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Running head: ACUTE RESPIRATORY FAILURE

Acute Respiratory Failure; ICU Case Study


Beza Fissaha
Old Dominion University

ACUTE RESPIRATORY FAILURE

Acute Respiratory Failure


K.B is a 62 year-old female who was admitted to the ICU on February 1st, 2016 with
acute respiratory failure. During a cruise trip with her husband and daughter, the patient
experienced aspiration pneumonia which resulted unconsciousness. Aspiration causes gastric
contents to be present in the mouth and oropharynx, allowing bacteria to be present in the lungs
thus inevitably leading to aspiration pneumonia (Urdan, Stacey & Lough, 2014, p. 534).
Alteration in the airways leads to acute respiratory failure (Fournier, 2014). The patients family
thought she was sleeping for a period of twelve hours before they called help to the boat. K.B
would then be transported to Norfolk General Hospital by a helicopter. She was admitted to
GICU after being intubated by an endotracheal (ET) tube in the ER. The patient has a history of
obstructive sleep apnea, diabetes mellitus II, depression, COPD, and chronic back pain. After
consistent assessment of the family, the nurse discovered that the patient likely overdosed on her
mothers narcotics, responsible for the aspiration pneumonia. Respiratory failure caused by
aspiration pneumonia resulted in the alterations of multiple body systems, leading to ARDS and
MODS, essentially worsening her overall condition.
The purpose of this case study is to integrate knowledge from the humanities and
sciences, including nursing research and theory, to plan, provide, and evaluate holistic care
provided during this clinical rotation.
Medical Diagnosis
The patient was admitted to the ICU with acute respiratory failure. Acute respiratory
failure is caused by inadequate gas exchange as a result of multiple phenomenons (Fournier,
2014). Respiratory failure can be caused by dead space, shunt unit, silent unit, or a combination
of both. Dead space can be caused when perfusion is not present. Although ventilation occurs

ACUTE RESPIRATORY FAILURE


and the alveolis are inflated with oxygen, there is a lack of blood flow that prevents the
exchange of oxygen to the blood. This prevents oxygen from being perfused to vital organs
(Fournier, 2014). A shunt unit is perhaps the opposite of dead space; although perfusion (blood
flow) is present, there is not ventilation. In this case, the alveolis are not inflated with oxygen.
This also limits the organs consumption of oxygen (Fournier, 2014). Another cause of
respiratory distress is a silent unit, typically seen in acute respiratory distress syndrome and
commonly referred to as ARDS (Fournier, 2014). A shunt unit is caused by both a dead space
and a silent unit, a lack of both ventilation and perfusion (Fournier, 2014).
According to Abrams et al. (2013), when lung injury occurs, mediators such as histones
and histamines, causes injury to the capillaries surrounding the pulmonary system. This increases
permeability and overwhelms the lymphatic system, essentially resulting in interstitial
pulmonary edema. This was evident by the chest X-ray retrieved on admission; results indicated
the accumulation of fluid in the lungs. This was also seen by crackles present in the lungs during
many assessments. This all contributes to the formation of micro clots (micro thrombi), increased
artery pressure, and compression of the small airways (Fournier, 2014). Acute respiratory failure
is defined by hypoxemia with the possible rise in C02, a factor that dictates if the patients lung
failure is type I or II. In type I, the patient is hypoxemic but their C02 level remains normal, 3545.In type II, the patient is hypoxemic and the CO2 level is elevated, a value greater than 45
(Fournier,2014). In cases of type II lung failure, as demonstrated by this patient, there is a
reciprocal relationship between the PH and CO2, essentially causing respiratory acidosis
(Fournier, 2014). Lung failure is also defined by a decrease in PH level; a normal PH level is
7.35-7.45 (refer to Appendix A). In cases when the PH is lower than 7.25, the patient is often
intubated. The patient had a PH level of 7.24 when she was admitted and was immediately

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intubated.
Alterations in important components of the respiratory system such as alveolar-capillary
units, pulmonary circulation, airways, chest wall, nerves, and CNS/brainstem results in
inadequate gas exchange (Urdan, Stacey & Lough, 2014, p.516). There are many complications
(signs and symptoms) that can accompany respiratory failure. As stated previously, hypoxemia
and hypoxia are the most common complications. This leads to decreased tissue perfusion which
can also alter metabolism (Urdan, Stacey & Lough, 2014, p.528 ). In respiratory failure, the body
changes from aerobic metabolism to anaerobic metabolism. This is an issue because the
byproduct of anaerobic metabolism is lactic acid. Excess amount of lactic acid results in
metabolic acidosis, in addition to the already existing respiratory acidosis (Urdan, Stacey &
Lough, 2014, p.502). The patients bicarbonate (HC03) level was 21 on February 2nd and 19.2 on
February 3rd, a normal level is 22-28. This demonstrates metabolic acidosis in addition to the
respiratory acidosis that the patient presents.
Acute Respiratory Distress Syndrome, commonly known as ARDS is also another
complication of respiratory failure. ARDS is characterized by fluid accumulation in the lungs air
sacs, resulting in inflammation of the lungs. This leads to extreme hypoxemia and results in poor
perfusion to vital organs. In ARDS, injuries caused to the lungs increases permeability which
allows blood vessels to leak increased fluid to the air sacks. This results in non-cardiac
pulmonary edema, accumulation of fluid and protein in alveoli (Urdan, 2014, p.520). This
prevents oxygen from filling the lungs and getting transported to the blood stream (Matthay,
Ware, & Zimmerman, 2012). ARDS essentially results in V/Q mismatch, decreased cardiac
output, and impaired ventilation and gas exchange, all of which was manifested by this patient
(Matthay, Ware, & Zimmerman, 2012). The accumulation of fluid in the lungs along with

