Question

Overview: M.H. is a 55-year-old Caucasian male who arrived at the emergency department complaining of acute abdominal pain. Computed tomography of the abdomen revealed ischemic bowel. He was taken emergently to surgery where repair of a perforated colon with ascending colostomy formation and abdominal irrigation was performed. Estimated blood loss (EBL) during surgery was 6,000 ml. He had an episode of hypotension during the procedure with his systolic blood pressure (SBP) dropping to less than 70 mm HG. Hemostasis was achieved after administration of 7 units of packed red blood cells and 4 L of normal saline. He was successfully extubated post-operatively and transferred to the ICU on 60% oxygen via face mask with spontaneous respirations at a rate of 26 per minute with a SpO2 of 92%. The cardiac monitor shows a sinus tachycardia at a rate of 137 bpm. He has a triple lumen central line with an infusion of normal saline running at 125ml/hr. His indwelling urinary catheter has 60 mL of dark yellow urine in it.

Six hours post operatively, M.H.s vital signs are as follows:

T 97.2 F, HR 142, RR 33, B/P 94/54, SpO2 78%, CVP 3

He is showing signs and symptoms of respiratory distress with accessory muscle use. The physician is notified and M.H. is emergently re-intubated at the bedside. Chest x-ray shows bilateral dense infiltrates with a ground glass appearance.

Medication orders include: Pavulon (pancuronium) 0.1 mg/kg/hr for neuromuscular blockade

Levophed (norepinephrine) 5mcg/min to maintain SBP >90

Diprivan (propofol) 10 mcg/kg/min for sedation

His wife and two adult children are at his bedside voicing concerns and questions regarding his progress.

Assessment is as follows:

Objective data: M.H. is a sedated, paralyzed, well-nourished man; head of bed elevated 45 degrees; skin cool with moderate diaphoresis.

Respiratory: Patient on PSV ventilation with TV 650, FiO2 70%, RR 16 and PEEP 5; SpO2 85%; fine crackles at lung bases.

Cardiovascular: BP 95/60mm Hg; cardiac monitor shows sinus tachycardia at 120 beats/min, with equal apical-radial pulse; temperature 101°F rectally.

Gastrointestinal: Surgical dressing dry and intact; colostomy draining serosanguineous drainage.

Urologic: Urinary catheter draining concentrated urine < 30 ml/hr.

Diagnostic studies: ABG’s: pH 7.15, PaO2 59 mm Hg, PaCO2 57 mm Hg, HCO3 16 mEq/L, O2 saturation 86%. PaO2/FIO2 ratio < 200.

Topic 1: Care of the Patient with ARDS

M.H. is diagnosed with ARDS.

• What assessment data and patient history would support a diagnosis of ARDS for this patient?
• What are the possible complications and expected outcomes related to M.H.’s diagnosis?
• What are your top three nursing interventions with rationale for M.H.?
• What function does PEEP have in maintaining respiratory status?
• What position would the patient most benefit from?
• How can the nurse use therapeutic communication to discuss M.H.’s care to his family?

Answer 1

Acute respiratory distress syndrome- it is a form of pulmonary edema characterised by severe hypoxemia that can rapidly lead to acute respiratory failure. It is a common complication of a variety of illness.

1.Assessment data and patient history should include

Age

History of diabetes mellitus,pneumonia sepsis, trauma

-Assessment should include respiration rate,pattern

Discoloration of skin

-Diagnostic evaluation includes chest Xray and CT can explain pathophysiology of ARDS

ABG Assessment

Thermodynamic parameters

2.a.complications .It can be considered as

Pulmonary-pulmonary embolism, pulmonary fibrosis,ventilatorassociated pneumonia

Gastro-pnemoperitoneum

Neuro- hypoxic brain damage

Cardio-abnormal heart rythem

Kidney-Acute kidney failure.

Deep vein thrombosis, pressure ulcers

2b.Possible outcome-

Perfusion -maximise perfusion by increasing oxygen trasport between alveoli and pulmonary capillaries

Positioning-prefer prone position

Protective lung ventilation-use mechanical ventilation to open collapsed alveoli

Protocol weaning-it reduces the time and cost of the care.

3.nursing interventions and rationale

a.frequent turning and repositioning- found to improve ventilation and perfusion in the lungs and enhance secreation drainage.

b.encourage frequent coughing if the patient can,or else suction the airways-help to loosen excessive airway mucus and maintain open alveoli.

c.monitor patient for signs and symptoms of cardiovascular compromise particularly decreased cardiac output-it is caused by decreased venous returns or positive pressure ventilation.

c.monitor lab values especially haemoglobin-adequate hb is needed to carry oxygen

4 peep-(postitive end respiratory pressure ) used to improve oxygenation and prevent alveolar collapse in mechanically ventilated patient with ARDS.though peep in ARDS appears to protect alveoli and improve atrial oxygenation it also impair tissue oxygen delivery significantly.the higher level of applied peep is >5cmH