and closing actual tidal volume the patient of the alveoli cause injury to receives varies from breath to the lung units (atelectrauma), breath. Pressure control resulting in inhibited ventilation is used to limit and surfactant production, and control the amount of increased inflammation pressure in the lungs and (biotrauma), resulting in the decrease the incidence of release of mediators and an volutrauma. The goal is to increase in pulmonary keep the patient’s plateau capillary membrane pressure (end-inspiratory permeability. static pressure) lower than 30 - Excessive pressure in the cm H2O. A known problem alveoli (barotrauma) or with this mode of ventilation is excessive volume in the that as the patient’s lungs get alveoli (volutrauma) leads to stiffer, it becomes harder and excessive alveolar wall stress harder to maintain an and damage to the adequate tidal volume, and alveolar-capillary membrane, severe hypercapnia can occur. resulting in air escaping into - Inverse ratio ventilation the surrounding spaces. Another alternative ventilatory mode that is used in NCM 118: CRITICAL CARE NURSING NCM 119 REVIEWER PAGE 30 template by: @wonrika | transcribed by: @go7dss  NCM 118: CRITICAL CARE NURSING S.Y. ‘24 - ‘25 | SEM #1# | SIR ERVIN ROI CABIBIL & SIR MICHAEL ANGELO AMAUT MIDTERMS managing patients with ARDS intrapulmonary shunting and is inverse ratio ventilation increases compliance. PEEP (IRV), either pressure also has several negative controlled or volume effects, including controlled. IRV prolongs the - (1) decreasing CO as inspiratory time and shortens a result of decreasing the expiratory time, thus venous return reversing the normal secondary to inspiratory-to-expiratory ratio. increased The goal of IRV is to maintain intrathoracic pressure a more constant mean airway and pressure throughout the - (2) barotrauma as a ventilatory cycle, which helps result of gas escaping keep alveoli open and into the surrounding participating in gas exchange. spaces secondary to - High-frequency oscillatory alveolar rupture. ventilation. High-frequency - In most cases, a PEEP of 10 to oscillatory ventilation is 15 cm H2O is adequate. another alternative ventilatory - If PEEP is too high, it can mode that is used in patients result in overdistention of the who remain severely alveoli, which can impede hypoxemic despite the pulmonary capillary blood treatments previously flow, decrease surfactant described. The goal of this production, and worsen method of ventilation is intrapulmonary shunting. similar to that of IRV in that it - If PEEP is too low, it allows the uses a constant airway alveoli to collapse during pressure to promote alveolar expiration, which can result in recruitment while avoiding more damage to alveoli. overdistention of the alveoli. - Extracorporeal and - Oxygen therapy intracorporeal gas exchange. - Oxygen is administered at the Extracorporeal and lowest level possible to intracorporeal gas exchanges support tissue oxygenation. are last-resort techniques - The goal of oxygen therapy is used in the treatment of to maintain an arterial severe ARDS when hemoglobin oxygen saturation conventional therapy has of 90% or greater using the failed. These methods allow lowest level of oxygen, the lungs to rest by facilitating preferably less than 0.50. the removal of carbon dioxide - Positive end-expiratory and providing oxygen external pressure. Because the to the lungs by means of an “ hypoxemia that develops with artificial lung,” or membrane/ ARDS is often refractory or fiber oxygenator. unresponsive to oxygen - Extracorporeal therapy, it is necessary to membrane facilitate oxygenation with oxygenation (ECMO) PEEP. The purpose of using and extracorporeal PEEP in a patient with ARDS is carbon dioxide to improve oxygenation while removal are two reducing FIO 2 to less toxic techniques that levels. PEEP has several employ this type of positive effects on the lungs, technology. including opening collapsed - ECMO is similar to alveoli, stabilizing flooded cardiopulmonary alveoli, and increasing FRC. bypass in that blood is Thus PEEP decreases removed from the NCM 118: CRITICAL CARE NURSING NCM 119 REVIEWER PAGE 31 template by: @wonrika | transcribed by: @go7dss  NCM 118: CRITICAL CARE NURSING S.Y. ‘24 - ‘25 | SEM #1# | SIR ERVIN ROI CABIBIL & SIR MICHAEL ANGELO AMAUT MIDTERMS body and pumped through a membrane 3.3 Pneumonia oxygenator, where CO Description and Etiology 2 is removed and O 2 - Pneumonia is an acute inflammation is added, and then of the lung parenchyma that is caused returned to the body. by an infectious agent that can lead to - Extracorporeal carbon alveolar consolidation. dioxide removal is a - Pneumonia can be classified as variation of ECMO in a. community-acquired which the primary