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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, HC03 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, temperature102.0° F, respirations 14, oxygen saturation 72% on 6L via venture mask.

• Height 5 feet 6 inches, weight 75 kg
• Patient localizes to 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 PEEP5 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 8cm 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?