Case Scenario (SPRING 2015) Respiratory Failure (RF)

NAME: Aderonke Adeduro DATE: 02/22/15 Score: 3.25
WEEK: 6 Case Scenario (SPRING 2015) Respiratory Failure (RF)
Arthur M., a 57-year-old morbidly obese male, has just been transferred to the Surgical Intensive Care Unit (SICU) from the post-op recovery room following bariatric
surgery. The recovery room nurse informs you that Mr. M. self-extubated and the decision was made by the physician to allow him to remain extubated. He is awake but
very drowsy and is currently receiving oxygen 5 LPM via face mask (FM).
Past Medical History: hypertension, type 2 diabetes, and of sleep apnea with a c-pap machine used at home. He quit smoking 2 years ago following a 26 year history of
smoking 1 1/2 pack of cigarettes a day.
Current Medications: hydrochlorothiazide, glucovance, and oxygen at night with is c-pap machine.
Vital Signs and ABG upon admission to the SICU:
RR 10 breaths/min
BP 150/90
HR 86 bpm
SpO2 92% 5/L FM
Temp 96.2 oral
PaO2 94 mm Hg
SaO2 96%
pH 7.40
PaCO2 42 mm Hg
HCO3 26 mEp/L

Content: Wagner and Hardin-Pierce (2014): Chapters 6 and 33
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1. What risk factors does Mr. M have that decreases his oxygen consumption and places him at risk for respiratory failure? Explain the rationale for each risk
factor. (1. point) -.75
According to Wagner & Hardin-Pierce (2014), self-extubation poses serious health risks to Mr. M who was under mechanical ventilation. Complications arising
from the unplanned extubation may include aspiration pneumonia, bronchospasm, dysrhythmias, respiratory arrest and hypotension. Other risk factors related to self-
extubation include inappropriate use of sedatives and restraints, inexperience caregivers, and inadequate staffing (Wagner & Hardin-Pierce, 2014). Please read
questions carefully
Conditions that decrease oxygen consumption in Mr. M:
A. Hypoventilation: Mr. M is breathing 10 breaths/min.
B. Hypothermia: Mr. M has an oral temperature of 96.2
C. Anesthesia: Mr. M has just received bariatric surgery that requires anesthesia and he is still drowsy from it.
D. Inactivity: Mr. M is still drowsy and not moving very much at this time.
(Wagner & Hardin-Pierce, 2014) See page 798 box 33-7

2. In your report from the recovery room nurse, you remember that Mr. M extubated himself too early and he is still drowsy at this time. In your post extubation
follow up assessment, what will you pay particular attention to? (.75 points)
The primary goal is ensuring uninterrupted delivery of oxygen to the lungs of the patient, to avoid stimulation of the airway and developing back-up plans that
would permit re-intubation and ventilation with little delay and difficulty (Wagner & Hardin-Pierce, 2014). Emphasis should be on positioning, pre-oxygenation, and
suction. Tracheal tube is continuously deflated to generate passive inhalation to aid the expulsion of the resulting secretions, as well as reduce the incidences of
breath holding and laryngospasm. The patient does not have a trach -.5
“Following extubation, particular attention must be given to excellent pulmonary hygiene, including a routine of coughing, deep breathing, and incentive spirometry.
Various aerosol therapies, percussion, and postural drainage may be ordered to prevent or treat complications, if necessary” (Wagner & Hardin-Pierce, 2014, p. 145).

Scenario Continued: You have been monitoring Mr. M for 8 hours now and he is starting to show signs of respiratory deterioration including extreme somnolence. You
call the physician to report the following vital signs and he orders: ABGs and PFTs: The results are as follows:

RR 38 shallow and labored
BP 160/94
HR 112
SpO2 82%
Temp 97 oral
PaO2 55 mm Hg
SaO2 90%
pH 7.29
PaCO2 55 mm Hg
HCO3 26 mEq/L

Respiratory rate (f) 38 breaths/min
Vital capacity (VC) 12 mL/kg
Maximum inspiratory pressure (MIP) -14 cm H2O
3. Interpret the ABGs. (1 point)
The PaCO2 value for the patient is tending towards acidosis as it is higher than forty-five, which is attributed lower pH. The HCO3 value is normal because it
falls in the range between twenty-two and twenty six. Complete compensation is indicated by normal pH and abnormal PaCO2 values. Since the pH value is lower than 7.4,
compensated acidosis takes effect. Combined disturbance is when the pH is altered by HCO3 in the same way as the PaCO2. Therefore, the lower value of HCO3 and higher
value of PaCO2 depicted by the patient resulted to acidosis But it is respiratory acidosis -.25 (Wagner & Hardin-Pierce, 2014).

