● ACUTE RESP FAILURE
○ Occurs when one of the gas exchange functions fails/is inadequate
■ Impaired transfer of O2 and CO2 leading to acid base-imbalances and
ventilation-perfusion mismatch
● ventilation-perfusion mismatch is an imbalance between the
alveolar ventilation and alveolar blood flow. Can occur d/t reduced
ventilation of part of lung or reduced blood flow →
uncompensated respiratory acidosis
○ Most common reason for ICU admissions and is a leading cause of death
○ Two types of ARF
■ Hypoxemic: not enough O2 is in the blood
● Causes: fluid-filled alveolar sacs, loss of gas exchange surface area
(caused by alveolar collapse), loss of pulmonary tissue (caused by
lung tissue thickening or injury), shunting
■ Hypercapnic: failure of CO2 exchange → increased CO2 in arterial blood
● Causes: COPD, overdose, neuromuscular dx (ex: GBS)
■ Both types lead to respiratory acidosis
■ Contributing factors: obstruction, injury to lung, brain or spinal injury,
chemical influence, infection
○ Manifestations: tachypnea, blood oxygen desaturation, altered LOC, anxiety,
cyanosis, tachycardia, diaphoresis
○ Prioritization
■ Goals in tx: restore O2 levels, removed excess CO2
■ Priorities in tx: provide high acuity environment to stabilize resp health,
ensure holistic care, prevent infection
■ Address: airway, breathing, circulation, infection, nutrition status, family
understanding
○ Nursing interventions
■ Maintain patent airway, maintain resp support, maintain telemetry,
complete through assessment every shift, focused assessment ever 2hr,
HOB 30 degrees, repositioning, manage secretions and oral care,
administer meds, medicate for infection/fever/pain, promote nutrition,
prevent DVT/ulcer prophylaxis, review lab and diagnostic results, prevent
overexertion, collaborate with healthcare team , remove negative
distractions, communicate regularly
● HEART FAILURE
○ Heart cannot adequately pump oxygenated blood through the body resulting in
lack of organ and tissue perfusion
○ High BNP indicates large exacerbation of HF
○ Three types of HF
, ■ Left-sided: heart cannot contract enough to pump blood (systolic), left
ventricle cannot relax enough to fill (diastolic)
● Causes: HTN, CAD , valvular dx
● Manifestations: dyspnea, crackles, frothy sputum, S3 sound
(gallop)
■ Right-sided: right ventricle cannot empty completely, pressure builds up
behind ventricle
● Causes: MI, pulmonary HTN
● Manifestations: JVD, peripheral edema, ascites, hepatomegaly,
weight gain
■ High-output: heart cannot keep up with demand for blood flow to body
● Causes: hypermetabolic, high demand state
○ Nursing interventions: monitoring resp status, administering O2, elevate HOB,
administer meds (ACE inhibitors, digoxin, IV diuretics), monitor lytes, daily
weight and I&O, rest
● DIABETES NEPHROPATHY
○ Complication that results in nerve damage secondary to diabetic microvascular
changes in kidney and affects kidneys ability to remove waste products and
excrete excess fluid → Leads to kidney failure
○ Caused by hyperglycemia usually coupled with HTN leading to injury of kidneys,
glomeruli injury (protein denaturation, intraglomerular HTN exacerbated by
systemic HTN), glomeruli enlarges and tissue thickens leading to reduced blood
flow and filtration, GFR decreases (causing hyponatremia, reduced plasma
oncotic pressure, and fluid overload)
○ First manifestation is increased urine albumin
○ Eventually resulting in end stage KF
○ General symptoms: uncontrolled HTN, proteinuria, edema to extremities and
eyes, urinary frequency, drop in BG levels, N/V, poor appetite
○ Nursing interventions
■ Assess vital signs Q4 and BP trends, assess for edema, encourage
ambulation and elevation of extremities, minitot BG, report output less
than 30 mL/hr, record I&O and hydration status, admin meds to control bP
and reduce proteinuria (ACE, ARBs, antidiabetics, insulin, lipid-lowering
agents, diuretics, avoid nephrotoxic substances, monitor labs (BUN, CRE,
lytes, WBC), low sodium diet, pt education
● SEPSIS
○ Localized infection that progresses into the blood causing massive inflammatory
response. Life threatening organ dysfxn d/t inflammatory homeostasis
○ Important to recognize fast and treat quickly
