Case Study 27 Mechanically Ventilated Patient X Scenario P., a 33-year-old woman diagnosed with Guillain-Barr syndrome (GBS), is being cared for on a…

Question Answered step-by-step Case Study 27 Mechanically Ventilated PatientX Scenario P.W., a 33-year-oldwoman diagnosed with Guillain-Barré syndrome (GBS), is being cared for on a special ventilator unit of an extended care facility because she requires 24-hour-a-day nursing coverage. She has been intubated and mechanically ventilated for 3 weeks and has shown no signs of improvement in respiratory muscle strength. Her ventilator settings are assist-control (A/C) of 12 breaths/min, tidal volume (V T ) 700 mL, FiO2 0.50, and positive end-expiratory pressure (PEEP) 5 cm H 2 O. Her vital signs are 108/64, 118, 12, 100.6° F (38.1° C). She is receiving enteral nutrition by PEG (percutaneous endoscopic gastrostomy [with a transjejunal limb]) tube (2800 kcal/24 hr). 1. Why is P.W.’s ventilator mode on A/C? 2. P.W. is receiving lorazepam (Ativan) 1 mg slow IV push (IVP) q4h to reduce her anxiety. Identify two factors that should be considered when choosing lorazepam for P.W. 3. Identify nine nonpharmacologic strategies that you could use to reduce P.W.’s anxiety, increase her comfort, and reduce the need for lorazepam. Be creative! 4. You note that 2800 kcal/24 hr is a higher than expected caloric requirement for a woman who is 5′4″ and 123 pounds. Offer a possible explanation for her caloric needs. The given scenario tells us that P.W. is on a ventilator and has a fever; thus, she requires a higher daily caloric requirement. Difficulty: Advanced Setting: Extended care facility Index Words: Guillain-Barré syndrome (GBS), sedation, tracheostomy care, medications, mechanical ventilation, symptom management, crisis management Case Study 27 Mechanically Ventilated Patient 2 Respiratory124 PART 1 MEDICALSURGICAL CASES 5. You give P.W. a bath and note that her cheeks billow outward each time the ventilator delivers a breath. What could cause this phenomenon? 6. You try repositioning P.W., place a stopcock in the inflation valve, auscultate the lungs, check the length of the tube at the lip (the tube had not moved), check the cuff, and note the air pressure is low. You insert more air in the cuff to seal the leak. Over the next 24 hours, the leak becomes worse, and the ventilator’s low exhaled volume alarm repeatedly sounds. What action will you take? 7. The physician elects to insert a no. 8 Shiley tracheostomy (trach) tube with a disposable inner cannula. P.W. becomes increasingly anxious after receiving the news. How would you prepare P.W. and her husband for the tracheostomy?X Scenario C.E., a 73-year-old married man and retired railroad engineer, visits his internist, complaining: “Whenever I try to do anything, I get so out of breath I can’t go on. I think I’m just getting older, but my wife told me I had to come see you about it.” His resting Sa O2 registers 83%. He is sent to the local hospital for a chest x-ray and arterial blood gases to be drawn after resting 20 minutes on room air. C.E. returns to the office, and after obtaining the results, the physician tells him that he has severe emphysema and must start on continuous oxygen (O 2 ) therapy at 2 L flow rate.1. How should C.E.’s chief complaint be recorded? 2. What is emphysema? 3. What is the most common cause of emphysema? Smoking accounts for 82% of emphysema. 4. Based on this information, what questions will you ask about health behaviors? 5. What is the rationale for starting C.E. on oxygen at only 2 L flow rate? CASE STUDY PROGRESS The physician tells C.E. that his office will have a home health equipment company call him to make arrangements to deliver liquid O 2 equipment and educate him in its use. As a registered nurse (RN) working for the company, you are assigned to make the initial home visit.6. What general criteria need to be fulfilled for Medicare to pay for C.E.’s home oxygen therapy? 7. How would you prepare for the first visit? 8. What issues would you address with C.E. and his wife? services available to them. 9. The next time you visit, C.E. complains of sores behind his ears. He explains, “That long oxygen tubing seems to take on a life of its own. It twists around and gets caught under doors, chairs, everything. It darn near rips the ears off my head.” What can you tell him that could help? 10. You auscultate C.E.’s breath sounds and detect the odor of Vicks VapoRub. When you question C.E. about the use of Vicks, he tells you that he started to apply it in and around his nose to prevent his nose from becoming dry and sore. How would you counsel C.E. and his wife regarding safety issues with oxygen use?. CASE STUDY PROGRESS At your next visit 3 weeks later, C.E. tells you that the previous evening he walked to the kitchen for a snack and became increasingly short of breath. As per your instructions, C.E. removed the nasal cannula, tested the flow against his check, and felt no O 2 flowing from the catheter. He lacked the force and volume required to yell for help and was too short of breath to return to the living room to check his O 2 tank. He bent forward with his elbows on the countertop and struggled to breathe. He became more frightened with each passing second, and his breathing became increasingly more difficult. A minute later, C.E.’s wife found him and reconnected his O 2 tubing. C.E. sat at the table for 20 minutes before he could walk back to the living room. 11. Why did C.E. assume the peculiar position at the countertop?12. A week later you receive a call from C.E.’s wife. Since the incident, C.E. “doesn’t want her out of his sight.” She asks you to come to the house and “talk some sense into him.” What teaching strategies will you use with C.E. and his wife? • 13. C.E.’s wife asks you what her husband can do to help her around the house. She says, “The doctor told him to go home and take it easy. He sits in a chair all day. He won’t even get up to get himself a glass of water. I’ve got a bad hip and this has been very hard on me.” How would you address her issue? 14. What referrals could you consider at this time? 15. C.E. states, “You seem to know what you are talking about, so let me ask you something. I wake up with a headache almost every morning. My wife says it’s because I snore so loud and don’t breathe right when I sleep. Do you know anything about that?” After asking several questions, you inform C.E. that it sounds like he might not be getting enough O 2 at night. CASE STUDY PROGRESS C.E. seems impressed by your explanation. He asks whether there is anything that can be done for his problem. You inform him that the first step is to identify the problem. You report to the covering health care provider, and an oximetry study is ordered. You comment that C.E. sounds like he has a cold. He replies, “Oh, our great-grandchildren were over to visit several days ago and they all had snotty noses. I suspect that I’ll get it pretty soon. The problem is, every time I get a cold it goes straight to my lungs16. What information would you want to review with C.E. and his wife about the signs and symptoms of infection and when to seek treatment?. 17. What basic hygiene measures can C.E. and his wife take to prevent his developing an infection? (List at least four.) 18. Why is it important for people with lung disease to seek early intervention for infection? 19. C.E.’s wife says she would like to read more about emphysema on the Internet. List an authoritative Internet resource of professional and patient or family information on lung disease. Health Science Science Nursing Share QuestionEmailCopy link Comments (0)