Acute Respiratory Distress Syndrome (ARDS)

Acute Respiratory Distress Syndrome (ARDS) is a type of pulmonary insufficiency caused by various disorders that cause fluid accumulation in the lungs (pulmonary edema). This syndrome is considered a medical emergency that can occur even in people who previously had normal lungs. Although it may sometimes be called adult respiratory distress syndrome, this disorder may also occur in children.

What are the causes?

The cause may be any disease that directly or indirectly causes lung injury. Approximately one-third of individuals with the syndrome develop it due to a widespread and serious infection (sepsis). When the alveoli and pulmonary capillaries are damaged, blood and fluid escape into the interalveolar spaces and finally into the alveoli. Subsequent inflammation can lead to the formation of scar tissue. As
consequently, the lungs can not function normally.

What are the Symptoms and Diagnosis?

Typically, acute respiratory distress syndrome occurs 24 or 48 hours after the injury or the original illness. Initially, the individual is short of breath, almost always accompanied by a superficial and rapid breathing. With the help of a stethoscope, the doctor may hear crackling sounds or wheezing in the lungs. Due to the low levels of oxygen in the blood, the skin may become mottled or bluish and the function of other organs, such as the heart and brain, may be compromised.

Arterial blood gases reveal low levels of oxygen in the blood and radiographies indicate the presence of fluid in the spaces that should be filled with air. Sometimes other tests are needed to confirm that the cause of the problem is not heart failure.

Main causes of Acute Respiratory Distress Syndrome

Severe disseminated infection (septicemia);
Pneumonia;
Severe arterial hypotension (shock);
Aspiration of food into the lungs;
Multiple blood transfusions;
Pulmonary injury resulting from elevated oxygen concentrations;
Pulmonary embolism;
Thoracic injury;
Burns;
Drowning;
Cardiopulmonary bypass surgery;
Inflammation of the pancreas (pancreatitis);
Excessive dose of some type of drug, such as heroin, methadone, propoxyphene or aspirin.

What are the complications and prognosis?

The lack of oxygen caused by this syndrome can produce complications in other organs soon after the onset of the condition or, when there is no improvement in the condition, over days or weeks. Prolonged lack of oxygen can cause serious complications, such as kidney failure. Without immediate treatment, severe oxygen deprivation caused by the syndrome causes death in 90% of patients.

However, with proper treatment, about 50% of affected individuals survive. As individuals with acute respiratory distress syndrome are less resistant to lung infections, they commonly develop bacterial pneumonia at some point in the course of the disease.

How is the treatment done?

Patients with acute respiratory distress syndrome are treated in the intensive care unit. Oxygen therapy is essential for the correction of low oxygen levels. If oxygen administered with the use of a face mask does not correct the problem, a ventilator should be used. It delivers oxygen under pressure through a tube inserted into the nostril, mouth, or trachea. This pressure helps force the passage of oxygen to the blood.

The pressure is adjusted to help keep the small airways and alveoli open, and to ensure that the lungs do not receive an excessive concentration of oxygen. This is important because too much oxygen concentration can injure the lungs and aggravate acute respiratory distress syndrome. It is also important to institute other adjuvant treatments, such as the administration of liquid or nutrients through the intravenous route, since dehydration or malnutrition increases the likelihood of disruption of the functioning of multiple organs (multiple organ failure).

Additional treatment crucial to success depends on the underlying cause of acute respiratory distress syndrome. For example, antibiotics are given to fight an infection. Patients who respond normally to treatment regain well with little or no long-term pulmonary change. For those patients whose treatment depends on long periods under assisted breathing (with the aid of a ventilator), the possibility of pulmonary scar formation is greater. However, these scars may improve a few months after the patient has stopped using the ventilator.

What are Nursing Care with the patient in ARDS?

Reassure the client in psychological support;
Encourage semi – Fowler or Fowler position for better ventilation;
Perform Hydrolitic control;
Observe distension of the jugular vein (peripheral edema);
Provide adequate nutritional support;
Provide assisted diet;
Maintain calibrated venous access, pulse oximeter and cardiac monitor;
Maintain oral (tracheobronchial) and body hygiene;
Assist the physician in endotracheal or orotracheal intubation, and in mechanical ventilation;
Administer medications according to medical prescription;
Check vital signs;
Observe, communicate and note intercurrences.

Plegia, Paralysis and Paresis: The Differences

The terms can be very confusing, when making a note, and even the evaluation that the doctor and the nurse can do, during an anamnesis.

The term paralysis (where Plegia is synonymous) refers to the loss of capacity for voluntary muscular contraction, functional or organic disruption at any point of the motorway, which can go from the cerebral cortex to the muscle itself; paralysis is spoken when any movement in these proportions is impossible.