pneumonia (CAP) focus is removal of b. hospital-acquired pneumonia CO2. (HAP) - Tissue Perfusion c. ventilator associated - An adequate CO and pneumonia (VAP) hemoglobin level is critical to - Pneumonia is referred to as oxygen transport. CO depends community acquired when it occurs on heart rate, preload, outside of the hospital or within 48 afterload, and contractility. hours of admission to the hospital. - Newer approaches to fluid Severe CAP requires admission to the management include critical care unit and accounts for maintaining a very low approximately 22% of all patients with intravascular volume pneumonia. The mortality for this (pulmonary artery occlusion patient group is approximately 50%, pressure of 5 to 8 mm Hg) with increasing age as a major risk with fluid restriction and factor. diuretics, while supporting the - Pneumonia is referred to as hospital CO with vasoactive and acquired when it occurs while the inotropic medications. patient is in the hospital for at least 48 - The goal is to decrease the hours and not associated with amount of fluid leakage into mechanical ventilation. the lungs. - VAP refers to development of Nursing Management pneumonia occurring at least 48 hours - The nurse has a significant role in after the insertion of an artificial optimizing oxygenation and airway. VAP is one of the most ventilation, providing comfort and common infections acquired in the emotional support, and maintaining critical care unit. surveillance for complications. - Severe Community-Acquired - Nursing interventions to optimize Pneumonia Pathogens that can cause oxygenation and ventilation include severe CAP include Streptococcus positioning, preventing desaturation, pneumoniae, Legionella spp., and promoting secretion clearance. Haemophilus influenzae, Moraxella - One additional nursing intervention catarrhalis, Staphylococcus aureus, that can be used to improve the Mycoplasma pneumoniae, respiratory oxygenation and ventilation of a viruses, Chlamydia pneumoniae, and patient with ARDS is prone Pseudomonas aeruginosa. positioning. - Numerous factors increase the risk for - Prone positioning results in an developing CAP, including alcoholism; improvement in oxygenation. Turning chronic obstructive pulmonary the patient prone improves perfusion disease; and comorbid conditions to less damaged parts of lungs and such as diabetes, malignancy, and improves V/Q matching and coronary artery disease. decreases intrapulmonary shunting. - Impaired swallowing and altered Prone positioning appears to be more mental status also contribute to the effective when initiated during the development of CAP, because they early phases of ARDS and applied for result in an increased exposure to the at least 12 hours a day. various pathogens related to chronic aspiration of oropharyngeal NCM 118: CRITICAL CARE NURSING NCM 119 REVIEWER PAGE 32 template by: @wonrika | transcribed by: @go7dss  NCM 118: CRITICAL CARE NURSING S.Y. ‘24 - ‘25 | SEM #1# | SIR ERVIN ROI CABIBIL & SIR MICHAEL ANGELO AMAUT MIDTERMS secretions. - Hospital - Acquired Pneumonia Pathogens that can cause HAP include Escherichia coli, H. influenzae, methicillin-sensitive S. aureus, S. pneumoniae, P. aeruginosa, Acinetobacter baumannii, methicillin-resistant S. aureus, Klebsiella spp., and Enterobacter spp.o of the pathogens. Assessment and Diagnosis - The patient may first be seen with a variety of signs and symptoms including dyspnea, fever, and cough productive or nonproductive). Coarse crackles on auscultation and dullness to percussion may also be present. - Patients with severe CAP may present with confusion and disorientation, - Ventilator-Associated Pneumonia The tachypnea, hypoxemia, uremia, types of pathogens that can cause leukopenia, thrombocytopenia, VAP vary with the time of onset. hypothermia, and hypotension. Pathogens associated with early-onset - Chest radiography is used to evaluate VAP include Enterobacteriaceae, a patient with suspected pneumonia. Candida albicans, and Staphylococcus The diagnosis is established by the aureus, whereas pathogens presence of a new pulmonary associated with late-onset VAP infiltrate. The radiographic pattern of include Pseudomonas aeruginosa, the infiltrates varies with the organism Klebsiella pneumoniae, and - A diagnostic bronchoscopy may be Escherichia coli. Most frequently needed, particularly if the diagnosis is associated with VAP are S. aureus and unclear or current therapy is not P. aeruginosa. working. Pathophysiology - In addition, a complete blood count with differential, chemistry panel, blood cultures, and ABGs is obtained. Medical Management - Medical management of a patient with pneumonia includes antibiotic therapy, oxygen therapy for hypoxemia, mechanical ventilation if ALF develops, fluid