Reference no: EM133570017
Case Study Episode 1:
J.T. Winters is a 19-year-old male admitted to the emergency department after sustaining injuries in a motor vehicle collision (MVC). He was traveling at a high rate of speed when he lost control and went off the road. It is estimated that his car struck a tree at 35 miles per hour. He was not wearing a seat belt, but his air bag did deploy. He was conscious at the scene. Upon his arrival to the emergency department, J.T.'s vital signs are as follows:
HR - 115 bpm
SpO2 - 93% (on 2 L N/C)
Temp - 99.3 F (37.4 C)
BP - 106/54 mm Hg
RR - 32 breaths/minute
Pain - 10/10
J.T. is complaining of pain across his sternum and on his left side. Inspection reveals a broad ecchymotic area across the front of his chest and a deformity along his left side in the region of his fifth through eighth ribs. With each inhalation, this part of his thorax moves inward. Someone uses the phrase "paradoxical movement" to describe what is observed. Upon auscultation, no breath sounds are heard on the left side. A chest tube is inserted, and 400 mL of blood is rapidly drained.
RECOGNIZE CUES
Which assessment data is abnormal?
Explain possible reasons for the elevated heart rate in this patient.
What is the cause of the "paradoxical movement" noted upon observation of the patient's breathing?
What is the cause of the absent breath sounds on the left side of the patient's chest?
What medical diagnosis was the reason for chest tube insertion?
Case Study: Episode 2:
After stabilization of his injuries, J.T. is admitted to the intensive care unit (ICU). The bleeding into the thoracic cavity has stopped, but the lung has not fully expanded. On the second day in the unit, it is noted that his pulse oximetry readings continue to decline in spite of increased FIO2 via 100% nonrebreather mask. He is tachypneic and tachycardic. A chest x-ray shows diffuse infiltrates bilaterally. An ABG shows the following: pH 7.50, PaCO2 of 32, PaO2 of 50, HCO3 of 26 while on 70% FIO2. It is determined that J.T. has developed ARDS.
Which assessment data supports the diagnosis of acute respiratory distress syndrome (ARDS)? (Recognize cues)
What is your interpretation of the arterial blood gas results? Is he in respiratory failure? If so, which type? Explain the related pathophysiology causing these results. (Analyze the data)
What is/are the priority problem(s) for this patient? (Prioritize hypotheses)
Which collaborative interventions do you expect to implement for J.T. ? (Generate solutions)
Case Study Episode 3:
J.T. is intubated, and mechanical ventilation is initiated. J.T. remains in the ICU, sedated on the ventilator. He is managed with conventional mechanical ventilation with low tidal volumes to protect his lungs from injury. His fluid balance is managed judiciously. He is started on enteral feeding to support his nutrition. Initially prone positioning is utilized to improve gas exchange. He has frequent position changes and ROM exercises.
What is the rationale for administering sedatives to this patient?
What medications/treatments does the nurse anticipate may be used to manage fluid balance in this patient?
Describe the 2 types of nutrition used for patients on mechanical ventilation and risks for each.
What are the benefits of using prone positioning for J.T.?
What assessments would the nurse perform in order to verify correct endotracheal tube placement?
What interventions should the nurse implement to prevent ventilator-associated pneumonia for J.T.?
Which of the following interventions should the nurse implement for J. T. while he is on the mechanical ventilator? Select all that apply.
a. Assess frequently for changes in vital signs, pulse oximetry, respiratory
status, cardiac status and level of consciousness.
b. Monitor ventilator settings and alarm settings.
c. Assess lung sounds and need for suctioning every 2 hours.
d. Ensure ETT cuff pressure is maintained at 5-10 mm Hg of air every 4 hours.
e. Keep HOB elevated at 30 degrees (unless prone positioning is ordered)
f. Maintain a nasogastric tube on continuous suction.
g. Avoid use of anticoagulants.
After 5 days of careful monitoring and meticulous care, J.T. begins to improve. His oxygenation status stabilizes, and he is able to be slowly weaned from the ventilator. By day 7 in the ICU, J.T. is extubated, placed on nasal cannula and out of bed sitting in the chair.