Already, paresis refers to when the movement is only limited or weak. The term paresis comes from the Greek PARESIS and means relaxation, weakness. In cases of paresis, the motility occurs only in a below-normal pattern, regarding muscle strength, movement precision, range of motion and localized muscular resistance, ie, it refers to a partial impairment, to a semi-paralysis.

Know the Types of Insulins: The Beginning, Peak and Duration

Like all medicines used, once you know your characteristics better, treatment and adherence become easier and more enjoyable.

The main function of insulin is to carry glucose into cells, where it is used as energy.

When we feed, the pancreas is stimulated to produce insulin, thus carrying excess glucose into the various organs of the human body for use and storage.

And when are we fasting?

During the fast, insulin is also produced. Remembering that also during the fasting the insulin must load the glucose into the cells, so that they have energy. In this period, glucose comes from deposits present, mainly in the liver and muscles.

As we can see, even in our body, insulin acts in different ways, with an action that is continuous, which is that of fasting, and another that happens in peaks, which is that which happens in the meal.

In order to try to mimic what happens in the body without diabetes, the used insulins also have different characteristics: according to the beginning period of their action (when they begin to act), their maximum action (called peak action) and time in which it remains acting (duration of action).

Fast and Ultrafast Insulin

Insulins used for the bolus are fast and ultra fast calls. They have as action the feeding period, promoting a good glycemic control in the periods close to feeding.

Fast or regular insulin begins to act in 30 to 60 minutes and has its peak of action in 2 to 3 hours and duration of action of 6 hours and 30 minutes. Therefore, it should be used 30 to 45 minutes before the meal. Ultrafast insulin – lispro, aspart or glulisine – begins to act in 10 to 15 minutes, has its peak of action in 1 to 2 hours and duration of action of 3 to 5 hours. Therefore, it should be used in less than 15 minutes before the meal, or even during the meal. The latter has a lower risk of hypoglycemia than the rapid one.

Slow and Ultra slow insulins

The insulins used for the basal role are the slow and ultralent. Its main goal is to maintain stable glycemia between meals.

NPH insulin is the only representative of slow insulins. It begins to act in 1 to 3 hours, has its peak action in 5 to 8 hours and duration of action of up to 18 hours. Ultralent insulin is represented by Insulin Detemir – with onset of action in 1 to 2 hours, discrete peak of action in 2 hours and duration of action of 16 to 24 hours – and Insulin Glargine – with onset of action in 1 to 2 hours , absence of peak action and duration of action of up to 24 hours.

Use of Insulin in Type 1 and Type 2 Diabetes

Patients with type 1 diabetes, as they do not produce any insulin, should always use both types of insulin – called full insulinization. When feeding, they should use fast or ultra-fast insulins, respecting their application times. If your capillary glycemia (or dextro) is elevated before feeding, you should use a larger dose to correct this value, in addition to that required for feeding. For basal insulin, they should use the slow or ultralast, even if fasted, to maintain adequate levels of their blood glucose. Users of the subcutaneous insulin pump use ultrafast insulin continuously for this purpose.

In patients with type 2 diabetes, full insulinization is only performed in later stages of disease progression, when what is called “pancreas failure” occurs. That is, the pancreas, over time, fails to produce enough insulin to fulfill its functions of maintaining glycemia during fasting and covering the excess glucose from the diet. In earlier stages, use may be necessary when blood glucose levels are very high, or in situations where oral medications are contraindicated, such as during surgery or serious illness.

Heart Attack: Acute Myocardial Infarction (AMI)

The medical term for most known heart attack is Myocardial Infarction. It can also be called myocardial infarction, ischemic heart disease, coronary obstruction, cardiac crisis. In our setting, the most commonly used term is infarction.

But what is myocardial infarction?

Myocardial infarction occurs when the blood supply to a part of the heart muscle is reduced or cut completely. This happens when a coronary artery is contracted or obstructed, partially or totally.

With the total or partial suppression of the supply of blood to the heart muscle, it suffers an irreversible injury and stops functioning, which can lead to sudden death, late death or heart failure with consequences ranging from severe limitations of physical activity to complete recovery.

There are more than 150 thousand cases of AMI in Brazil. Myocardial infarction may also occur in people who have normal coronary arteries. This happens when the coronary arteries have a spasm, contracting violently and also producing a partial or total deficit of blood supply to the heart muscle irrigated by the contracted vessel.

This type of spasm can also occur in vessels already compromised by atherosclerosis.

What are the risk factors?