ACUTE RESPIRATORY FAILURE


hypoxemia often leads to the development of multiple organ dysfunction syndrome (MODS).
MODS was manifested by the patient as seen by severe sepsis, acute kidney failure, neurogenic
shock, cardiovascular changes and liver shock reflected by significantly elevated liver function
tests (LFTs) (refer to Appendix A).If the lungs are not working adequately most, if not all, other
organs are greatly affected thus significantly altering homeostasis. This causes many changes
that are seen in two or more organ systems. The lack of oxygen perfusion to essential organs
such as the kidneys, liver, gut, heart, and brain can lead to a gradual deterioration of the body
(Fournier, 2014).
The patient presented many clinical manifestations often associated with acute respiratory
failure. The lungs inability to adequately provide oxygen to organs can cause cardiac ischemia
and dysrhythmias. This patient had an elevated CPK MB as well as an elevated troponin (refer
to Appendix A). Cardiovascular changes was also seen in the patient by tachycardia. When the
lungs fail to provide adequate oxygen to the body, the heart attempts to compensate by an
increased heart rate. This happens in efforts to try to pump out more oxygen. This however,
increases demand without increasing supply which will initially cause an increase in blood
pressure (Fournier, 2014). The patient remained hypertensive for most of her hospital stay (refer
to Appendix B).Another sign was decreased urinary output. Impaired function of the lungs causes
inadequate perfusion of oxygen to the kidneys. This has a substantial impact on the kidneys and
often leads to acute kidney failure. This was manifested by the patient as intake and output (I
&O) reflected oliguria, the production of abnormally low amounts of urine (Urdan, 2014) (refer
to Appendix C). A build of urine can cause toxins to accumulate in the kidney; this was seen in
the patient by an elevated BUN and Creatinine (refer to Appendix C). GI symptoms are also seen
in respiratory failure. Digestion is impaired due to lack of oxygen perfusion to the gut (Urdan,

ACUTE RESPIRATORY FAILURE

Stacey & Lough, 2014). This is manifested by decreased bowel sounds; although the patient had
present bowel sounds, it was primarily due to medical interventions that assisted with intake and
metabolism. In addition, the liver is also impacted by respiratory failure. Inflammation in the
liver causes the injured liver cells to leak high amounts of liver enzymes, ultimately leading to
congestive hepatomegaly. This is primarily caused by decreased perfusion (low cardiac output)
(Alvarez & Mukherjee, 2011). This is of course the consequence of impaired gas exchange
caused by respiratory failure. The backup of fluid impairs liver function and elevates the livers
biochemical parameters (AST, ALT) to two or three times its normal referenced value which
often causes shock liver (Alvarez & Mukherjee, 2011).When admitted, the patient demonstrated
an AST level greater than 7,000 and an ALT of 4390, both extremely high values that indicate
shock liver (refer to Appendix C). Reduction in tissue perfusion also causes severe sepsis, a
systematic inflammatory state (Burney et al.,2012). This was reflected by the patients elevated
WBC (refer to Appendix C). In addition to all of these complications caused by respiratory
failure, the stress that the body is under can also affect electrolytes, glucose levels, and
neurologic state (Alvarez & Mukherjee, 2011).The patient was completely unconscious and
unable to follow commands until the eleventh day from admission date.
Nursing Diagnosis
The priority nursing diagnosis for this patient is ineffective gas exchange related to
altered V/ Q mismatch, pulmonary edema, and alveolar damage as evidence by inadequate
ventilation, crackles, hypoxemia, and abnormal arterial blood gases (refer to Appendix A)
(Gulanick & Myers, 2013). Ineffective gas exchange is chosen as the priority diagnosis because
it is the main factor responsible for the alteration in other body systems; the lack of gas exchange
is what leads to hypoxemia, essentially causing inadequate perfusion to essential organs

ACUTE RESPIRATORY FAILURE


(Ignatavicius & Workman, 2012). Inadequate gas exchange also causes an alteration in oxygen
carrying capacity, as demonstrated by an increase H & H in this patient (refer to Appendix C).
This causes inadequate delivery of oxygen to the organs, often resulting in hypoventilation.
Arterial blood gases (ABGs) demonstrated hypoventilation by elevated CO2 levels (refer to
Appendix A). Changes that occur in alveolar-capillary membranes is responsible for
inflammatory effects (Alvarez & Mukherjee, 2011).The theorists that best correlates with this
diagnosis is Betty Neuman, founder of the Neuman Systems Model (Neuman & Fawcett, 2012).
The System Model focuses on the use of nursing preventions and interventions in response to
actual or potential environmental stressors. The prevention and interventions used are designed
to attain, retain, or/and maintain optimal health and wellness in the bodys systems (Neuman &
Fawcett, 2012). Neuman states that nurses should work to prevent stress invasion; in cases when
stress occurs to the body, Neuman recommends that the nurse works to protect the patients basic
structure by maintaining maximum level of function (Neuman & Fawcett, 2012). Furthermore,
Neuman views human beings as an open system that is impacted by stressors as well as enteral
and external environmental phenomenons (Newman & Fawcett, 2012). Neumans system model
greatly correlates to this this patient because the internal stressor that initiated an interruption of
homeostasis, was experienced by the patient. In relation to the system model, Aspiration
pneumonia is viewed as an internal environment stressor. (Neuman & Fawcett, 2012). The
patients nurse provided care that correlates to Neumans theory. The nurse prevented further
stress invasion by inhibiting the occurrence of further infections, providing adequate ventilation,
and administering medications that treats pain. In addition, the nurse also prevented blood clots,
corrected glucose levels, and sustains adequate levels of electrolytes. This was achieved by
administering antibiotics that treats and prevents infection, providing analgesics and sedatives

ACUTE RESPIRATORY FAILURE


such as Fentanyl and Ativan, using heparin for DVT prophylaxis, administering insulin for the
management of glucose levels, and providing fluid replacements to correct altered electrolyte
levels. This all contributed to the management of optimal client wellness, the central idea of
Neumans theory.

