NR 341
CHAMBERLAIN COLLEGE OF NURSING NR 341 Complex Adult Health Nursing CASE STUDY EXERCISE Ventilatory
CHAMBERLAIN COLLEGE OF NURSING NR 341 Complex
... [Show More] Adult Health Nursing
NR 341 Complex Adult Health Nursing CASE STUDY EXERCISE Ventilatory
CASE STUDY: Ventilatory Assistance & Acute Respiratory Failure 1
Mr. R is a 66-year-old man who has smoked 1.5 packs of cigarettes a day for 40 years. He is admitted with an acute exacerbation of COPD. His baseline ABGs drawn in the ER showed: pH, 7.36; PaCO2, 55mmHg; PaO2, 69mmHg; Bicarbonate, 30 mEq/L; SaO2, 92% on 4Lvia NC. In the critical care unit, Mr. R has course crackles in his left lower lung base and a mild expiratory wheeze bilaterally. His cough is productive of thick yellow sputum. His skin turgor is poor; he is febrile, tachycardic, and tachypneic requiring 6L via NC to keep Sats >88%.
1. What is your interpretation of Mr. R’s baseline ABGs from the ER? Did his symptoms improve on admission to CCU? What may have caused his exacerbation? What assessment findings lead you to this conclusion? What ventilatory assistance may improve his symptoms? How?
According to the patient’s report, Mr. R’s baseline ABGs shows that his pH is within the normal range, but the rest of his ABG levels reveal compensated respiratory acidosis. Mr. R did not show improvement of symptoms upon admittance to the CCU. Mr. R’s history of chronic smoking; being 1.5 packs of cigarettes a day for 40 years has caused extensive damage to his lungs and could be what caused the exacerbation of COPD. Mr. R could benefit from the use of a BiPAP machine, which provides pressurized air to help open up the lungs and alveoli. Another option would be noninvasive positive-pressure ventilation. Noninvasive positive-pressure ventilation is beneficial for COPD patients, in helping to reduce inspiratory muscle activity in return allows for better gas exchange in the alveoli. It is also the least invasive form of ventilation to start treatment.
2. Per physician order, Mr. R is placed on NPPV via face mask with PEEP of 15 and FiO2 50% with sats 92%. The doctor also orders blood and sputum cultures and antibiotics IV to be initiated ASAP. What technique is maintained during blood cultures? During sputum cultures? When should nurse administer antibiotics? What organisms are commonly seen in respiratory infections?
Clean technique should be practiced when receiving a blood culture and the site should be sterilized. The best time to get a sputum sample from the patient would be in the morning right after patient wakes up. It is imperative that both blood and sputum specimens should be sent to the lab immediately following their collection as samples that are a few hours old in various climate conditions could result in positive/negative results. It is also important for the lab to receive the samples right away so antibiotic therapy can be started immediately as needed. Antibiotics should not be taken before obtaining the samples as in doing so could result in skewed results of the samples. Some common organisms found in respiratory infections include Streptococcus pyogenes, Haemophilus influenza, Streptococcus pneumoniae, and Legionella pneumophila.
3. One hour post-NPPV ABGs results showed: pH 7.3, PaCO2 67, PaO2 45, HCO3 26, SaO2 85% on PEEP of 20 and FiO2 60% NPPV. What is your interpretation of his current ABG results? What ventilatory assistance does Mr. R require? What lab findings indicate this? What airway is optimal for him and why?
Recent ABG levels indicate uncompensated respiratory acidosis. Mr. R. requires endotracheal intubation. The patient’s lab results show a decrease in pH,PaCO2, and SaO2 which supports the decision for endotracheal intubation. These results suggest that improvements are not being made from the BiPAP machine and an alternative is needed. The upper airway is most optimal and comfortable for Mr. R.
4. The physician is preparing for endotracheal intubation. What equipment is needed for this procedure? What is the nurse’s role during intubation? What is the procedure for intubation? As a patient advocate, what may the nurse suggest the patient receive prior to intubation?