management for hydration, nutrition support, and treatment of associated medical problems and complications. For patients having difficulty mobilizing secretions, a therapeutic bronchoscopy may be necessary - Antibiotic Therapy Empiric therapy has become a generally acceptable approach. In this approach, choice of NCM 118: CRITICAL CARE NURSING NCM 119 REVIEWER PAGE 33 template by: @wonrika | transcribed by: @go7dss  NCM 118: CRITICAL CARE NURSING S.Y. ‘24 - ‘25 | SEM #1# | SIR ERVIN ROI CABIBIL & SIR MICHAEL ANGELO AMAUT MIDTERMS antibiotic treatment is based on the most likely etiologic organism while avoiding toxicity, superinfection. Failure to respond to such therapy may indicate that the chosen antibiotic regimen does not appropriately cover all the etiologic pathogens or that a new source of infection has developed. A recent systematic review concluded that in the patient with community-acquired pneumonia antibiotic therapy should be initiated within 4 to 8 hours of hospital arrival - Independent Lung Ventilation patients with unilateral pneumonia or severely asymmetric pneumonia, independent lung ventilation, an alternative mode of mechanical ventilation, may be 3.4 Aspiration Pneumonitis necessary to facilitate oxygenation. Description and Etiology Independent lung ventilation allows - The presence of abnormal substances each lung to be ventilated separately, in the airways and alveoli as a result of controlling the amount of flow, volume, aspiration is misleadingly called and pressure each lung receives. A aspiration pneumonia. This term is double-lumen endotracheal tube is misleading because the aspiration of inserted, and each lumen is usually toxic substances into the lung may or attached to a separate mechanical may not involve an infection. ventilator. The ventilator settings are Aspiration pneumonitis is a more then customized to the needs of each accurate term because injury to the lung to facilitate optimal oxygenation lung can result from the chemical, and ventilation. mechanical, or bacterial Nursing Management characteristics of the aspirate. - The nurse has a significant role in optimizing oxygenation and ventilation, preventing the spread of infection, providing comfort and emotional support, and maintaining surveillance for complications. The patient’s response to antibiotic therapy is monitored for adverse effects. - Nursing interventions to optimize oxygenation and ventilation include positioning, preventing desaturation, and promoting secretion clearance. - Prevent Spread of Infection, Proper hand hygiene is the most important measure available to prevent the spread of bacteria from person to person Pathophysiology - The type of lung injury that develops after aspiration is determined by many factors, including the quality of the aspirate and the status of the patient’s respiratory defense mechanisms. - ACID LIQUID The aspiration of acid NCM 118: CRITICAL CARE NURSING NCM 119 REVIEWER PAGE 34 template by: @wonrika | transcribed by: @go7dss  NCM 118: CRITICAL CARE NURSING S.Y. ‘24 - ‘25 | SEM #1# | SIR ERVIN ROI CABIBIL & SIR MICHAEL ANGELO AMAUT MIDTERMS (pH less than 2.5) liquid gastric of breath, coughing, wheezing, contents results in the development of cyanosis, and signs of hypoxemia. bronchospasm and atelectasis almost Tachypnea, tachycardia, hypotension, immediately. Over the next 4 hours, fever, and crackles also are present. tracheal damage, bronchitis, Copious amounts of sputum are bronchiolitis, alveolar-capillary produced as alveolar edema develops. breakdown, interstitial edema, and - ABGs reflect severe hypoxemia. alveolar congestion and hemorrhage Changes on chest radiography appear occur. Severe hypoxemia develops as 12 to 24 hours after the initial a result of intrapulmonary shunting aspiration, with no one pattern being and V/Q mismatching. As the disorder diagnostic of the event. Infiltrates progresses, necrotic debris and fibrin appear in various distribution patterns fill the alveoli, hyaline membranes depending on the position of the form, and hypoxic vasoconstriction patient during aspiration and the occurs, resulting in elevated volume of the aspirate. If bacterial pulmonary artery pressures. The infection becomes established, clinical course follows one of three leukocytosis and positive sputum patterns: (1) rapid improvement in 1 cultures occur. week, (2) initial improvement followed Medical Management by deterioration and development of - Management of a patient with ARDS or pneumonia, or (3) rapid death aspiration lung disorder includes both from progressive ALF. emergency and follow-up treatment. - ACID FOOD PARTICLES The aspiration - When aspiration is witnessed, of acid (pH less than 2.5), emergency treatment is instituted to nonobstructing food particles