The second nursing diagnosis that correlates with this patient is risk for infection. Since

this is a risk diagnosis and has not actually occurred, no relation or evidence is provided in the
diagnosis statement (Gulanick & Myers, 2013). Risk for infection is an important diagnosis
related to this patient because the patient presents with many predisposing factors that can
potentially cause infection. Although the patient already has an existing infection as reflected by
elevated WBC levels (refer to Appendix C) , it is essential that the nurse prevents other infections
such as ventilator associated pneumonia (VAP), and central-line associated bloodstream
infection (CLABSI). The theory that best correlates to this nursing diagnosis is Callista Roys
Adaptation Model. Roys Adaptation Model views the patient as a system that is consistently
interacting with both internal and external stimuli while identifying adaptation as the result of
positive environmental changes. Roy identifies fostering successful adaptations as the goal of
nursing care (Masters, 2011). This theory correlates to the patient because interventions that
were implemented by the nurse all contributed to positive adaptation. Decreased levels of WBC
after the, absence of hospital acquired infection, and spontaneous ventilation reflect successful
adaptation by the patient, a key component to Roys theory.
The third nursing diagnosis that best correlates to this patient is ineffective breathing
pattern. This is related to decreased lung compliance and trachea-bronchial secretions, secondary
to pneumonia, as evidence by changes in both respiratory rate and pattern from baseline

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(Gulanick & Myers, 2013). This is a significant diagnosis because the patients ventilator mode

was set on pressure controlled mandatory ventilation, often referred to as PCMV (refer to
Appendix A), for the majority of her hospital stay. This indicates that respirations were initiated
primarily by the ventilator. In addition, secretions also impacts breathing patterns (Miller, 2013).
The theory that best relates to this diagnosis is the Health Promotion Model, designed by Nola
Pender. Penders theory views health as a positive dynamic state as opposed to the absence of
disease (Masters, 2011, p.71). This model highlights the multidimensional aspects of the
individual in relation to both the physical and interpersonal environments involved in reaching
optimal health (Masters, 2011, p.71). Behavior specific variables, in this case the patients
inability to adequately initiate respirations, is the target that dictates what interventions are done
by the nurse as they are conditions amenable for change (Masters, 2011, p.71).This theory
correlates to the patient because the nurse was able to alter variables that dictates effective
breathing patterns. The nurse contentiously suctioned the patient which provides airways
conducive to effective respirations. In addition, the ventilator settings was consistently tweaked
to correlate to the patients condition. The nurse was able to control changes in the environment
in efforts to initiate a behavioral change, a concept influenced by Penders theory (Masters,
2011, p.71).
The last two diagnosis that best fit this patient is impaired spontaneous ventilation and
compromised family coping, prioritized respectively. The patients inability to initiate
respirations supports the diagnosis of impaired spontaneous ventilation related to alveolarcapillary damage and respiratory muscle fatigue (secondary to acute respiratory failure). This is
evidenced by hypoxemia and increased pC02 levels (refer to Appendix A)( Gulanick & Myers,

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2013). The patients family is also at risk for compromised family coping related to situational
crisis. Both the nursing diagnosis of impaired spontaneous ventilation and compromised family
coping can be supported by Florence Nightingales environmental theory (Masters, 2011, p.49).
Nightingales theory focuses on the patient and environment. Nightingale states that the nurse
should manipulate and manage environmental conditions in efforts to enhance the patients
overall health. She extends the definition of health beyond a patients well-being adding that
health also reflects the ability to use every power that our body is capable of (Masters, 2011,
p.49). This correlates with the diagnosis of impaired spontaneous ventilation because the
environment, in this case ventilation settings, was consistently altered. The nurse and physician
attempted to a wean trial in hopes that the patient will gradually initiate spontaneous respirations.
Virginia Hendersons need theory also relates to the diagnosis of impaired spontaneous
ventilation. Henderson emphasized the importance of enhancing a patients independence, this
was also reflected by the wean attempts designed to get start spontaneous ventilations (Masters,
2011, p.50). Nightingales environmental theory also correlates to the diagnosis of compromised
family coping (Masters, 2011, p.49). The nurse consistently altered the environment to better
assist the family in coping with the patients condition. The nurse ensured that the patient looked
presentable by providing consistent hygiene care. This contributes to factors that can potentially
decrease family stressors (Masters, 2011, p.49). In addition, Hildegard Peplaus theory of
interpersonal relations also correlates with compromised family coping (Masters, 2011, p.69).
Peplaus theory focused on the importance of building a therapeutic relationship. The patient was
able to establish a therapeutic relationship with the patients family. The family was able to trust
the nurse and discuss their concerns and needs, demonstrating the positive outcomes of building
a therapeutic relationship (Masters, 2011, p.69).

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Outcomes

Identification of expected outcomes for the top two prioritized nursing diagnosis assists
in providing goals that help the patient reach optimal health (Gulanick & Myers, 2013). There
are multiple outcomes that are related to impaired gas exchange. The patient should have clear
lung sounds by the end of hospitalization and most importantly, initiate spontaneous ventilation
(Miller, 2013). The patient should also maintain oxygen saturation greater than 90% with fi02 of
less than 50%. In addition, complications that alter oxygen delivery such as hyperthermia and
sepsis should be managed and prevented (Fournier, 2014). The positive end-expiratory pressure,
referred to as PEEP, should gradually be decreased. PEEP improves oxygenation while reducing
fi02, the amount of oxygen inhaled. This essentially improves alveolar gas exchange by
increasing the volume of gas remained in the lungs during the end of expiration. PEEP improves
alveolar gas exchange because the pressure left in the lungs during expiration, pushes fluid out of
the lungs while providing more room for gas exchange (Miller, 2013). The PEEP setting should
be targeted to five, a value considered within therapeutic range. Ventilation and perfusion (V/Q)
matching should also be enhanced to better improve the efficiency of the respiratory system.
Related risk factors and associated signs and symptoms of respiratory insufficiency should be
identified upon initiation of Human Response Clinical Practice Guidelines (CPG) (Fournier,
2014).ABGs should also be close to, if not within normal limits post extubation (Fournier,
2014). In addition, airways should be dilated and clear of any sub-glottic secretions during
hospital stay (Fournier, 2014). Gas exchange should be promoted continuously to prevent
instances of desaturation and hypoventilation. Furthermore, complications of impaired gas
exchange including VAP, ARDS, and MODS should be prevented and managed (Fournier,
2014).

