Question

Patient Profile

R.B. is a 55-year-old woman who presented to the emergency department (ED) via ambulance for acute shortness of breath. Her daughter called an ambulance after finding her mother with an increased respiratory rate and shortness of breath. Upon arrival to the ED, R.B.’s respirations were 40 and shallow with wheezing in the lower lobes and rhonchi in the upper lobes bilaterally. She had positive jugular vein distention and a heart rate of 128. After treatment with albuterol nebulizer via mask, her vital signs were temperature 96.8°F, pulse 98, respirations 28, blood pressure 148/84, and O₂ saturation 94% with 15 LPM via mask. Arterial blood gasses showed her pH 7.19, pCO₂ 90, PO₂ 92%, HCO₃ 38. R.B. was intubated for hypercapnia. After an echocardiogram showed an ejection fraction less than 50%, she had an emergency left heart catheterization done with two stent placements into the left anterior descending artery. A pulmonary artery catheter was placed, and the initial hemodynamic readings show elevated left ventricular preload. R.B. is now being transferred to the intensive care unit (ICU).

Subjective Data

• Lives with her single daughter, who cares for D.B. full time
• Daughter is not present at bedside
• Smokes 1 pack of cigarettes per day
• No longer active outside of the home because of her chronic illness
• Does not drink alcohol

Objective Data

Physical Examination

• Orally intubated #8 endotracheal (ET) tube taped at 26 cm to lip
• Ventilator settings: FIO₂ 60%, tidal volume 700, assist control (A/C), rate 16, PEEP of 5
• Height 5'5", weight 117 kg
• Alert and oriented to person, place, and time
• Fine crackles and wheezes bilateral lower lobes
• 2+ pitting edema bilateral lower extremities

Diagnostic Studies

• Chest x-ray postintubation: ET tube 4 cm from carina. Infiltrates in both bases; left base is worse than right
• 12-lead ECG: ST elevation
• Troponin: 41.94
• Lung V/Q scan negative for pulmonary embolism
• Urinalysis: dark yellow and cloudy, protein 28 mg/dL, positive for casts, positive for red blood cells and white blood cells, positive for glucose and ketones

Question 1

On arrival to the ICU, R.B. begins to thrash, kick her legs, and wave her arms. The portable transport ventilator alarms are ringing. What is the priority nursing assessment?

Question 2

During the assessment, it was noted that R.B. partially extubated herself and now must be reintubated. What equipment is needed?

Question 3

After reinserting R.B.’s endotracheal tube, how is placement verified?

Question 4

After R.B. is reintubated and sedated, you notice there is no waveform on the monitor for the pulmonary artery catheter. List the initial nursing trouble shooting interventions.

Question 5

You obtain a set of hemodynamic monitoring values. Interpret these results.

Heart rate	110	Blood pressure	142/58
Cardiac output (CO)	4.06 L/min	Pulmonary artery	52/32 mm Hg
Central venous pressure (CVP)	10 mm Hg	Systemic vascular resistance (SVR)	1499 dynes/sec/cm-5
Pulmonary artery wedge pressure (PAWP)	16 mm Hg	Pulmonary vascular resistance (SVR)	549 dynes/sec/cm-5
Cardiac index (CI)	2.25 L/min/m2	Mixed venous oxygen saturation	SvO2 62%

Question 6

Describe each of R.B.’s ventilator settings and the rationale for the selection of each.

Question 7

How does PEEP lower CO?

Question 8

R.B. is started on intravenous dobutamine and sodium nitroprusside. How will these medications affect her hemodynamic status?

Answer 1

1) * check all the tubings are connected correctly, or any disconnection occurring due to movement of the patient. * check for any obstructions of the ET TUBE from mucus or biting the tube by patient. 2) LARYNGOSCOPE is needed for Reintubation. 3) *First method is Direct visualisation of insertion of ET TUBE into Trachea. * Assess for Adequate chest wall movement * Through LARYNGOSCOPY. * Confirmed by Wave form Capnography Or Chest Radiography. 4)* Check the monitor for correct scale is used. * check the pressure in bag. * Check for any loose connection or Disconnection * Remove the Air bubble spontaneously. * Check tubings for Blood clots, or Air. * Change transducer. * Sometimes catheter Will repositioned to less turbulent area. * Avoid Flushing of Catheter. * Notify the physician for repositioning of catheter. * Observe waveform on monitor while injecting air. * Remove Kinks * Slowly Aspirate for blood return If blood returns happens inform to physician to remove