Age: Men aged 45 years and over and women over 55 years old are at high risk.
Smoking: Prolonged exposure to other people’s smoke gives you a high risk of cardiovascular disease.
High cholesterol levels: If you have high levels of triglycerides and low HDL (high density lipoprotein), you are likely to have a higher risk of heart attack.
Diabetes, especially if it is not treated.
Family history of heart attack: If someone in your family has a history of a heart attack, you may also have it.
Sedentary lifestyle: Not being physically active leads to high levels of bad cholesterol that can cause plaque formation.
Obesity: If you lose 10% of your body weight, it will also reduce your risk of heart attack.
Stress: German researchers have found that when you have stress, white blood cell levels increase. They, in turn, increase the risk of developing atherosclerosis and plaque rupture.
Use of illicit drugs: The use of cocaine or amphetamines can cause coronary artery spasm.
Pre-eclampsia history: If you had high blood pressure during pregnancy, your risk of having a heart attack is high.
History of autoimmune disease, such as rheumatoid arthritis or lupus.

If you have any of these risk factors, I suggest you visit your doctor to keep you protected against heart attacks or any cardiovascular disease.

Signs and symptoms of a heart attack

Some people may have mild symptoms or no symptoms of heart attack – this is called a silent heart attack. It happens mostly in people with diabetes.

To avoid premature death related to heart disease, note other common symptoms of this fatal problem:

Chest pain or discomfort: This is the most common symptom when having a heart attack. Some people may have a sudden sharp pain, while others may have only mild pain. This can last for a few minutes or a few hours.
Upper Body Discomfort: You may feel pain or discomfort in the arms, back, shoulders, neck, jaw or upper stomach.
Shortness of breath: Some people may have only this symptom, or it may happen along with chest pain.
Cold sweat, nausea, vomiting and sudden dizziness: These symptoms are more common among women.
Unusual tiredness: You may feel tired for unknown reasons and sometimes this can last for several days.

Older people who have one or more of these symptoms usually ignore them, thinking that they are the only signs of aging. However, if you experience one or more of these symptoms, have someone call an ambulance immediately.

How to avoid a heart attack?

Most cardiovascular disease can be prevented. I recommend these lifestyle practices to help you avoid a heart attack or heart disease:

Have a healthy diet;
Exercise regularly;
Stop smoking;
Avoid alcohol consumption;
Feel as little as possible;
Improve your vitamin D levels;
Try to walk barefoot;
Get rid of stress.

The Importance of Constant Sanitization of Manual Resuscitators

Do you know that manual resuscitator (bag valve mask-BMV, commonly called “Ambu bag”), which in many hospitals stays on the countertops waiting to be reused for days, including for manual hyperinsufflation maneuvers?

Yes, they can contribute (and a lot!) To increase the risk of pneumonia!

A paper presented in the Society of Critical Care Medicine (SCCM) 42nd Critical Care Congress, por Rasnake et al, with rescuers of 147 patients found that bacterial cultures increased every two days, although they visually appeared clean.

They also observed that the more the device is manipulated, the greater the colonization.

One more reason to think about carrying out the hygienization and constant sterilization of these devices, and also to perform the same patient swapping!

Nasogastric and Nasoenteric: Differences in Enteral Nutrition

Not everyone can get food through their mouths. In this case, one option is enteral nutrition, which works with a probe implanted in the stomach, jejunum, or duodenum. In liquid or powder form, the diet is made in this system to balance nutrients, proteins, carbohydrates, fats, vitamins and minerals of the diet.

This feature is widely used by people who needed to be hospitalized and, after some surgical procedure or treatment, can no longer perform the feeding in the conventional way.

For there to be no organic imbalance, weight loss or infections, proper nutrition is critical. Therefore, enteral nutrition is very important to maintain balance and ensure quality of life for patients.

It is necessary to know how to differentiate the use of both types, for cases of drainage of gastric contents, infusion of enteral diets, and until where its lease is carried out.

Gastric lavage is a procedure that aims to prepare the digestive system for examinations or surgeries, stagnate gastric or esophageal bleeding using ice liquids and remove from the stomach excessive or harmful gastric contents. For the accomplishment of this procedure it is necessary initially the passage of a orogastric or nasogastric of great caliber probe.

Although the polling procedure appears to be relatively simple, this technique requires scientific knowledge and technical skill to the extent that it is not risk free. The most common complications are the incorrect insertion, misalignment of the catheter, accidental removal, the type of external fixation, and the length of time the catheter is present, and include excoriations, hyperemias, perforations in the digestive system, infections in the upper and lower airways, nausea, abdominal distension and partial or total catheter obstruction.

Within the nursing team, it is incumbent upon the nurse to perform the procedure of establishing the enteral nutrition route, same way adopted for the gastric lavage procedure, thus, the nursing technician is responsible for:

a) To participate in training, according to established programs, guaranteeing the training and updating regarding the good practices of Nutrition Therapy;

b) Promote general patient care according to the prescribed nursing prescription or protocol;

c) Communicate to the Nurse any intercurrence resulting from Parenteral Nutrition Therapy;

d) Record the actions taken, in the patient’s chart, in a clear, precise and timely manner.