A patient with exacerbated left-sided heart failure presents with labored breathing, wheezing, crackles, and elevated jugular venous pressure. Despite initiating high-flow oxygen and diuretics, the patient's oxygen saturation remains marginally improved at 90%. Which intervention should the nurse anticipate the healthcare team will implement next to improve the patient's respiratory status?

B) Initiate continuous positive airway pressure (CPAP)

A) Administer bronchodilators to relieve wheezing

B) Initiate continuous positive airway pressure (CPAP)

C) Increase the dosage of diuretics

D) Position the patient in Trendelenburg to enhance oxygenation

A patient with acute pulmonary edema is experiencing significant respiratory distress and hypoxemia despite initial interventions. The healthcare team is considering the use of continuous positive airway pressure (CPAP). What is the primary rationale for using CPAP in this clinical scenario?

D) To reduce preload and decrease fluid accumulation in the alveoli.

A) To increase cardiac output by decreasing afterload.

B) To improve alveolar ventilation and reduce carbon dioxide retention.

C) To facilitate the clearance of pulmonary secretions.

D) To reduce preload and decrease fluid accumulation in the alveoli.

A patient with worsening respiratory acidosis is being treated with CPAP and vasopressors due to acute respiratory failure secondary to pulmonary edema. Which nursing intervention is most critical in evaluating the effectiveness of these treatments?

B) Assessing the patient's breath sounds and respiratory effort frequently.

A) Monitoring the patient's urine output every 2 hours.

B) Assessing the patient's breath sounds and respiratory effort frequently.

C) Checking the patient's peripheral pulse oximetry readings hourly.

D) Evaluating the patient's level of consciousness every 4 hours.

A patient with worsening respiratory acidosis and hemodynamic instability has been placed on CPAP and started on a vasopressor infusion. The nurse assesses the patient and notes an improvement in oxygen saturation to 92% but observes continued tachypnea and anxiety. What is the nurse's priority action at this time?

D) Prepare for possible endotracheal intubation and mechanical ventilation

A) Increase the CPAP pressure to further improve oxygenation

B) Administer a sedative to reduce the patient's anxiety and respiratory rate

C) Reassess the patient's blood pressure and adjust the vasopressor dosage as needed

D) Prepare for possible endotracheal intubation and mechanical ventilation

A patient with respiratory distress is being managed with CPAP and vasopressor support. Despite slight improvements, the patient's ABG indicates continued respiratory compromise with a pH of 7.30, PaCO2 of 56 mmHg, and PaO2 of 60 mmHg. The healthcare team is considering transitioning to invasive mechanical ventilation. Which clinical finding most strongly supports the need for this intervention?

A) Oxygen saturation of 90% with persistent accessory muscle use

B) Heart rate stabilizing at 110 bpm

C) Blood pressure reading of 92/58 mmHg

A patient in respiratory distress is on CPAP therapy with slight improvement in oxygen saturation, but persistent hypercapnia and borderline hypoxemia remain. The healthcare team is considering transitioning to invasive mechanical ventilation. Which of the following findings is most critical in deciding to initiate mechanical ventilation?

C) Persistent use of accessory muscles and elevated PaCO2

A) Oxygen saturation improving to 92%

B) Respiratory rate decreasing to 28 breaths per minute

C) Persistent use of accessory muscles and elevated PaCO2

D) Blood pressure stabilizing at 110/70 mmHg

A patient with worsening pulmonary edema and a decreasing Glasgow Coma Scale score is being prepared for intubation. Which nursing intervention is the most critical to perform immediately before the procedure to ensure patient safety?

B) Ensure suction equipment is operational and immediately available.

A) Administer a sedative to ensure the patient is calm during intubation.

B) Ensure suction equipment is operational and immediately available.

C) Position the patient in a semi-Fowler's position to improve ventilation.

D) Obtain an arterial blood gas sample to assess the current respiratory status.

A patient with worsening pulmonary edema and right-sided pleural effusion is being prepared for intubation due to declining respiratory status and decreased level of consciousness. Which nursing intervention should be prioritized to optimize the patient's hemodynamic status before intubation?

A) Administering diuretics to reduce fluid overload

B) Positioning the patient in semi-Fowler's position to enhance oxygenation

C) Initiating vasopressor support to stabilize blood pressure

D) Providing high-flow oxygen therapy to increase oxygen saturation

A patient recently transitioned to mechanical ventilation is experiencing significant hypotension with a blood pressure of 85/50 mmHg. Given the presence of mild metabolic acidosis and pulmonary edema, which of the following nursing interventions is most appropriate to address the patient's hemodynamic instability?

B) Administer vasopressors to improve vasomotor tone and stabilize blood pressure.

A) Rapidly administer intravenous fluids to increase circulating volume.

B) Administer vasopressors to improve vasomotor tone and stabilize blood pressure.

C) Increase the positive end-expiratory pressure (PEEP) to improve oxygenation.