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There are also many goals for risk for infection. WBC should gradually but significantly
decrease after the removal of central lines and foreign objects. Vital signs should all remain close
to patients baseline without any signs of hyperthermia (Boev, Xue, & Lingersoll, 2015). In
addition, healthcare associated infections such as VAP and CLABSI should not occur during
hospital stay (Boev, Xue, & Lingersoll, 2015). The cardiovascular symptoms of sepsis should be
managed as evident by normal EKG levels. In addition, BNP levels should decrease after the
management of sepsis and acute kidney injury (Guerin et al., 2013). Factors that affect the
prevention and management of infection, including electrolyte management, should be also be
corrected. This includes factors that results in the accumulation of toxins in the body (elevated
BUN and creatinine) (Fournier, 2014). In addition to monitoring culture results, the use of a
Foley catheter should be removed to prevent any UTIs (Fournier, 2014). The source of any
existing infection should be identified and managed effectively (Fournier, 2014). Factors that can
cause infections such as elevated glucose levels should be monitored and sustained within
therapeutic limits. Furthermore, underlying conditions such as kidney failure and sepsis should
be corrected to reduce the risk of infections (Fournier, 2014).
Interventions

During care of this patient, many interventions were implemented to improve altered gas

exchange and prevent further infections. Interventions for impaired gas exchange all worked to
essentially improve V/Q mismatch. On Feburary 9th, 2016, the patient was put on a spontaneous
breathing trial, a test to see if the patient is able to breath independently (Miller, 2013) .Shortly
after, the patient experienced a decrease in oxygen saturation; the oxygen saturation decreased to
86%. The PEEP setting on the ventilator was increased to ten shortly after to compensate for

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hypoxemia (Miller, 2013). Having an elevated PEEP can have negative impacts; decreased
cardiac output is usually seen since the heart no longer opens and fills passively, essentially
causing it to work harder (Miller, 2013). In addition, the fi02 was also increased to 60% . This
was also done to improve hypoxemia. Administering oxygen that is greater than 50% can cause
excess oxygen in the body and lead to oxygen free radicals, a molecular bi-product of oxygen
metabolism. Excess levels of oxygen can significantly alter a persons DNA (Connell &
Kearney, 2012). However, supplemental 02 should still be provided in relation to the patients
oxygen levels. Increased respiratory rate was also noted, another contributor to a failed wean
trial. Increased respiratory rate is a common cause of extubation failure (Kawsar & Ricaurte,
2013). Increased work of breathing is manifested by increase in respirations, hypoxia and
hypercapnia, all indications that the body is not able to compensate with spontaneous ventilation
(Miller, 2013). Abnormal respiratory parameters demonstrate the lack of the bodys ability to
sustain homeostasis (Miller, 2013). During a wean trial, the patient had a P02 level of 46,
substantially lower than the therapeutic level of 80-100 (refer to Appendix A). In addition, the
patient was hypercapnic; the PC02 level at the time of wean was 26.3 (refer to Appendix A). The
patient was taken off spontaneous mode and put back on PCMV mode as a failed wean trial was
noted. Hypoxemia leads to respiratory acidosis; this causes the body to retain bicarbonate in an
attempt to compensate. This alters the PH and results in metabolic alkalosis. Returning the
patient back on PCMV mode improved hypoxemia and acidosis. Both the nurse and respiratory
therapists followed weaning protocols; the patient was hemodynamically stable, slightly
arousable, and nasal cannula was used to administer oxygen. In addition, levels of PEEP and
ventilator support was low; all critical protocols that identifies a patient ready for a wean trial
(Miller, 2013). It is important that the aim of tidal volume is low; using lower tidal volumes

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diminishes distention of the alveolis. This can also decrease the production of inflammatory
mediators (Miller, 2013).
Decreased level of consciousness due to constant administration of sedatives and
analgesics can contribute to persistent need of ventilation support (Miller, 2013). The patient was
given Fentanyl as needed at 25mcg/ hr. In addition, Ativan was also provided. Continuous use of
medications that dramatically depresses the central nervous system can lead to neurologic
impairment, an independent factor that can lead to unsuccessful wean trials (Miller, 2013). In
addition, MRI results retrieved on February 8th, 2016, reflected a cerebral infarct. In respiratory
failure, impaired gas exchange decreases oxygen perfusion to the brain. This can significantly
impact the brain since it is particularly sensitive to oxygen supply (Miller, 2013). In efforts to
reserve neurologic function, the patient was placed on permissive hypertension, intentionally
increasing blood pressure to better perfuse vital organs (Urdan, Stacey & Lough, 2014,
p.516).Increased blood pressure allows more blood and oxygen to be sent out to the body. This
can also act as a treatment of MODS. The patients blood pressure averaged in 154/100 preextubation (refer to Appendix B). The patient was weaned off the ventilator and successfully
extubated on February 10th, 2016. Spontaneous ventilation reflected oxygen saturation levels
that averaged from 92%-100%. This is an indicator of success in independent ventilations
(Miller, 2013). The patient was put on high flow cannula that contained thirty liters of oxygen
with a fi02 of 80%. This is significant because it reflects the continuing effects of lung injury;
although the patient is no longer on a ventilator, structural damages are not able to return to prelung injury phase (Guerin et al., 2013). High-flow systems delivers oxygen that is sufficient to
meet the inspiratory volume requirements (Urdan, 2014, p.551). High levels of oxygen is

