Question

Patient Profile

Z.Q., 74-year-old Hispanic man, came to the emergency department (ED) 7 days ago with 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 examination 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 3 days.

Subjective Data

• Z.Q. and wife have been married 45 years and live with a daughter and two grandchildren.
• They speak both English and Spanish.

Objective Data

Physical Examination

• Blood pressure 167/98, pulse 112, temperature 102.0°F, respirations 14, oxygen saturation 72%
• Height 5'6", weight 75 kg
• Patient localizes to endotracheal (ET) tube and is intermittently aroused, making several attempts to pull ET tube
• Orally intubated #7.5 ET tube, 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 PEEP 5 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 examination reveals diffuse white out in middle and lower lobes; endotracheal tube present with tip well above the carina; left subclavian central venous catheter is in the superior vena cava
• Computed tomography scan reveals alveolar opacities with increasing effusions in the gravity-dependent areas of the lungs

Case Study Questions:

1. You have read the patient’s profile and physical assessment data. What clinical data from this information is relevant and must be recognized as significant to you as the nurse? Student Must List at Least 7 answers
   1. Blood pressure 167/98,
   2. pulse 112,
   3. temperature 102.0°F,
   4. respirations 14,
   5. oxygen saturation 72%
   6. Peripheral pulses weak at 1/4 with
   7. capillary refill greater than 4 seconds
   8. 2+ pitting edema in the bilateral lower extremities

2. Blood pressure 167/98, pulse 112, temperature 102.0°F, respirations 14, oxygen saturation 72%

What are your nursing interpretations of the client’s presenting vital signs? What would be your initial assumption from your already learned knowledge – Student’s are to apply their own assumption/thinking, faculty want you to think on your own; see what you come up with. Student Must Address All Vital Signs:

• Temp = high- which might indicate infection, fever
• BP = High- hypertension
• Pulse á = high- tachycardia
• RR =   tachypnea
• O2 Sat â = hypoxemia

3. What would be your initial nursing priority that will guide the plan of care for Z.Q.?

The initial nursing priority are maintaining the airway, providing sufficient oxygenation (Breathing)and circulation. This process are often refer to as ABC. In Z.Q. case, maintain the airway, providing oxygenation and supporting hemodynamic function are prioritize.

4. What would be two prioritized nursing diagnoses for Z.Q. prior to providing client care? Include all 3 parts of nursing diagnosis. Student Must List at Least 2

5. Although Z.Q. speaks both Spanish and English, what would be two cultural aspects to consider in caring for the client? Student Must List at Least 2

6. What 5 prioritized nursing interventions will be initiated by you as the nurse based on your listed initial nursing priority in question 3? Student Must List at Least 5

7. Once treatment has been initiated, what relevant clinical assessment data would you need to closely monitor in detecting a possible change in status or complications? Student Must List at Least 4

How would you as the nurse, evaluate the effectiveness of your nursing interventions for Z.Q.? Student Must List at Least 4

Answer 1

Question 3: Two prioritised   Nursing Diagnosis  

i) Impaired gas exchange related to altered oxygen supply (due to obstruction of airway by secretions and bronchospasm ) as evidenced by abnormal ABG values of PaO2 and PaCO2.

ii) Hyperthermia related to infection and the illness  as evidenced by the temperature reading 102 degree F .

4 . Two cultural aspects :

While caring for the client, the nurse has to consider the cultural factors also. As Mr. ZQ is a Hispanic man, the Health care professional has to ensure his  English language understanding capacity.

*They are more individualistic , so focus on the client, communicate with him mainly regarding the adherence to medications. Listening to his problems and showing respect to their opinion and beliefs and participating them in their plan of care can greately help in the recovery.

* Family ties and relationship is important for them. So they may get adequate family support.  

5. Five priority Nursing Interventions:

* Maintain a patent airway by doing the suctioning of secretions from the airway

* Hyperoxygenate the patient before and after suctioning procedure, helps to prevent the desaturaion of oxygen  

* Administer humidified oxygen to the patient to prevent the dryness of mucous membrane

* Remove excess clothing and covers and adjust the room temperature and ventilation to reduce body temperature.  

* Administer medications such as Antihypertensives, Antidiabetics, brochodilators, anti-inflammatory and antipyretics to the patient, as per physician's order.

6. Clinical Assessment data:

* As the patient is in the ventilator , monitor the vital signs frequently as per policy.

* Monitor ABG values and oxygen saturation. Check the level of PaO2 and PCO2 to assess for any existing hypoxia and hypercapnoea.  

* Check the pH abnormalities to detect any respiratory acidosis or alkalosis.

7. Evaluate the effectiveness of nursing interventions : Check the outcome

* Demonstrate adequate oxygenation and improved ventilation by ABG's within normal range .( PaO2 should be above 80 ) and be free of symptoms of respiratory distress.

* Patient maintain a body temperature below 101 degree F.

* Patient maintain airway patency with breath sounds clear.

* Patient maintain a normal blood pressure range below 140 / 90 .