Mechanical Ventilation + Chart Assignment

Case Study

P.R., a 66-year-old woman who has no history of respiratory disease, is being admitted to your intensive care unit (ICU) from the emergency department (ED) with a diagnosis of pneumonia and acute respiratory failure (ARF). The ED nurse tells you that P.R. was stuporous and cyanotic on her arrival to the ED. Her initial vital signs (VS) were 90/68, 134, 38, 101° F (38.3° C) and Spo₂ of 53%. She was endotracheally intubated orally, was placed on mechanical ventilation, and has equal breath sounds. Her ventilator settings are synchronized intermittent mandatory ventilation of 12/min, tidal volume (V_T) 700 mL, Fio₂ 0.50, and positive end-expiratory pressure (PEEP) 5 cm H₂O. The nurse tells you P.R. had a chest x-ray (CXR) examination that confirmed the diagnosis of pneumonia before being intubated, but she needs an another CXR examination STAT.

1. Describe the pathophysiology of ARF.
2. How does the underlying pathophysiology relate to P.R.’s presenting signs and symptoms?
3. Describe each of P.R.’s ventilator settings and the rationale for each.
4. Why does P.R. need a second CXR examination?

Arterial Blood Gases

5. The ABG results from the sample drawn in the ED before intubation are sent to you. Interpret P.R.’s ABG results.

CASE STUDY PROGRESS

The ICU attending assesses P.R. and after reviewing the ED orders, writes the following orders in addition to the mechanical ventilation protocol.

Physician’s Orders

Blood and sputum cultures STAT
ABGs via arterial line every 6 hours
NGT to intermittent, low suction
Insert indwelling urinary catheter
Enoxaparin (Lovenox) 40 mg subcutaneous q24 hrs at 1700
Apply anti-embolism and intermittent pneumatic compression stockings
Pantoprazole (Protonix) IV 40 mg daily
Lorazepam 1 mg IV every 4 hours
Ceftriaxone 1gram IV q 8 hours
D₅ ½ NS at 125 mL/hr
Albuterol 2.5 mg plus ipratropium 250 mcg nebulizer treatment q 4 hours

6. What is the rationale for each order?
7. What is your priority nursing goal at this time?
8. Describe the interventions you will perform over the next 2 hours based on this priority and the orders you need to implement.
9. P.R. is not heavily sedated and seems anxious about all that is going on. Describe how you can help her.

Arterial Blood Gases

10. ABGs are redrawn after P.R. has been on mechanical ventilation for 2 hours. What ventilator setting changes do you expect based on your interpretation? Select all that apply and explain your rationale.
11. Decreasing the Fio₂to 0.40
12. Increasing the V_Tto 850 mL
13. Increasing the PEEP to 10 cm
14. Increasing the rate on the ventilator to 16/min
15. Changing to continuous mandatory ventilation

11. Evaluate each statement about caring for P.R. or a similar patient receiving mechanical ventilation with an endotracheal tube (ETT). Enter Tfor true or Ffor false. State why the false statements are incorrect.

_____ 1. Give muscle-paralyzing agents to keep P.R. from “fighting the vent.”
_____ 2. Check ventilator settings at the beginning of each shift and then hourly.
_____ 3. When suctioning the ETT, each pass should not exceed 15 seconds.
_____ 4. Assign experienced UAP to take vital signs every 2 to 4 hours.
_____ 5. Perform a respiratory assessment once per shift.
_____ 6. Empty excess water that collects in the ventilation tubing back into the humidifier.
_____ 7. Keep a resuscitation bag at the bedside.
_____ 8. Monitor the cuff pressure of the ETT every 8 hours.
_____ 9. Silence ventilator alarms when in the room to maintain a quiet environment.
_____10. Change all ventilator tubing every 24 hours.

12. What are 3 evidence-based practices you will need to implement to prevent ventilator-assisted pneumonia?
13. You hear the high-pressure alarm sounding on the mechanical ventilator and see that P.R.’s Sao₂is 80%. What are potential causes of this problem?
14. You decide that P.R. needs to be suctioned. Place in order the steps for safely performing in-line or closed suctioning.

_____ 1. Hyper oxygenate the patient.
_____ 2. Use 5 to 10 mL of saline to rinse the catheter clear of secretions.
_____ 3. Insert catheter until you meet resistance or the patient coughs.
_____ 4. Assess patient’s status and document procedure.
_____ 5. Put on clean gloves and face shield and attach suction.
_____ 6. Apply suction as you withdraw the catheter, not exceeding 10 seconds.
_____ 7. Reassess patient status and suction again as needed.

CASE STUDY PROGRESS

As P.R.’s primary nurse, you are responsible for her nursing care plan. Although the primary concern is her respiratory status, you are concerned about hydration, nutrition, oral hygiene, and skin integrity and decide to address each of these areas in P.R.’s plan of care.

15. Discuss 5 indicators you can use to assess her fluid status.
16. Write a nutrition-related outcome for P.R.
17. Describe 4 interventions that could assist in meeting P.R.’s nutrition goals.
18. You plan to assess P.R.’s skin every 4 hours. Name 4 other strategies that will help meet the expected outcome of maintaining skin integrity?

CASE STUDY PROGRESS

Over the next few days, P.R. progressively regains adequate respiratory functioning.

19. What factors would be considered in deciding when P.R. is ready to be weaned from mechanical ventilation?
20. What are your responsibilities during the weaning process?
21. Which assessment finding during the weaning process would indicate P.R. should be placed back on the ventilator?

CASE STUDY OUTCOME

P.R. is easily weaned from the ventilator, and her respiratory function continued to improve. Unfortunately, she developed a urinary tract infection, experienced acute confusion for a few days, and had difficulty ambulating. She stayed 7 more days after being weaned before being discharged home.