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required because the lungs are not able to quickly adapt to spontaneous ventilation (Guerin et al.,
2013).
Implementing rotation and prone therapy maximized V/Q mismatch. Evidenced based
data demonstrates there 70-80% of patients show improvement in oxygenation and respiratory
mechanics after the implementation of prone therapy (Drahnak & Custer, 2015). The prone
position causes trans-pulmonary pressure that is delivered in homogenous distribution as
opposed to the supine position in which alveolar inflation solely depends on the trans-pulmonary
pressure available. In cases of respiratory failure patients, particularly in ARDS, there is already
a significant decrease in available pressure (Drahnak & Custer, 2015). The ability of prone
positioning to improve V/Q mismatch causes a reduction in the physiologic shunt, substantially
improving impaired gas exchange (Drahnak & Custer, 2015). Turning the patient every four
hours and rotating the lung zones, as related to the critical care standards of practice, also
improves V/Q mismatch because it promotes increased diffusion, perfusing the alveolar surface
space adequately (Drahnak & Custer, 2015). Considerations related to the critical standards of
practice also indicates that respiratory therapy, in addition to breathing exercises, is used to
promote an effective airway clearance (Drahnak & Custer, 2015). An intensive spirometer was
used to increase and maximize diffusion and expand the alveolar surface area (Fournier, 2014).
Teaching was provided to the family regarding the use of the incentive spirometer. The nurse
demonstrated proper use of the spirometer and asked the family to call her if she had any
questions. She encouraged the family to routinely use the incentive spirometer. The patients
husband wanted to refrain from providing any interventions for respect to his wife. The nurse
encouraged him to share any other concerns and ensured him that she would let him know any

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time she would perform any procedures. The nurse consistently informed him during remaining
procedures.
Factors that impair adequate gas exchange was also prevented. Suctioning was
persistently used to prevent any secretions in the airways. Suctioning is able to provide clearance
of the airways in addition to preventing VAP (Guerin et al., 2013). In an event that aspiration is
witnessed, the nurse should secure the airway and minimize pulmonary damage. This can be
done by turning the patient on right side tendelenberg before suctioning. This is done because the
trachea bifurcates as more of a slope on the right while the left side consists of a sharp
bifurcation (Guerin et al., 2013).
Practices that prevent further damage in the airways was also implemented. Chest therapy
was provided to loosen up secretions in the airways. The barium swallow test was used to
examine the patients ability to intake food and water by mouth. This test is used to identify any
signs of difficulty or pain when swallowing. The identification of this assists in preventing
aspiration and respectively further damage to the airways (Carlucci, Graf, Simmions, &
Corbridge, 2014). In addition, Heparin was administered at 1,200 units. The inflammation
caused by sepsis can cause blood clots and block oxygen perfusion, further impairing adequate
gas exchange (Barney et al., 2011). Heparin, an anticoagulant, prevents blood clots thus
promoting movement of blood flow (Barney et al., 2011). The nurse was able to follow Sentara
Hospitals aPTT protocol when facilitating heparin administration. The patient was on
18units/kg/hr on February 10th. After checking the aPTT level, the nurse gave a bolus of
80units/kg then increased her infusion by four. The patient was then on 22units/kg/hr. This was
done because the patient had an aPTT of 31, a decreased result as reference levels indicate 45-80.

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In addition to managing impaired gas exchange, there were also interventions for risk of
infection, conducted to prevent any further complications. Interventions that were aimed at
preventing further infections included correcting lab values, discontinuing invasive lines,
localizing the source of increased WBC, correcting I & O, managing therapeutic vital signs, and
adequately treating the manifestation of MODS and sepsis. There were many lab values that
indicated possible risk for infection. There was an increased level of WBC; it was 32.2 on
February 9th, 2016. This was accompanied by a temperature of 100.3 (refer to Appendix B). This
is indicative of a developing infection (Kleinpell, Aitken, & Schorr, 2013). An infection would
contribute to the preexisting sepsis, essentially adding to the inflammatory state and worsening
her condition (Kleinpell, Aitken, & Schorr, 2013). The cellular process caused by the effects of
inflammation can further impair perfusion and worsen the damage of the organs (Kleinpell,
Aitken, & Schorr, 2013). To identify the source of foreign attack, the patient was scheduled for
an Indium scan. This procedure consists of retrieving white blood cells, particularly neutrophils,
and injecting them into the patient after the blood is tagged with a radioactive chemical known as
Indium. This is injected through IV and is able to provide a visual on the location of infection.
This is done to further specify interventions that will decrease risks and decrease white blood
count (Kleinpell, Aitken, & Schorr, 2013); results were not obtained as they were pending during
point of care. In order to prevent further elevation of WBC, all central lines and invasive
interventions were removed, a concept referred to as holiday line. This consisted of
discontinuing the Foley catheter, fecal monitoring system, and any other invasive procedures.
This also discontinued dialysis; on February 11th, the patient had an intake of 569.57 and an
output of 0ml, demonstrating ineffective urine production without the use of dialysis. This is
done to decrease WBC count as the infection source can possibly be due to CLABI (Humphrey,