○ Occurs when one of the gas exchange functions fails/is inadequate
■ Impaired transfer of O2 and CO2 leading to acid base-imbalances and
ventilation-perfusion mismatch
● ventilation-perfusion mismatch is an imbalance between the
alveolar ventilation and alveolar blood flow. Can occur d/t reduced
ventilation of part of lung or reduced blood flow →
uncompensated respiratory acidosis
○ Most common reason for ICU admissions and is a leading cause of death
○ Two types of ARF
■ Hypoxemic: not enough O2 is in the blood
● Causes: fluid-filled alveolar sacs, loss of gas exchange surface area
(caused by alveolar collapse), loss of pulmonary tissue (caused by
lung tissue thickening or injury), shunting
■ Hypercapnic: failure of CO2 exchange → increased CO2 in arterial blood
● Causes: COPD, overdose, neuromuscular dx (ex: GBS)
■ Both types lead to respiratory acidosis
■ Contributing factors: obstruction, injury to lung, brain or spinal injury,
chemical influence, infection
○ Manifestations: tachypnea, blood oxygen desaturation, altered LOC, anxiety,
cyanosis, tachycardia, diaphoresis
○ Prioritization
■ Goals in tx: restore O2 levels, removed excess CO2
■ Priorities in tx: provide high acuity environment to stabilize resp health,
ensure holistic care, prevent infection
■ Address: airway, breathing, circulation, infection, nutrition status, family
understanding
○ Nursing interventions
■ Maintain patent airway, maintain resp support, maintain telemetry,
complete through assessment every shift, focused assessment ever 2hr,
HOB 30 degrees, repositioning, manage secretions and oral care,
administer meds, medicate for infection/fever/pain, promote nutrition,
prevent DVT/ulcer prophylaxis, review lab and diagnostic results, prevent
overexertion, collaborate with healthcare team , remove negative
distractions, communicate regularly
● HEART FAILURE
○ Heart cannot adequately pump oxygenated blood through the body resulting in
lack of organ and tissue perfusion
○ High BNP indicates large exacerbation of HF
○ Three types of HF
, ■ Left-sided: heart cannot contract enough to pump blood (systolic), left
ventricle cannot relax enough to fill (diastolic)
● Causes: HTN, CAD , valvular dx
● Manifestations: dyspnea, crackles, frothy sputum, S3 sound
(gallop)
■ Right-sided: right ventricle cannot empty completely, pressure builds up
behind ventricle
● Causes: MI, pulmonary HTN
● Manifestations: JVD, peripheral edema, ascites, hepatomegaly,
weight gain
■ High-output: heart cannot keep up with demand for blood flow to body
● Causes: hypermetabolic, high demand state
○ Nursing interventions: monitoring resp status, administering O2, elevate HOB,
administer meds (ACE inhibitors, digoxin, IV diuretics), monitor lytes, daily
weight and I&O, rest
● DIABETES NEPHROPATHY
○ Complication that results in nerve damage secondary to diabetic microvascular
changes in kidney and affects kidneys ability to remove waste products and
excrete excess fluid → Leads to kidney failure
○ Caused by hyperglycemia usually coupled with HTN leading to injury of kidneys,
glomeruli injury (protein denaturation, intraglomerular HTN exacerbated by
systemic HTN), glomeruli enlarges and tissue thickens leading to reduced blood
flow and filtration, GFR decreases (causing hyponatremia, reduced plasma
oncotic pressure, and fluid overload)
○ First manifestation is increased urine albumin
○ Eventually resulting in end stage KF
○ General symptoms: uncontrolled HTN, proteinuria, edema to extremities and
eyes, urinary frequency, drop in BG levels, N/V, poor appetite
○ Nursing interventions
■ Assess vital signs Q4 and BP trends, assess for edema, encourage
ambulation and elevation of extremities, minitot BG, report output less
than 30 mL/hr, record I&O and hydration status, admin meds to control bP
and reduce proteinuria (ACE, ARBs, antidiabetics, insulin, lipid-lowering
agents, diuretics, avoid nephrotoxic substances, monitor labs (BUN, CRE,
lytes, WBC), low sodium diet, pt education
● SEPSIS
○ Localized infection that progresses into the blood causing massive inflammatory
response. Life threatening organ dysfxn d/t inflammatory homeostasis
○ Important to recognize fast and treat quickly
