Question

Phil Nelson, 19 year old, was brought to the ER following a near-drowning. He was not breathing when the paramedics pulled him out of the lake. CPR was given and he awoke. Upon arrival to the ER, he was extremely anxious with a BP of 118/62 and respiratory rate of 26. He was alert and oriented X 3 and the nurse auscultated crackles along with expiratory wheezing throughout all lung fields. A 40% face mask was applied and his ABGs were:

pH 7.48          PaCO₂   28      PaO₂ 48          O₂sat 90%      HCO₃   24. All other labs were normal.

Interpretation of this ABG __________________________________________________

Phil remained stable for the next 24 hours but became dyspneic, tachypneic, tachycardic and developed progressive hypoxemia. Despite the ICU nurse increasing the FIO₂, his ABGs continued to deteriorate. On 100% nonrebreather mask, his ABGs were:

pH 7.50          PaCO₂   28      PaO₂ 48          O₂sat 77%      HCO₃   24

Interpretation of this ABG __________________________________________________

He was intubated and ventilated with the following settings:            AC 12, FIO₂ 60%, TV 800ml, and PEEP of 5. Post intubation X-ray showing proper ET placement but bilateral diffuse, patchy infiltrates were noted. A pulmonary artery catheter was inserted and the following readings were obtained:

PA 25/10                   pH 7.48

PAWP 8                     PCO₂ 30

CVP 6                        PaO₂ 58

CO 7.5                        O₂ sat 89%

                                    HCO₃ 24

Interpretation of this ABG __________________________________________________

Phil Nelson was diagnosed with ARDS.

1.     What is ARDS? What is the diagnostic criterion for ARDS?

2.     What clinical conditions are commonly associated with ARDS?

3.     What are the major pathophysiologic alterations in ARDS?

4.     What are the clinical signs and symptoms of ARDS?

5.     What is the usual cause of hypoxemia in ARDS?

6.     What is the treatment for an intrapulmonary shunt?

7.     How can PEEP affect O₂ transport?

Phil Nelson’s ABGs were not improving as expected. The physician ordered a PEEP of 10. Thirty minutes later another set of ABGs were drawn but the PaCO₂ remained 32 and the PaO₂ only increased to 65. The physician increased the PEEP to 15 and the PaO₂ increased to 88 and the O₂ sat increased to 95%. However, the nurse performed a cardiac output which was reported as 3.8. Why?

8.     The physician was hesitant to increase the FIO₂ further than 60%. What was the physician concerned about?

9.     Phil was restless and the nurse notes that he is “bucking” the vent. Why is this a concern? What should the nurse assess for?

Despite the typical medical/nursing interventions, the client has not improved, and the physician orders a neuromuscular blockade. What is this therapy and why is it used?

10. What are the most essential nursing responsibilities when caring for a mechanically ventilated client receiving neuromuscular blockade?

11. Morphine was prescribed to Phil’s drug regimen. Why? What other medications do you anticipate the physician ordering for a patient who is on neuromuscular blockade?

12. Phil’s BP drops to 90/58 and his CVP to 2, and his PAWP to 4. Urine output is less than 30ml/hr. What therapy do you anticipate?

13. Phil is started on enteral feedings. Why is nutrition important in the patient with ARDS?

14. What is the leading cause of death in patients with ARDS?

15. Identify and prioritize three of the most important nursing diagnoses that are appropriate in caring for Phil.

Answer 1

Ans.1) Acute Respiratory Distress Syndrome (ARDS) is an acute inflammatory syndrome which causes increased permeability of the alveolar-capillary membrane.

Its diagnosis is based five features –

• associated risk factor
• severe hypoxemia despite adequate oxygen supplementation
• bilateral infiltrates on chest x-ray
• decreased lung compliance
• no evidence of congestive heart failure

2.) The clinical conditions are commonly associated with ARDS are given below -

• rigorous shortness of breath
• labored and unusually rapid breathing
• low blood pressure
• extreme tiredness

3.) The major pathophysiologic alterations in ARDS includes

• increased capillary permeability
• inflammation due to neutrophil activation
• pulmonary hypertension (PH)

4.) Clinical signs and symptoms of ARDS –

• dyspnea (shortness of breath)
• tachypnea (abnormally rapid breathing)
• hypoxaemia (low oxygen concentration in the blood)
• pulmonary hypertension (high blood pressure in the pulmonary arteries)

5.) The usual cause of hypoxemia in ARDS is intrapulmonary shunting of blood resulting from airspace filling or collapse.

6.) Treatment for an intrapulmonary shunt includes

• oxygen therapy: For hypoxia, hypoventilation, reduced diffusion, and V/Q mismatch
• sometimes, additional ventilatory stimulation or mechanical ventilation
• oxygen is not effective for shunting.

14.) Most common cause of death in patients with ARDS is multiple organ failure (30 - 50%), whereas respiratory failure causes (13 - 19%) of deaths.

15.) The three of the most important nursing diagnoses that are appropriate in caring for Phil are

• Oxygen therapy
• Ventillator support
• Prone positioning