Patient Profile
Z.Q., 84-year-old Hispanic male, came to the emergency department (ED) 7 days ago with complaints of shortness of breath. His wife stated that he had a history of hypertension, depression, and chronic obstructive pulmonary disease (COPD). The admission chest x-ray revealed dense consolidation of the left lower lobe. An arterial blood gas (ABG) at that time showed: pH 7.60, PaCO2 29mm/Hg, HC03 32mmol/L, and PaO2 75mm/Hg. Z.Q. quickly deteriorated and subsequently was intubated. He has been in the intensive care unit for 5 days.
Subjective Data
· Z.Q. and wife have been married 45 years and live with a daughter and 2 grandchildren
· Z.Q. and his wife speak both English and Spanish
Objective Data
Physical Examination
· Blood pressure 167/98, pulse 112, temperature102.0° F, respirations 14, oxygen saturation 72% on 6L via venture mask.
· Height 5 feet 6 inches, weight 75 kg
· Patient localizes to endotracheal tube (ETT) and is intermittently aroused, making several attempts to pull ETT
· Orally intubated #7.5 ETT, taped at 27 cm to lip
· Volume cycled ventilator at FIO2 – 60%, in assist control mode of 14 breaths per minute, tidal volume 450, positive end-expiratory pressure PEEP5 cm H2O
· Breath sounds decreased in bases with bilateral crackles that do not clear after suctioning
· Brown/yellow secretions returned with suctioning
· Peripheral pulses weak at 1/4 with capillary refill greater than 4 seconds
· 2+ pitting edema in the bilateral lower extremities
Newly Obtained Diagnostic Study Results
· Arterial blood gas (ABG) pH 7.31, PaCO2 58mm/Hg, HCO3 28mmol/L, PaO2 54mm/Hg, EtCO2 38 mm/Hg
· Chest x-ray reveals diffuse white out in middle and lower lobes; endotracheal tube present with tip well above the carina; left subclavian central venous catheter is located in the superior vena cava
· CT scan reveals alveolar opacities with increasing effusions in the gravity-dependent areas of the lungs
Complete the following Case study questions. Answers must be thorough and cited appropriately in APA format
Interpret Z.Q.’s latest set of ABGs.
Describe each of Z.Q.’s ventilator settings and the rationale for the selection of each.
After reviewing Z.Q’s ABG results, the provider increases the PEEP from 5 cm H2O to 8cm H2O. Why would this be necessary and what is the expected outcome associated with this action?
The provider decides to begin Z.Q. on IV dopamine and milrinone. What is the rationale for using each of these medications?
Based on the assessment data, what are the nursing priorities for Z.Q.?
List three potential adverse complications with mechanical ventilation.
You are concerned about Z.Q.’s nutritional status and approach the provider for a dietary consult, thinking that Z.Q. is a candidate for enteral feedings with Pulmocare. What is your reason for making this recommendation?