Equipment needed for endotracheal intubation: Laryngoscope, stylet, endotracheal tube with syringe, lubrication, suction equipment, tape, and ambu bag. A physician or anesthesiologist performs this procedure with a nurse assisting. It is also the role of the nurse to unsure all equipment for procedure is in the room. The nurse before procedure can suggest sedation of the patient by nurse’s own observations, patient feedback or assessments.
Procedure: With the patient’s head tilted back the physician or anesthesiologist will advance the laryngoscope into the patient’s mouth, inserting it into the trachea and the endotracheal tube is guided in along the laryngoscope. This procedure allows 30 seconds for successful insertion of the endotracheal tube. If the tube is not properly placed within the 30 second time frame, the procedure stops and will be tried again.
5. The physician successfully intubated the patient with ETT and placement was confirmed. What assessment findings suggest placement? What device and diagnostic procedure may confirm placement? How?
Inspection: Observing chest movement, looking for symmetrical rise and fall chest movements during breaths. Auscultation: Bilateral lung sounds verifies placement of the endotracheal tube. However the most definitive confirmation of proper placement is achieved through a chest X-ray
6. The physician orders for Mr. R to be placed on mechanical ventilation via a volume ventilation, SIMV mode, with PEEP 8, Rate of 15, tidal volume 7mL/kg, I:E ratio 1:4, FiO2 65% . What is the function of SIMV? Is A/C mode a better choice for this patient? Which setting is controlled and which varied in this type of ventilation?
SIMV mode assists the already breathing patient designed with a preset back up rate which aids in breathing for the patient if he cannot do so on his own. A/C mode does allow Mr. R to rest his respiratory muscles and will take over most of the WOB. However, it lacks the back up rate which could prove to be more beneficial for Mr. R in the long term. A/C ventilation is more controlled than SIMV mode by doing all of the WOB, whereas SIMV is working alongside Mr. R in assisting in the already breathing patient.
7. Another ABG was obtained 1 hour post intubation showing: pH 7.33, PaCO2 57, PaO2 60, HCO3 30. He did not make any changes to the vent settings and orders for another ABG to drawn in 2 hours. What is your interpretation of Mr. R’s current ABG results? What is beneficial to this patient if he is requiring frequent blood gases?
Patient’s labs indicates the respiratory acidosis is partially compensated. An arterial catheter can be more convenient for both healthcare provider and patient for those in need of frequent ABGS.
8. Mr. R has been on mechanical ventilation for 2 days in the CCU now. He is receiving PPN via an antecubital IV and antibiotics. His vent settings have been weaned according to his ABGs and current vent settings are: SIMV with rate of 10, Peep 5, tidal volume 7mL/kg, FiO2 60%. Since it appears that Mr. R continues to require mechanical ventilation, what is he at high risk for? What interventions will help prevent this? According to his vent settings, what else is he at high risk for? And what interventions will help prevent these risks?
This patient is at a higher risk for infections, pneumothorax, VAP, or peptic ulcers along with becoming dependent of the ventilator for breathing. The removal of the ventilator from Mr. R’s plan of care as soon as it’s safe for him, could eliminate the potential problems listed above. But there are many different nursing interventions a nurse could implement to decrease the odds of one occurring such as assessing the effectiveness of the ventilator and that it is still in proper placement by inspection and auscultation of the chest and lungs, monitoring the settings of the vent, suctioning secretions PRN can decrease the chance of VAP, administering prescribed antibiotics along with H2 antagonists for the prevention of peptic ulcers. Patient will also be immobile, so the use of DVT prevention stockings with SCD machine or air mattress are tools that could help with the prevention of blood clots in the patient
9. During the initial assessment on Mr. R’s 3rd day of ventilation, the CCU nurse heard breath sounds on the right and diminished breath sounds on left side, with unequal chest rise. She notified the physician and a CXR was ordered to evaluate ETT placement. What do you suspect is happening? What will need to occur to resolve this problem? Will this patient require re-intubation?
I would suspect the patient’s tube has moved. I would confirm by inspection and auscultation. Respiratory will need to be called and they will pull the tube back up and re-inflate the balloon to facilitate placement of tube. [Show Less]