D) Reduce sedation to allow for spontaneous breathing efforts to increase cardiac output.

A patient who was recently intubated and placed on mechanical ventilation is experiencing a significant drop in blood pressure. The healthcare team is considering various interventions. Which of the following actions should the nurse prioritize to address the patient's hypotension while minimizing the risk of exacerbating pulmonary edema?

B) Start a norepinephrine drip to stabilize blood pressure.

A) Administer a rapid bolus of 500 mL normal saline.

B) Start a norepinephrine drip to stabilize blood pressure.

C) Increase the ventilator's positive end-expiratory pressure (PEEP) setting.

D) Administer diuretics to reduce fluid overload.

Pulmonary Edema - Nursing Case Study

Pathophysiology

• Primary mechanism: Increased hydrostatic pressure in pulmonary capillaries, often due to left-sided heart failure, forces fluid into alveolar spaces, impairing gas exchange and causing respiratory distress.

• Secondary mechanism: Damage to the alveolar-capillary membrane, as seen in acute respiratory distress syndrome (ARDS), increases permeability, allowing proteins and fluid to leak into alveoli.

• Key complication: Accumulation of fluid in alveoli reduces lung compliance and oxygenation, leading to hypoxemia and increased work of breathing, which can rapidly progress to respiratory failure if untreated.

Patient Profile

Demographics:

62-year-old male, retired construction worker

History:

• Key past medical history: Hypertension, coronary artery disease, previous myocardial infarction

• Current medications: Lisinopril 10 mg daily, Metoprolol 50 mg twice daily, Aspirin 81 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Shortness of breath and difficulty breathing

• Key symptoms: Persistent cough with frothy sputum, orthopnea, paroxysmal nocturnal dyspnea, fatigue

• Vital signs: Blood pressure 160/95 mmHg, heart rate 110 bpm, respiratory rate 28 breaths per minute, oxygen saturation 88% on room air, temperature 37.2°C

Section 1

During the initial assessment, the nurse observes that the patient is in visible distress, with labored breathing and an audible wheeze upon auscultation of the lungs. Crackles are present in both lower lobes, indicating fluid accumulation. The patient is using accessory muscles to breathe, and his skin appears pale and slightly diaphoretic. The jugular venous pressure is elevated, suggesting increased central venous pressure and potential right-sided heart strain secondary to left-sided heart failure. The patient's extremities are cool to the touch, and there is mild pitting edema in the lower limbs, consistent with fluid overload.

Given these findings, the healthcare team orders a chest X-ray and arterial blood gas (ABG) analysis to further assess the extent of pulmonary involvement and gas exchange efficiency. The chest X-ray reveals bilateral pulmonary infiltrates, consistent with pulmonary edema, and mild cardiomegaly, suggesting exacerbation of cardiac issues. The ABG results indicate respiratory acidosis with a pH of 7.30, PaCO2 of 55 mmHg, and PaO2 of 60 mmHg, confirming significant hypoxemia and hypercapnia due to impaired ventilation.

In response to these findings, the care team initiates high-flow oxygen therapy to improve oxygen saturation and diuretics to reduce fluid overload. The patient is placed in a semi-Fowler's position to aid breathing. Despite these interventions, his oxygen saturation only marginally improves to 90%, and his respiratory rate remains elevated. The team considers further intervention, such as continuous positive airway pressure (CPAP) to provide respiratory support and decrease the work of breathing, while closely monitoring for potential complications like acute respiratory failure. This situation prompts the team to prepare for potential escalation to more advanced respiratory support, should the patient's condition deteriorate further.

Section 2

As the healthcare team continues to monitor the patient, they note a change in his status that raises concern for new complications. Despite the initial interventions, the patient's respiratory distress persists, and his oxygen saturation begins to decline again, dropping to 86% on high-flow oxygen. His respiratory rate increases to 34 breaths per minute, indicating increased respiratory effort and potential fatigue. The nurse observes that the use of accessory muscles is now more pronounced, and the patient appears increasingly anxious, struggling to maintain adequate ventilation.

A repeat arterial blood gas analysis is performed, revealing worsening respiratory acidosis with a pH of 7.28, PaCO2 of 58 mmHg, and PaO2 of 55 mmHg. These results indicate that the patient is not effectively clearing carbon dioxide, leading to further respiratory compromise. His heart rate has increased to 120 beats per minute, and blood pressure has decreased to 90/60 mmHg, suggesting potential hemodynamic instability. The team recognizes that these changes could indicate the onset of acute respiratory failure, secondary to the pulmonary edema and underlying cardiac issues.

In response to these developments, the healthcare team decides to escalate respiratory support to CPAP to help decrease the work of breathing and improve gas exchange. Simultaneously, they initiate an intravenous infusion of a vasopressor to support the patient's blood pressure and ensure adequate perfusion. The team remains vigilant for signs of further decompensation and prepares to initiate invasive mechanical ventilation if CPAP proves insufficient. This decision-making process reflects the need for critical thinking and timely intervention to address the complex interplay of respiratory and cardiac complications in this patient.

