NR 341 Week 2 Case Study Exercise: Mechanical Ventilation Case Study
1. What items should you consider on the differential diagnosis for a patient who
... [Show More] cannot be liberated from the mechanical ventilator?
2. What diagnostic steps can you consider to help you sort through this differential?
3. What can you do to help her get off the ventilator?
4. At what point do you consider placing a tracheostomy tube in this patient?
Answers
1. What items should you consider on the differential diagnosis for a patient who cannot be liberated from the mechanical ventilator?
One of the main reasons why a patient fails the spontaneous breathing trail is because their primary process hasn’t regained sufficiently. Some other reasons why a person would fail their breathing trails could be related to neurologic issues, neuromuscular competence or the demands on the patient’s body are too hard to high. Neurological issues can be a result from left over medications such as sedatives and narcotics, or an insufficient respiratory drive. Neuromuscular competence may be related to weakness from the patient that they simply cannot breathe on their own yet because their illness is so critical. Lastly, a patient who is on a mechanical ventilator has many things going on within the body, that the requirements to breathe may be too much for them. Patients especially with COPD, weak respiratory system, acute respiratory distress syndrome, pulmonary edema, pleural effusion, abdominal distention may also contribute to the patient not being able to successful pass a breathing trail.
2. What diagnostic steps can you consider to help you sort through this differential?
First of a physical exam of the patient may be helpful to know if the patient has any underlying issues like abdominal distention or a fluid shift. It would also be helpful to review the patients’ medical history, fluids, what is ordered, any laboratory work, and images the patient has gone for.
3. What can you do to help her get off the ventilator?
Before taking the patient off the ventilator it is important to exam the whole system to ensure no underlying issues would cause the patient to fail without the ventilator. For example, if a patient has a pleural effusion it would be beneficial to drain before trying the breathing trail. Many patients’ need some time to heal and regain their strength to successfully come off the ventilator. As the nurse you could encourage the patient to do daily breathing trials using a T-piece and only do the trail once a day.
4. At what point do you consider placing a tracheostomy tube in this patient?
Patients’ who cannot successfully be weaned of the ventilatory may require a tracheostomy. The tracheostomy is placed to reduce the risk of complications related to long term ET tube. Following hospital protocol as to when a tracheostomy is placed is different, but many prefer to insert a tracheostomy within the first week especially for patients who acute respiratory distress syndrome. Other than that, then most facilities wait at least 4 weeks before initialing a tracheostomy.
Reference:
Moseley, Mary Lou Sole & Deborah Goldenberg Klein & Marthe J. Introduction to Critical Care Nursing, 7th Edition. Elsevier (HS-US), 102016. VitalBook file. [Show Less]