4. What is acute ventilatory failure (AVF), how is it diagnosed? What are the criteria for ventilatory support and what are Mr. M’s critical values that meet
this criteria?(1.25 points)
Acute ventilation failure is an increasing yet challenging medical emergency that results from a number of disease processes capping in hypercapnia and
hypoxaema. AVF causes malfunctioning of the respiratory system to effectively oxygenate the blood as well as the removal of carbon dioxide. Hypoxaemia occurs when the
PaO2 and PaC02 values are higher than sixty. This is not correct The values from Mr. M show that he is not at the risk of AVF because the value of both PaO2 and PaC02
are lower though approaching the mark. Respiratory acidosis is developing as the pH is reducing following the decrease in the value of hydrogen carbonate in the blood
(Wagner & Hardin-Pierce, 2014). You did not answer the second part of the question (see highlighted part) -1
“Acute ventilatory failure (AVF) is the most common indication for ventilator support. AVF is the inability of the lungs to maintain adequate alveolar ventilation.
It is diagnosed on the basis of the acid-base imbalance it creates-acute respiratory acidosis, which is expressed as Paco2 greater than 50 mm Hg and pH less than 7.30”
(Wagner and Hardin-Pierce, 2014, p. 119).
• “Acute ventilatory failure: PaCO2 greater than 50 mm Hg, pH less than 7.30
• Acute oxygenation failure (hypoxemia): PaO2 less than 60 mm Hg
• Pulmonary mechanics: Respiratory rate (f): f greater than 35 breaths/min
• Vital capacity (VC): VC less than 10 to 15 mL/kg (normal : 65 to 75 mL)
• Maximum inspiratory pressure (MIP): Less than -20 to 0 cm H2O (Normal: -100 to -50 cm H2O)” (Wagner & Hardin-Pierce, 2014, p. 119). Table 6-1

Mr. M: Paco2: 55 mm Hg; pH is 7.29; pao2 is 55 mm Hg; respiratory rate of 38; VC is 12 mL; MIP is -14 cm H20.

5. The physician tells you that he wants to use an endotracheal tube for intubation. You grab all the supplies, the physician successfully intubates Mr. M., and
now you are performing your post intubation assessment. Explain what will be included in this assessment. (1 point)

After intubation, assessment will involve checking of the carbon dioxide detector. The tube is usually in the right depth when it is between twenty-two and
twenty-four centimeters at the lips (Wagner & Hardin-Pierce, 2014). The sounds of bilateral breath are checked using ambu-bagged breaths. Thereafter, X-Ray is done to
establish whether the tube in positioned correctly. The tube is considered to be positioned correctly when it is two or three centimeters above carina.

Mr. M. has been sedated on a propofol drip and the physician has ordered the settings below.
Ventilator Settings
Tidal Volume 500 mL
Fio2 0.40 or 40%
PEEP 5 cm
Ventilation Mode: PRVC Setting Only
Respiratory Rate 12 Breaths/min
6. Please explain (thoroughly) Tidal Volume, Fio2, and PEEP. (1 point) -.5
TIDAL VOLUME:

Fio2:

PEEP
According to Wagner & and Hardin-Pierce (2014), tidal volume, FiO2 and PEEP are measures used in the assessment of the oxygenation status. FIO2 exerts pressure on the
alveolar to reduce the possibility of shutting?? while PEEP aids the reopening of the alveoli to free carbon dioxide (Wagner & Hardin-Pierce, 2014). The P/F ratio is
calculated as shown: PaO2/FiO2. For instance, the P/F ratio for Mr. M is calculated as 5/0.40, equivalent to 137.5. Values greater than three hundred are considered to
be normal unlike the case of Mr. M. Values lower than three hundred indicate acute lung injury, hypoxemia or refractory hypoxemia, which is irresponsive to therapy.
Although Mr. M is receiving forty percent of oxygen, as indicated by the FiO2 value of 0.40, his PaO2 ought to be five times the amount of oxygen being supplied, which
is the tidal volume where did you get this information??. Need to define/explain tidal volume. Respiratory rate implies the number of breaths that the patient takes
in every minute.
TIDAL VOLUME:
“Tidal volume (VT or TV) is the amount of air that moves in and out of the lungs in one normal breath. Normal VT ranges from 7 to 9 mL/kg (or 500 to 800 mL in an
adult)” (Wagner & Hardin-Pierce, 2014, p. 125).

Fio2:
“Fio2 means the fraction of inspired oxygen. It is expressed as a decimal, although clinicians often discuss it in percentages, in terms of oxygen concentrations. At
sea level, the room air that is inhaled into the alveoli is composed of oxygen that is 0.21of the total concentration of gases in the alveoli. A mechanical ventilator
is able to deliver a wide range of Fio2, from 0.21 to 1.0 (an oxygen concentration of 21% to 100%) (Wagner & Hardin-Pierce, 2014, p. 126).

PEEP
“Positive end-expiratory pressure (PEEP) is set to provide pressure at the end of expiration, to prevent alveolar collapse. Theoretically, PEEP supports oxygenation
and levels of 5 cm H2O provide support. As PEEP levels increase, cardiac output may decrease because of the increase in intrathoracic pressure and decreasing venous
return; therefore hemodynamic stability is assessed with ventilator adjustments” (Wagner& Hardin-Pierce, 2014, p. 126).

7. Mr. M. is at high risk for ventilator-associated pneumonia (VAP). Explain, in detail, what this is, how it happens, and what measures can be taken to prevent
VAP? (.75 points)
Ventilation-associated pneumonia is a lung infection common in patient under mechanical oxygenation. Mechanical ventilation -.25 The condition normally affects
patient in ICU and is a major cause of death and illness (Wagner & Hardin-Pierce, 2014). Diagnosis of the condition varies considerably among providers and hospitals,
although it requires infiltration of the chest through X-Rays what does this mean?. A temperature between thirty-six and thirty-eight degree, with white blood cell
count lower that 12 × 109/ml, pus-filled secretions and reduction of in the level of gas exchange are some of the symptoms used in diagnosing VAP. You did not
answer the end of the question, how do you prevent VAP? -.25
8. What interventions will you perform to prevent common complications of mechanical ventilation? (1.25 point)
Caregivers are required to continuously check intrusive devices to prevent possible complications (Wagner & Hardin-Pierce, 2014). Application of evidence-based
guidelines and protocols for sedation and restraint is critical in promoting best practices and improving patient outcomes. Wrist restraints are important in
preventing patients from removing invasive devices, as well as in the prevention of complications associated with mechanical ventilation. ????? This is way off
the mark. -1.25
• “Institute ventilator bundle orders:
• Head-of-bed elevated 30 degrees or higher unless contraindicated
• Use ET tube with continuous suction above cuff if patient is to be intubated more than 48 hours; no routine changing of ventilator circuits
• Oral hygiene two or more times per day
• Brush teeth, gums and tongue with soft toothbrush; oral moisturizing to oral mucosa and lips q 2-4 hours
• During perioperative period in adults undergoing cardiac surgery: Use chlorhexidine gluconate (p.12%) oral rinse twice per day
• Deep vein thrombosis prophylaxis
• Mechanical prophylaxis: Graduated compression stockings; intermittent pneumatic compression devices. Assure proper fit
• Other interventions to prevent DVT: Early ambulation, anticoagulant therapy, antiembolism stockings, compression boots, elevation of injured leg above hear
level” (Wagner & Hardin-Pierce, 2014, p. 137).
REFERENCE
Wagner, K., & Hardin-Pierce, K. (2014). High-acuity nursing (6th ed.). Boston, MA: Pearson.

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