Case Study: Acute Respiratory Distress Syndrome Patient ✓ Solved

Case Study Acute Respiratory Distress Syndrome Patient P

Case Study Acute Respiratory Distress Syndrome 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, HCO3 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, temperature 102.0° F, respirations 14, oxygen saturation 72% on 6L via venturi mask. Height 5 feet 6 inches, weight 75 kg. Patient localizes to the 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 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 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 8 cm 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 dobutamine 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?

Paper For Above Instructions

Acute Respiratory Distress Syndrome (ARDS) is a severe condition characterized by the rapid onset of widespread inflammation in the lungs, leading to impaired gas exchange and respiratory failure. Z.Q., an 84-year-old male, has shown critical signs that necessitate a thorough analysis of his current clinical status. This paper will interpret Z.Q.'s arterial blood gases (ABGs), describe his ventilator settings, discuss medication rationale, identify nursing priorities, evaluate potential complications from mechanical ventilation, and justify the recommendation for enteral feeding.

Interpretation of Z.Q.’s Latest ABGs

The arterial blood gas (ABG) analysis shows a pH of 7.31, PaCO2 of 58 mmHg, HCO3 of 28 mmol/L, and PaO2 of 54 mmHg. These values suggest the following: the pH is acidotic (normal pH: 7.35-7.45), which indicates respiratory acidosis primarily due to elevated PaCO2 levels, reflecting hypoventilation and inadequate ventilatory support. The HCO3 level is within the normal range (normal: 22-26 mmol/L), indicating that there is no metabolic compensation at this moment. The low PaO2 indicates significant hypoxemia (normal PaO2: 75-100 mmHg), affirming the severity of Z.Q.'s respiratory condition and the necessity for intensive intervention.

Description of Ventilator Settings

Z.Q. is on a volume-cycled ventilator set with the following parameters:

  • FIO2: 60% - This high fraction of inspired oxygen is necessary due to Z.Q.'s significant hypoxemia, aiming to improve oxygen delivery.
  • Assist Control Mode: 14 breaths per minute - This ensures that the patient receives a minimum of 14 breaths, allowing spontaneous breaths but guaranteeing a baseline ventilation level, crucial given his deteriorating respiratory function.
  • Tidal Volume: 450 mL - This volume is chosen based on Z.Q.'s ideal body weight, ensuring adequate lung inflation while reducing the risk of volutrauma.
  • PEEP: 5 cm H2O - This setting helps to recruit collapsed alveoli, improving oxygenation and reducing shunting, which is critical in ARDS management.

Increase of PEEP from 5 cm H2O to 8 cm H2O

Increasing the PEEP from 5 cm H2O to 8 cm H2O can enhance end-expiratory lung volume by preventing alveolar collapse during expiration. This action is vital in ARDS cases, as it aims to improve oxygenation by increasing functional residual capacity and recruiting collapsed alveoli. The expected outcome includes improved PaO2 levels, leading to enhanced ventilation-perfusion matching and decreased shunting.

Rationale for Using Dobutamine and Milrinone

The provider's decision to initiate IV dobutamine and milrinone is rooted in the need to improve cardiac output and manage potential heart failure secondary to Z.Q.'s respiratory distress. Dobutamine is a positive inotropic agent that enhances myocardial contractility and increases heart rate, thereby improving cardiac output, which can be compromised due to hypoxia. Meanwhile, Milrinone is a phosphodiesterase inhibitor that increases contractility and decreases systemic vascular resistance, making it easier for the heart to pump blood effectively. Together, these medications support overall cardiovascular function, which may be impaired by hypoxemic conditions.

Nursing Priorities for Z.Q.

Given Z.Q.'s condition, the following nursing priorities should be addressed:

  1. Respiratory Support: Closely monitor respiratory status and adjust ventilator settings as necessary to optimize oxygenation and ventilation.
  2. Hemodynamic Stability: Monitor vital signs and cardiac status to ensure adequate perfusion and manage complications associated with dobutamine and milrinone.
  3. Nutritional Support: Evaluate Z.Q.'s nutritional needs and initiate enteral feeding as appropriate, given his prolonged critical condition.

Potential Adverse Complications with Mechanical Ventilation

Mechanical ventilation can lead to several complications, including:

  • Ventilator-Associated Pneumonia (VAP): The risk of pneumonia increases with prolonged mechanical ventilation due to impaired airway protection and colonization of bacteria.
  • Barotrauma: High pressures associated with ventilation can cause lung injury and pneumothorax.
  • Patient-Ventilator Asynchrony: Misalignment between the patient's breathing efforts and ventilator support can lead to discomfort and inadequate ventilation.

Justification for Enteral Feeding with Pulmocare

Given Z.Q.'s nutritional status and the stresses of critical illness, enteral feeding is recommended to provide adequate caloric intake, preserve gut integrity, and support metabolic needs. Pulmocare, a specialized formula designed for patients with respiratory conditions, provides appropriate macronutrient ratios that can help mitigate CO2 production and support optimal respiratory function. Enteral feeding also aids in the maintenance of immune function and prevents catabolism, which is crucial for recovery during prolonged illness.

Conclusion

Z.Q.’s case illustrates the complexities involved in managing an elderly patient presenting with ARDS. From interpreting ABG results to formulating nursing priorities and considering medication interventions, every aspect of care is crucial for improving outcomes. Continuous monitoring and tailoring of ventilation, hemodynamic support, and nutritional strategies will play a significant role in facilitating Z.Q.'s recovery.

References

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  • Hernandez, G. et al. (2019). High vs. low PEEP in patients with acute respiratory distress syndrome. American Journal of Respiratory and Critical Care Medicine, 200(5), 708-715.
  • Walsh, B. K., & Rojas, A. (2020). Mechanical ventilation: An overview. Respiratory Care, 65(2), 236–255.
  • McIntyre, S., et al. (2018). Pharmacotherapy for cardiogenic shock and heart failure. American Journal of Cardiovascular Drugs, 18(5), 311-317.
  • Bae, S. et al. (2018). Nutrition in mechanically ventilated patients. Journal of Clinical Medicine, 7(5), 86.
  • Marini, J. J., & Gattinoni, L. (2018). Acute respiratory distress syndrome: The role of mechanical ventilation and airway management. Anaesthesia, 73(7), 835-845.
  • Sanders, K. A. et al. (2017). Ventilator strategies in acute lung injury. Critical Care Reviews , 139-145.
  • Chung, C. K., & McAuliffe, M. (2019). Optimizing oxygenation in ARDS: Role of PEEP. Journal of Clinical Anesthesia, 52, 105-109.
  • Rice, T. W. et al. (2017). The acute respiratory distress syndrome: A historical perspective. Chest, 152(6), 1108-1116.

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