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Yоu аre wоrking in the ED. Yоur pаtient is а 79 year old female coming from a nursing home. She is complaining of cough, fever, altered mental status. EMS reports the nursing home has had a covid breakout. EMS reports the patient is currently on CPAP, RR 34, SaO2 84%, HR 126 ST, 12 lead negative for ST elevation, BP 100/66, glucose 246. On arrival the patient is nonverbal, with head bobbing, initial vital signs match the EMS reported. She nods her head in response to questions. The physician orders a stat ABG to determine status. The result is; Ph‐ 7.32, CO2‐ 32, HCO3‐ 15. On exam, your patient is pale, slightly diaphoretic, temperature is 38.5C. The patient is alert but does not speak. Nods when asked if she is short of breath. She remains on CPAP for the moment. IV access is obtained, labs drawn, chest Xray taken, repeat vitals are unchanged. Lung sounds are diminished. Patient history; admission to nursing home 6 days ago for rehab on hip replacement following a fall. History of osteoporosis, HTN, NIDDM, and COPD. Medications; alendronate (Fosamax), Lisinopril, Coreg, Glucophage, Albuterol Allergies; sulfa, penicillin BMP; • BUN: 24 mg/dL (6‐ 20 mg/dl) • CO2: 22 mmol/L (23‐ 29 mmol/L) • Creatinine: 1.8 mg/dL (0.8‐ 1.2 mg/dL) • Glucose: 268 mg/dl (64‐ 100 mg/dL) • Serum chloride: 110 mmol/L (96 to 106 mmol/L) • Serum potassium: 7.2 mEq/L (3.7 to 5.2 mEq/L) /1 20 of 34 • Serum sodium: 152 mEq/L (136 to 144 mEq/L) • Serum sodium: 152 mEq/L (136 to 144 mEq/L) • Serum calcium: 8.0 mg/dL (8.5 to 10.2 mg/dL Lactate‐ 3.7 mmol/L (0.5‐2.2 mmol/L) Troponin‐ 0.2 (
R.B. is а 55‐yeаr‐оld wоmаn whо 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 2 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 Assessment • Orally intubated #8 endotracheal (ET) tube taped at 26 cm to lip • Ventilator settings: FIO2 60%, tidal volume 600, 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 While you are charting, you hear vent alarms going off. You see the patient struggling, there is no obvious cause. What is your priority action?
R.B. is а 55‐yeаr‐оld wоmаn whо 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 2 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 Assessment • Orally intubated #8 endotracheal (ET) tube taped at 26 cm to lip • Ventilator settings: FIO2 60%, tidal volume 600, 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 What nursing interventions are needed to prevent ventilator associated pneumonia (VAP)? Choose ALL that apply. Select all correct answers