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2015). Although dialysis was discontinued, the patient was put back on it shortly after. Evidence
based practice demonstrates that the prevention of CLABI requires a compressive understanding
of factors that can possibly contaminate catheters. The nurse consistently followed practice
guidelines as she ensured to prevent nosocomial infections; this was done by compliancy to daily
recommended nursing practice including hand hygiene (Humphrey, 2015). Other preventions
included sterile barrier precautions, appropriate technique and selection of insertion site, and
implementing IV care (Humphrey, 2015). The patients daughter frequently asked questions
about why things were being done. The nurse always gave reassuring answers and consistently
kept her informed.
Glucose levels were managed by administering one to six units of Insulin
subcutaneously, every six hours. Although the patient did have diabetes mellitus II, her glucose
levels was only managed by diet control. The stress in addition to the administration of
corticosteroid drugs, a class of medications known to increase glucose levels, significantly
increased her glucose, requiring the administration of insulin (Kleinpell, Aitken, & Schorr,
2013). The patient had a glucose level of 173 on February 9th, 2016. The patient was given one to
six units of Insulin subcutaneously every eight hours. The BUN and creatinine levels were also
elevated. Elevation in these lab values indicate an accumulation of waste in the body (Ware et
al.,2013).On February 9th, the patient had a BUN level of 86 and a creatinine level of 5.7, both
elevated values (refer to Appendix C). In addition, the effects of MODS is reflected by kidney
damage. This is seen as the patient experienced oliguria, abnormally decreased amount of urine
(Ware et al., 2013). The patients intake was 2175 ml on February 9th. The outtake was
documented as 1155 ml. This reflects a net fluid of 1020 ml. The patient was put on dialysis to

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assist with impaired renal function (Wald et al., 2015). Kidney injury prevents effective
clearance of excess fluid and wastes from the blood stream, as demonstrated by elevated
creatinine levels. Dialysis is able to filter and purify the blood using a machine (Wald et al.,
2015). Although dialysis is able to assist in filtering the blood, it does not correct other functions
of the kidney such as the production of erythropoietin, a hormone that increases the production
of blood cells. Ergocalciferol (Vitamin D2) of 50,000 was scheduled every seven days to
improve kidney function. Vitamin D assists in regulating the immune system, a key component
to the patients recovery (Wald et al., 2015)
Managing other disease manifestations such as sepsis secondary to aspiration pneumonia
and preventing hospital acquired infections is critical in preventing new infections (Ware et al.,
2013). Secretions can pull above the ETT cuff and contaminate the lower respiratory tract (Boev,
Xue, & Lingersoll, 2015). This can cause further infection in addition to continued structural
damage of the pulmonary system (Boev, Xue, & Lingersoll, 2015). The nurse followed standards
of practice by checking the position of the ET tube every four hours. Prevention practices such as
using the CASS tube, elevating the head of bed to 30 degrees and mouth care were implemented
in reference to the recommended guidelines (Boev, Xue, & Lingersoll, 2015). This all assist in
the prevention of ventilator associated pneumonia. The nurse also provided instructions on how
to provide mouth care to the patients family. The patient did not want anyone but her daughter
to provide mouth care. After the discontinuation of ventilation support, the patient was placed on
a swallow test to evaluate her tolerance to fluid in the lungs. This is done to see if feeding can be
initiated and serves as a hallmark for the risk of aspiration. Medications were also provided to
manage Sepsis and act as a prophylactic for other infections. The patient was given Vancomycin

ACUTE RESPIRATORY FAILURE

20

that was dosed based on cultures. The patient was also on Meropenem, an antibiotic; one gram
in 100 ml of NS was given through IV every twenty four hours. In the event that the patient is
discharged, the nurse should implement teachings on the importance of finishing the full
prescribed dose of antibiotics. This will help prevent resistance (Burney et al., 2012). Managing
septic shock and MODS is also critical in preventing other infections. Septic shock occurs as a
complication of infection when wastes and toxins build up and initiate a systemic inflammatory
response (Barney et al., 2011). This was managed by antibiotics and pain medications (Barney et
al., 2011) Hepatoxins including certain medication should also be avoided to help resolve shock
liver secondary to.
Literature Review
The research articles used in this case study all correlate to the phenomenon of acute
respiratory failure. The following three articles specifically support rationales for the outcomes
and interventions used for this patient. The following articles had both advantages and
limitations.

The first source utilized was, Set The Stages For Ventilator, a journal written by Nichole

Miller. This article applies to this patient because it discusses modes on ventilators and explains
how each mode effects the pulmonary system. The article has many advantages that strengthen
the case study. The author has a BSN degree and is a direct care ICU nurse; this adds credibility
to information pertained to nursing process and nursing interventions implemented in the
intensive care unit. The article is also a nursing journal, demonstrating the contribution of
evidence based practice in the field of Nursing. The journal provides thorough explanations of
various ventilator settings and provides indications for each mode. This is beneficial in

ACUTE RESPIRATORY FAILURE


21

correlating the patients ventilator settings to what they indicate physiologically. In addition, the
journal also provides tables and visuals, making the information more organized. The journal
also contains pictures, demonstrating multiple methods to promote the concepts addressed. The
journal was also written in 2013, an appropriate time frame that still reflects credibility in current
practice. The journal engages the reader and consists of an easy but informative read. Although
there are many advantages, there are also some limitations. The journal is written by one author;
this can be a limitation because some statements can be based solely on clinical experience while
others can be bias. In addition, the lack of authors can limit information validation.
The second journal used was Early Detection and Treatment of Severe Sepsis in the
Emergency Department: Identifying Barriers to Implementation of a Protocol-based Approach
written by Maura Burney and colleagues. This journal was chosen because the patient developed
severe sepsis and went into septic shock; literature on sepsis can help identify the best
interventions that the nurse can implement. This journal also has both advantages and
limitations. The journal is written my seven authors and consists of both doctors and nurses. This
is beneficial because although the practices of profession differs, both work towards the common
goal of maximizing patients function. Multiple authors also provide more validity as bias is
limited. In addition, the journal also provides a quantitative study that was implemented. This
provides barriers that prevent or delay adequate treatment of sepsis/septic shock; this is
important because it can assist in improving standards of practice. The journal consists of many
graphs and tables, demonstrating credibility to the study implemented. The authors also address
limitations to the survey; this assists in adding credibility and validity to the results. There are
also disadvantages to this journal. The study itself is longer than the implications and discussion