Section 3

As the healthcare team implements CPAP and the vasopressor infusion to stabilize the patient, they remain vigilant for signs of improvement or further deterioration. Over the next hour, the team closely monitors the patient's response to these interventions. Initially, his oxygen saturation shows a slight improvement, rising to 90%. However, his respiratory rate remains elevated at 32 breaths per minute, and the use of accessory muscles continues to be significant. The patient remains anxious, although his heart rate stabilizes slightly at 110 beats per minute, suggesting some response to the vasopressor support. Blood pressure readings, however, remain concerning at 92/58 mmHg, indicating persistent hemodynamic instability.

A follow-up arterial blood gas analysis is performed to assess the effectiveness of the CPAP therapy. The results show a marginal improvement in pH to 7.30, yet the PaCO2 remains elevated at 56 mmHg, and PaO2 has only slightly increased to 60 mmHg. These findings suggest that while some respiratory support is being achieved, the patient continues to experience significant respiratory compromise. The persistent hypercapnia and borderline hypoxemia indicate that CPAP alone may not be sufficient to address the underlying issues.

Recognizing the potential for further decompensation, the team discusses the possibility of transitioning to invasive mechanical ventilation to provide more controlled respiratory support. They consider the risks and benefits, weighing the need for improved ventilation against the potential complications of intubation, such as barotrauma or ventilator-associated pneumonia. This decision-making process underscores the complexity of managing the patient's condition and highlights the need for ongoing reassessment and adaptation of the treatment plan to prevent further deterioration. As preparations for possible intubation begin, the team continues to monitor the patient closely, ready to adjust their approach based on his evolving clinical status.

Section 4

As the team prepares for the potential need for mechanical ventilation, the patient's condition takes a concerning turn. Over the next 30 minutes, despite continued CPAP support, his level of consciousness begins to fluctuate, and he becomes less responsive to verbal stimuli. His Glasgow Coma Scale score decreases to 11, indicating a decline in neurological status. Concurrently, his oxygen saturation begins to drop again, falling to 85%, and his respiratory rate increases to 36 breaths per minute, accompanied by worsening accessory muscle use and audible wheezing. These changes raise alarms about his ability to maintain adequate ventilation and perfusion.

A new chest X-ray is obtained to assess for any progression of pulmonary edema or other complications. The imaging reveals diffuse bilateral infiltrates consistent with worsening pulmonary edema, and there is also a new right-sided pleural effusion that was not present on previous imaging. These findings suggest that the patient's pulmonary condition is deteriorating, potentially exacerbated by increased fluid overload or an evolving cardiac issue, such as acute heart failure.

In light of these developments, the team decides to proceed with intubation to provide more controlled ventilatory support. This decision is also driven by the patient's decreasing responsiveness and worsening respiratory parameters, which indicate that non-invasive measures are no longer sufficient. The team prepares for the procedure, ensuring that all necessary equipment and medications are readily available to minimize complications and facilitate a smooth transition to invasive ventilation. As they move forward with this critical intervention, the team remains focused on optimizing the patient's hemodynamic status and closely monitoring for signs of further complications, such as worsening pleural effusion or potential infection.

Section 5

Following the decision to intubate, the patient is successfully transitioned to mechanical ventilation. Initial ventilator settings are established to ensure adequate oxygenation and ventilation, with a focus on minimizing further lung injury. However, within the first hour of intubation, the patient exhibits a new complication: his blood pressure begins to drop significantly, with readings falling to 85/50 mmHg. This hypotensive episode raises concerns about potential underlying causes, such as decreased cardiac output or vasodilation due to sedation or the mechanical ventilation itself.

To address this acute change, the team promptly initiates hemodynamic support. Intravenous fluids are administered cautiously, given the patient's existing pulmonary edema, and vasopressors are considered to stabilize his blood pressure. Concurrently, a repeat set of laboratory tests is conducted to evaluate for possible electrolyte imbalances, renal function compromise, or acid-base disturbances that may be contributing to his hemodynamic instability. The results of these tests reveal a mild metabolic acidosis with a pH of 7.32 and a bicarbonate level of 18 mEq/L, suggesting a potential compensatory response to the respiratory compromise and inadequate tissue perfusion.

With the patient's condition remaining fragile, the team continues to monitor for further complications. The presence of the new right-sided pleural effusion necessitates close observation, as it poses an additional risk for impaired respiratory mechanics. A consult with the cardiology team is also sought to evaluate for any exacerbation of cardiac dysfunction, given the patient's history and the current clinical picture. As the team works to stabilize the patient, they remain vigilant for signs of infection, given the invasive nature of mechanical ventilation, and adjust their management plan accordingly to address the evolving clinical challenges.