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%.
2.Per physician order, Mr. R is placed on NPPV via face mask with PEEP of 15 and FiO2 50% with sats 92%. He also order for blood and sputum cultures and triple 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?
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?
4.The physician is preparing for endotracheal intubation. What equipment is needed for this procedure? What is nursing role during intubation? What is the procedure for intubation? As a patient advocate, what may the nurse suggest the patient receive prior to intubation?
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?
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? What is the I:E ratio and how will the ordered ratio benefit this 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. Râs current ABG results? What is beneficial to this patient if he is requiring frequent blood gases? What test may be done to assess perfusion status prior to this procedure? Good perfusion in which vessel will decrease complications?
8.Mr. R has been on mechanical ventilation for 2 days in the CCU now. He is receiving PPN via an antecubital PIV and triple antibiotics. His vent settings has been weaned according to his ABGs and current vent settings are: SIMV with rate of 10, Peep 5, tidal volume 7mL/kg, I:E ratio 1:4, 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?
9.During the initial assessment on Mr. Râs 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 reintubation?
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%.
2.Per physician order, Mr. R is placed on NPPV via face mask with PEEP of 15 and FiO2 50% with sats 92%. He also order for blood and sputum cultures and triple 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?
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?
4.The physician is preparing for endotracheal intubation. What equipment is needed for this procedure? What is nursing role during intubation? What is the procedure for intubation? As a patient advocate, what may the nurse suggest the patient receive prior to intubation?
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?
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? What is the I:E ratio and how will the ordered ratio benefit this 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. Râs current ABG results? What is beneficial to this patient if he is requiring frequent blood gases? What test may be done to assess perfusion status prior to this procedure? Good perfusion in which vessel will decrease complications?
8.Mr. R has been on mechanical ventilation for 2 days in the CCU now. He is receiving PPN via an antecubital PIV and triple antibiotics. His vent settings has been weaned according to his ABGs and current vent settings are: SIMV with rate of 10, Peep 5, tidal volume 7mL/kg, I:E ratio 1:4, 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?
9.During the initial assessment on Mr. Râs 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 reintubation?