ACUTE RESPIRATORY FAILURE


22

section. This limits nursing indications concluded by the results. In addition, the article is from
the journal of emergency nursing, perhaps a more hectic environment than the ICU. The study
was also conducted through an online survey, a method that can greatly influence bias and
invalidity. (Barney et al., 2011)

The third journal that supported this case study was Prone Positioning of Patients with

Acute Respiratory Distress Syndrome written by Dawn M. Drahnak and Ncole Custer. This
article was chosen because the lung injury that caused alterations in V/Q mismatch gradually led
to the development of ARDS. This journal was used because prone positioning helps maximize
V/Q mismatch by redistributing blood flow to dependent lung units, a concept that improves
oxygenation and perfusion, essentially improving gas exchange. There are many advantages to
this this journal. Both of the authors are nurses, adding credibility to findings related to nursing
process and nursing practice. In addition, the journal is organized and broken into sections with
subheadings. This allows the reader to easily follow. The article also provides many aspects of
ARDS, in relation to prone therapy, including evidence to support the use of prone positioning
with ARDS, procedures for achieving prone positioning, and nursing implications. This reflects
thorough information provided about prone therapy as it relates to ARDS, effectively
contributing to the field of nursing. The journal also provides tables that contains sections of
focused agenda; for example, causes of ARDS is identified and categorized into direct and
indirect injuries. This provides a comprehensive method in providing important information. The
journal also provides a very detailed section on nursing implications. This helps contribute to the
field of nursing. In addition there are also pictures that accompany some sections, assisting the
reader in better understanding the concept. This journal also has a few limitations. The journal

ACUTE RESPIRATORY FAILURE

23

does not identify any potential complications of prone therapy, an important component to be
aware of. In addition the journal also fails to provide adequate information on contraindications
to prone therapy (Drahnak & Custer, 2015).
Evaluation
There were both successful and unsuccessful outcomes for the interventions
implemented. The patient was able to maintain adequate gas exchange as spontaneous ventilation
was initiated. She was able to sustain oxygen saturation levels of 92-100%. In addition, sepsis,
MODS, and prevention of nosocomial infections were effectively managed. The patients WBC
decreased to 99.6 and shock liver was also resolved. The patient also screened negative for Cdiff. Furthermore, cutlers were negative when the patient was tested for central line associated
infections; this demonstrated effective protocol procedures that prevent hospital acquired
infections. There was also an improvement seen in the patients ABGs post ventilation support.
The patient had a PH level of 7.49, PC02 of 31.7, and HC03 of 24.3. Although the patient
remains slightly acidotic, the levels demonstrate a decreasing trend indicating an effective
compensation. The patients P02 level was 78, a significantly low value. This can be managed by
increasing oxygen levels on the high flow. The patient also had decreased rhonchi. This is a
significant finding because it reflects decreased secretions thus demonstrating an improved
airway (Miller, 2013). The patient was also able to pass any permissive hypertension window.
There was also significant improvement in the patients altered mental status. Shortly after
spontaneous ventilation was initiated, the patient was able to follow commands and demonstrate
both voluntary and involuntary movements. The patient did not display agitation or delirium.

ACUTE RESPIRATORY FAILURE

24

Neurologic function is essential in monitoring adequate perfusion to organs (Matthay &


Zimmerman, 2012).
There were also many interventions that did not have successful outcomes. After the
removal of all invasive lines (line holiday), the patient still demonstrated an increased WBC
count; her WBC was 32 on February 11th. In addition, BUN & creatinine remained elevated
(BUN-84 Creatinine-6.4). This however, can be caused because the patient has acute kidney
failure. Dialysis had to be held since the blood culture that tests for CLABI were not retrieved.
This is because cultures have to be negative for approximately 48 hours before declaring
negative for CLABI (Humphrey, 2015). Lung sounds demonstrated decreased sounds in left
lower lobe; no wheezing was present. In this case, the absence of wheezing is actually a negative
finding. In patients with ARDS, wheezing can actually indicate improvement of breathing; the
absence of wheezing indicates great constriction of the airways (Boev, Xue, & Lingersoll,
2015).The patient also failed the bed side swallow test (2 times) as she had difficulty drinking
small amounts of water. Speech test was pending at the time of care. These are all results that are
not out of the ordinary; after ARDS, the lungs do not generally recover to the pre-ARDS level of
function. Structural and vascular remodeling are initiated after weeks during the resolution phase
(Miller, 2013). In addition, glucose levels also increased to 105 during the initiation of insulin
therapy. The patients corticosteroids were also discontinued during the reading of this value.
Further stress can be decreased by altering the environment and providing pain medication.
Stress has a significant impact on glucose levels (Humphrey, 2015).
Conclusion

ACUTE RESPIRATORY FAILURE


25

This case study highlights an ideal ventilator patient that is admitted to the ICU.
Although admission diagnosis can differ from patient to patient, the systematic effects that one
organ can cause on another can only be grasped by comprehending that one system is not able to
function without the others. This patient demonstrated this phenomenon as injury to the lungs
disrupted multiple body circuits. The damaged lungs caused a V/Q mismatch eventually leading
to ARDS. The lack of adequate oxygen perfusion also led the patient to develop sepsis, further
damaging the lungs and other systems. Lung injury caused pulmonary, CNS, CV, renal, GI, and
systemic influences demonstrating that a mismatch in ventilation and perfusion can dramatically
alter the bodys homeostasis.
I have learned a lot in this clinical rotation and have gained an in-depth understanding of
acute respiratory failure through research and data related to this case study. Specifically, I
comprehend the significance of surveillance and protocol used in the critical care unit. The
learning experience gained from this case study will enhance my ability to provide care altered to
the critical care patient.

