Acute Respiratory Distress Syndrome A. Patient Profile Z.Q.,74-year-old Hispanic male, came to the emergency department (ED) 7days ago with complaints of shortness of breath. His wife statedthat he had a history of hypertension, depression, and chronicobstructive pulmonary disease (COPD). The admission chest x-rayrevealed dense consolidation of the left lower lobe. An arterialblood gas (ABG) at that time showed: pH 7.60, PaCO2 29 mm/Hg, HC0332 mmol/L, and PaO2 75 mm/Hg. Z.Q. quickly deteriorated andsubsequently was intubated. He has been in the intensive care unitfor 3 days. B. Subjective Data • Z.Q. and wife have been married 45years and live with a daughter and 2 grandchildren • Z.Q. and hiswife speak both English and Spanish C. Objective Data PhysicalExamination • Blood pressure 167/98, pulse 112, temperature 102.0°F, respirations 14, oxygen saturation 72% • Height 5 feet 6 inches,weight 75 kg • Patient localizes to endotracheal tube (ETT) and isintermittently aroused, making several attempts to pull ETT •Orally intubated #7.5 ETT, taped at 27 cm to lip • Volume cycledventilator at FIO2 – 60%, in assist control mode of 14 breath perminute, tidal volume 450, positive end-expiratory pressure PEEP 5cm H2O • Breath sounds decreased in bases with bilateral cracklesthat do not clear after suctioning • Brown/yellow secretionsreturned with suctioning • Peripheral pulses weak at 1/4 withcapillary refill greater than 4 seconds • 2+ pitting edema in thebilateral lower extremities Newly Obtained Diagnostic Study Results• Arterial blood gas (ABG) pH 7.31, PaCO2 58 mm/Hg, HC03 28 mmol/L,PaO2 54 mm/Hg, EtCO2 38 mm/Hg • Chest x-ray reveals diffuse whiteout in middle and lower lobes; endotracheal tube present with tipwell above the carina; left subclavian central venous catheter islocated in the superior vena cava • CT scan reveals alveolaropacities with increasing effusions in the gravity-dependent areasof the lungs D. Discussion Questions 1. Interpret Z.Q.’s latest setof ABGs. (Be detailed in ABG interpretation) 2. Describe each ofZ.Q.’s ventilator settings and the rationale for the selection ofeach. 3. After reviewing Z.Q’s ABG results, the physician increasesthe PEEP from 5 cm H2O to 8 cm H2O. Why would this be necessary andwhat is the expected outcome associated with this action? 4. Thephysician decides to begin Z.Q. on IV dobutamine (Dobutrex) andmilrinone (Primacor). What is the rationale for using each of thesemedications? What is the drug class for these medications? Explainhow these medications work, how they are administered, and nursingconsiderations when administering these medications. 5. Based onthe assessment data, what are the nursing priorities for Z.Q.? 6.What measures should be part of Z.Q.’s care to promote respiratoryfunction? 7. List three potential adverse complications withmechanical ventilation. 8. You are concerned about Z.Q.’snutritional status and approach the physician for a dietaryconsult, thinking that Z.Q. is a candidate for enteral feedingswith Pulmocare. What is your reason for making thisrecommendation?