can secure the airway and minimize produce the most severe pulmonary pulmonary damage. The patient’s reaction because of extensive head is turned to the side, and the oral pulmonary damage. Severe cavity and upper airway is suctioned hypoxemia, hypercapnia, and acidosis immediately to remove the gastric occur. contents. - NONACID LIQUID The aspiration of - Direct visualization by bronchoscopy nonacid (pH greater than 2.5) liquid is indicated to remove large gastric contents is similar to acid particulate aspirate or to confirm an liquid aspiration initially, but minimal unwitnessed aspiration event. structural damage occurs. - Bronchoalveolar lavage is not Intrapulmonary shunting and V/Q recommended, because this practice mismatching usually start to reverse disseminates the aspirate in lungs and within 4 hours, and hypoxemia clears increases damage. within 24 hours. - After airway clearance, attention is - NONACID FOOD PARTICLES The given to supporting oxygenation and aspiration of nonacid (pH greater than hemodynamics. Hypoxemia is 2.5), nonobstructing food particles is corrected with supplemental oxygen similar to acid aspiration initially, with or mechanical ventilation with PEEP, if significant edema and hemorrhage necessary. Hemodynamic changes occurring within 6 hours. After the result from fluid shifts into the lungs initial reaction, the response changes that can occur after massive to a foreign body type reaction with aspirations. granuloma formation occurring around - Monitoring intravascular volume is the food particles within 1 to 5 days. In essential, and judicious amounts of addition to hypoxemia, hypercapnia replacement fluids are instituted to and acidosis occur as a result of maintain adequate urinary output and hypoventilation. vital signs. Assessment and Diagnosis - Empiric antibiotic therapy is usually - Clinically patients present with signs not indicated after aspiration of of acute respiratory distress, and gastric contents. However, antibiotic gastric contents may be present in the therapy is considered if VAP is oropharynx. Patients have shortness suspected or the aspiration event NCM 118: CRITICAL CARE NURSING NCM 119 REVIEWER PAGE 35 template by: @wonrika | transcribed by: @go7dss  NCM 118: CRITICAL CARE NURSING S.Y. ‘24 - ‘25 | SEM #1# | SIR ERVIN ROI CABIBIL & SIR MICHAEL ANGELO AMAUT MIDTERMS occurred in the presence of a small the tube. For patients at risk bowel obstruction or colonized gastric for aspiration or intolerant of contents. gastric feedings, the feeding Nursing Management tube is placed in the small - The nurse has a significant role in bowel. optimizing oxygenation and ventilation, preventing further aspiration events, providing comfort and emotional support, and maintaining surveillance for complications. - Optimize Oxygenation and Ventilation - Nursing interventions to optimize oxygenation and ventilation include positioning, preventing desaturation, and promoting secretion clearance. - Prevent Aspiration - One of the most important interventions for preventing aspiration is identifying patients at risk for aspiration 4.0 NEUROLOGIC ALTERATIONS COMA Guillain Barre Syndrome Craniotomy Intracranial Hypertension 4.1 Coma Description and Etiology - Normal consciousness requires awareness and arousal. - Awareness is the combination of cognition (mental and intellectual) and affect (mood) that can be construed based on the patient’s interaction with - Actions to prevent aspiration the environment. include confirming feeding - Alterations of consciousness may be tube placement, checking for the result of deficits in awareness, signs and symptoms of arousal, or both. feeding intolerance, elevating - The four discrete disorders of the head of the bed at least 30 consciousness are (1) coma, (2) to 45 degrees feeding the vegetative state, (3) minimally patient via a small-bore conscious state, and (4) locked-in feeding tube or gastrostomy syndrome. tube, avoiding the use of a - Coma is characterized by the absence large-bore nasogastric tube, of both wakefulness and awareness. ensuring proper inflation of - Vegetative state is characterized by artificial airway cuffs, and the presence of wakefulness with the frequent suctioning of the absence of awareness. oropharynx of an intubated - In a minimally conscious state, patient to prevent secretions wakefulness is present, and from pooling above the cuff of awareness is severely diminished but NCM 118: CRITICAL CARE NURSING NCM 119 REVIEWER PAGE 36 template by: @wonrika | transcribed by: @go7dss  NCM 118: CRITICAL CARE NURSING S.Y. ‘24 - ‘25 | SEM #1# | SIR ERVIN ROI CABIBIL & SIR MICHAEL ANGELO AMAUT MIDTERMS not absent. - Locked-in syndrome is characterized by the presence of wakefulness and awareness, but with quadriplegia and