ACUTE RESPIRATORY FAILURE

26

References
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Circulating Histones Are Mediators of Trauma-associated Lung Injury. Am J Respir Crit
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Alvarez, A., & Mukherjee, D. (2011). Liver Abnormalities in Cardiac Diseases and Heart
Failure. Int J Angiol International Journal of Angiology, 20(03), 135-142. Retrieved
February 21, 2016.
Boev, C., Xue, Y., & Ingersoll, G. L. (2015). Nursing job satisfaction, certification and
healthcare-associated infections in critical care. Intensive and Critical Care Nursing, 31(5), 276284. Retrieved February 21, 2016.

ACUTE RESPIRATORY FAILURE


27

Burney, M., Underwood, J., Mcevoy, S., Nelson, G., Dzierba, A., Kauari, V., & Chong, D.
(2012). Early Detection and Treatment of Severe Sepsis in the Emergency Department:
Identifying Barriers to Implementation of a Protocol-based Approach. Journal of Emergency
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Drahnak, D. M., & Custer, N. (2015). Prone Positioning of Patients With Acute Respiratory
Distress Syndrome. Critical Care Nurse, 35(6), 29-37.
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outcomes (8th ed.). St. Louis, MO: Mosby.

Fournier, M. (2014). Caring for patients in respiratory failure. American Nurse Today, 9(11).
Retrieved February 20, 2016.
Humphrey, J. S. (2015). Improving Registered Nurses' Knowledge of Evidence-Based Practice
Guidelines to Decrease the Incidence of Central Line-Associated Bloodstream Infections:
An Educational Intervention. Journal of the Association for Vascular Access, 20(3), 143-149.
Retrieved February 21, 2016.
Ignatavicius, D. D., & Workman, M. L. (2010). Medical-surgical nursing: Patient-centered
collaborative care. St. Louis, MO: Saunders/Elsevier.
Kawsar, H., & Rocaurte, B. (2013). Weaning Patients from the Ventilator. New England Journal
of Medicine. Retrieved February 21, 2016.
Kleinpell, R., Aitken, L., & Schorr, C. A. (2013). Implications of the New International Sepsis

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Guidelines for Nursing Care. American Journal of Critical Care, 22(3), 212-222.
Retrieved February 20, 2016.
Masters, K. (2012). Nursing theories: A framework for professional practice. Sudbury, MA:
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Matthay, M., Ware, L., & Zimmerman, G. (2012). The acute respiratory distress
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Miller, N. (2013). Set the stage for ventilator settings. Nursing Made Incredibly Easy!, 11(3), 4452. Retrieved February 21, 2016.
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Neuman, B., & Fawcett, J. (2012). Thoughts about the Neuman Systems Model: A
Dialogue. Nursing Science Quarterly, 25(4), 374-376.
O'connell, K. M., & Littleton-Kearney, M. T. (2012). The Role of Free Radicals in Traumatic
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Restrepo, R. D., Wettstein, R., Wittnebel, L., & Tracy, M. (2011). Incentive Spirometry:
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Schreiber, M. P., Colantuoni, E., Bienvenu, O. J., Neufeld, K. J., Chen, K., Shanholtz, C., . . .
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Acute Lung Injury*. Critical Care Medicine, 42(6), 1480-1486. Retrieved February 21, 2016.

Wald, R., Mcarthur, E., Adhikari, N. K., Bagshaw, S. M., Burns, K. E., Garg, A. X., . . .
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Appendix A:
Normal ABGS= PH-7.35-7.45___PC02-35-45___HC03-22-28___P02-80-100___02 Stat-95-100%

ABGs
PH
PCO2
HCO3
PO2
02 SAT

VENT SETTINGS

Mode
Fi02
Vent rate
Total Respirations
PEEP
VT Exh (ml)
VT ml/kg
Plateau
Cstat

VENT SETTINGS

Mode
Fi02

2/8/16
7.43
30 (L)
20.3 (L)
89
94& (L)

2/9/16
7.52 (H)
30.3 (L)
21.7 (L)
134 (H)
86% (L)
2/9 / 16
PCMV
60 (was temporarily set on 100)
12
26
10
323 ml
8.8 ml/kg
18
20
2/10/ 16
PCMV
50

2/10/16
7.49 (H)
31.7 (L)
24.3 (L)
78 (L)
96%

ACUTE RESPIRATORY FAILURE



Vent rate
Total Respirations
PEEP
VT Exh (ml)
VT ml/kg
Plateau
Cstat
Troponin
0.12 (H) 2/7/16


31

12
32
8
528
8.6 ml/kg
20
40
Other Significant lab values
CPK -MB
17.5 (H) 2/2

LFTs
AST > 7000 2/2
ALT-4390 2/2 901 2/8
Albumin- 2.9 2/6

Appendix B
VITALS

2/9/16

2/10/16

Temp

100.3

99.6

Resp

26

25

BP

165/86

143/78

2/11/16

Pulse

150/40

ACUTE RESPIRATORY FAILURE

32

Sp02

86%

90%

92%

Appendix C
Intake & Output
2/09/16

2/10/16

2/11/16

Intake

2175ml

3015ml

569.57ml

Output

1155ml

1490ml

0ml

Net

1020ml

1525ml

569.57ml

LABS

2/11/16

WBC

32 (H)

RBC

2.65 (L)

HGB

7.9 (L)

HCT

23.0 (L)

ACUTE RESPIRATORY FAILURE

33

LABS

2/9

2/10

2/11

BUN

86 (H)

57 (H)

84 (H)

Creatinine

5.7 (H)

4.7 (H)

6.4 (H)

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