Case Study
Critical Care and Mechanical Ventilation
Patient Profile Richard Kincaid is a 72-year-old man who collapsed on the street. He was unresponsive on admission and remains in the same state. He has an oral ET tube in place and is receiving mechanical ventilation. He weighs 90 kg. A subclavian central line was placed to monitor CVP and administer fluids.
Subjective Data
None; patient is unresponsive to painful stimuli.
Objective Data
Physical Examination
• Noninvasive BP is 100/75 mm Hg; heart rate is 128 (atrial fibrillation with a rapid ventricular response); temperature is 38.8°C; SpO2 is 98%.
• Purulent secretions from ET tube.
• Breath sounds: rhonchi bilaterally, decreased breath sounds on the right.
Diagnostic Studies
• Chest radiography reveals right lower lung consolidation.
• ABGs: pH 7.48; PaO2 : 94 mm Hg; PaCO2 : 30 mm Hg; bicarbonate (HCO3) 34 mmol/L.
• Computed tomography (CT) scan is positive for massive cerebro-vascular accident.
Collaborative Care
• Positive-pressure ventilation seings: assist-control mode
• Seings: FiO2 70%, VT 700 mL, respiratory rate 16 breaths/min, PEEP 5 cm H2O
• Enteral feeding at 25 mL/hr via small-bore feeding tube
• In-dwelling urinary catheter to bedside drainage
• HOB elevated at 40 degrees
• Position change every 2 hours
• Chest physical therapy performed every 2 to 4 hours
• Azithromycin (Zithromax) 500 mg intravenously q24h
• Cefotaxime (Claforan) 2 g intravenously q6h
• 5% dextrose in normal saline (D5NS) with potassium chloride (KCl) 20 mmol/L at 100 mL/hr
Discussion Questions
1. Identify two reasons for intubating and providing mechanical ventilation for Mr. Kincaid.
2. What do Mr. Kincaid's ABGs indicate, and which ventilator seing(s) should be changed?
3. What is his PaO2/FiO2 ratio and what does it signify?
4. Mr. Kincaid's BP drops to 80 mm Hg, and he remains in atrial fibrillation with a ventricular rate of 158. A PA catheter is inserted for further hemodynamic monitoring. What would be the purpose of hemodynamic monitoring (in addition to CVP monitoring) in this patient?
5. Priority decision: What are the two priority nursing considerations for a patient with a PA catheter?
6. Mr. Kincaid's initial PAOP is 14 mm Hg, CI is 2 L/min/m2 , and systemic vascular resistance index (SVRI) is 2 667 dynes/sec/cm−5/m2 . How would the nurse interpret these values? What medical interventions would the nurse anticipate?
7. Mr. Kincaid's pulmonary condition deteriorates. PaO2 drops to 70 mm Hg, and SpO2 is 89%. PEEP is increased to 7.5 cm H2O. What implications does this have for Mr. Kincaid given his hemodynamic status?
8. Based on the data presented, what are the actual and potential problems that the nurse can identify with this patient?
9. Evidence-informed practice: Mr. Kincaid's family wants to know why he is geing tube feedings. What should the nurse tell the family? What is the evidence to support the use of tube feedings?
10. After 4 days, Mr. Kincaid remains unresponsive and has developed renal failure. The physician believes the patient will not recover and wishes to discuss goals of care with the patient's caregiver. What would be the nurse's role in this meeting?