Case Scenario Arf

GROUP C
P.R., a 61-year-old woman who has no history of respiratory disease, is being admitted to your unit with a diagnosis of
pneumonia and acute respiratory failure. She was endotracheally intubated orally in the emergency room and placed on
mechanical ventilation. Her vital signs are 112/68, 134, 101° F (38.3° C) with an SaO2 of 53%. Her ventilator settings are
synchronized intermittent mandatory ventilation of 12 breaths/min (BPM), tidal volume (VT) 700 mL, FiO2 50%, positive end-
expiratory pressure (PEEP) 5 cm H2O.
1. Describe the pathophysiology of acute respiratory failure (ARF). Brief only.
 Acute respiratory failure occurs when fluid builds up in the air sacs into the lungs. When that happens, your lungs can't
release oxygen into your blood. In turn, your organs can't get enough oxygen-rich blood to function.
2. What assessment findings would you expect P.R. to exhibit?
 Assessment findings P.R. would exhibit are rapidly progressive dyspnea, tachypnea and hypoxemia. Check for acute
onset of symptoms, profound hypoxemia, bilateral pulmonary infiltrates, and the absence of left atrial hypertension. An
X-ray and body's oxygen level along with CO2 level with a pulse oximetry device can be used to determine the onset
and extent of ARF.
3. The arterial blood gas (ABG) results drawn in the emergency room before intubation are sent to you. Interpret P.R.'s ABG
results.
 Partially compensated primary respiratory acidosis with life- threatening low oxygen levels which could put patient into
severe hypoxemia.
4. List 4 interventions that would be implemented for P.R. and the rationale for each.
 Bronchodilator medicines and corticosteroids to reverse some types of airway obstruction.

 ET tube regular suctioning to make a clear airway for mechanical ventilation.
 Mechanical Ventilation or non-invasive positive-pressure ventilation sometimes called CPAP or BiPAP for assisted
breathing.
 Oxygen supplementation because the O2 saturation is very low
5. After the insertion of the endotracheal tube (ETT), how is correct placement verified?
 The esophageal Detector Device is a diagnostic tool used for confirmation of endotracheal intubation. An EDD
indicates the correct ETT position even in situations where the end-tidal CO2 concentration fails, such as severe
bronchospasm or CPR.
6. Describe each of P.R.'s ventilator settings and the rationale for the selection of each.
 The 12 bpm is used for partial mechanical assistance. A regular adult breathing pattern, therefore it's programmed to
generate a fixed tidal pattern to allow for spontaneous breathing, increase the volume.
o Tidal Volume of 700 ml is above normal (500ml) which means that the patient is supplied with extra volume
to cope up with normal breathing.
o VT is the amount of air that moves in or out of the lungs with each respiratory cycle.Fio2 is usually
maintained below 0.5 to avoid oxygen toxicity but in some cases where saturation is very low 100 % oxygen
can be used.
o PEEP 5 cm of water is normal and used to prevent decreases in functional residual capacity in those with
normal lungs.
7. Evaluate each of the following statements about caring for P.R. or a similar patient receiving mechanical ventilation with an
ETT. Enter “T” for true or “F” for false. Discuss why the false statements are incorrect.
__T___1. Administer mandatory muscle-paralyzing agents to keep the patient from “fighting the vent.”
__T___2. Check ventilator settings at the beginning of each shift and then hourly.
__T__3. When suctioning the ETT, each pass should not exceed 15 seconds.
__ F ___4. Assign an experienced NAP to take vital signs every 2 to 4 hours.
 Patients on ventilators should not be placed on NAP because obtaining vital signs requires assessment and critical
thinking, both of which must be performed by a registered nurse.
__T___5. Perform a respiratory assessment once per shift.
__ F ___6. Empty excess water collects in the ventilation tubing back into the humidifier.
 The water should always be removed. The water is being collected because the humidifier is filled with water that
needs to be reduced.
__T___7. Keep a resuscitation bag at the bedside.
_ T____8. Monitor the cuff pressure of the ETT every 8 hours.
__ F ___9. Keep ventilator alarms silenced when in the room to maintain a quiet environment.
 Never keep the ventilator alarms silenced as the warning signs of impending vital signs can be missed.
__ F ___10. Change the ventilator tubing every 12 hours.
 Ventilator tubing must be changed every 7 days. If it is changed often, studies show that it can cause ventilator-
associated pneumonia.
8. You hear the high pressure alarm sounding on the mechanical ventilator and see that P.R.'s Sao2 is 80%. What are the
potential causes of this problem?
 Firstly, the pulse oximeter probe might be loose or put incorrectly, so that should be readjusted and examined first in
low O2 level reading.
9. Discuss five indicators that would help you assess fluid status.
 The five measures that helps us to assess the fluid status of the patient are first we need to know the elasticity of the
skin, turgor, hourly monitoring of urine output, pitting edema and the patient jugular venous distention.
10. What are your nutritional goals for P.R.?
 Since the patient is on ventilator. The goal for P.R. is to provide adequate calories to support metabolic demands, to
preserve lean body mass and prevent muscle wasting. Rest should also be utilized to conserve calories, as the diet
objective is a high protein, high calorie diet.
11. Describe interventions that you could use to assist in meeting P.R.'s nutrition goals.
• Feeding must be tailored as per the patient's requirement and tolerance.

• P.R. has respiratory acidosis, so alkaline foods can be given like fruit juices.
• Protein requirement must be given by calculating 1.2-2.0 g/kg body weight.
• Calories must be in the range of 25-30 Kcal/kg body weight/day for most critically ill patients.
12. The goal related to P.R.'s mouth care is to preserve the oral mucosa and dentition. Identify three strategies for providing oral
hygiene with an ETT in place.
 In ETT in place patients, first remove any dentures.

 Use 0.12 % chlorhexidine. Soak the toothette in the solution and scrub along teeth, tongue and gum with circular
motion.
 Use suction to remove any chlorhexidine from mouth but do not rinse. It gives antibacterial activity against gram
positive organisms.
13. What is the rationale for not taking an oral temperature near an ETT?
 We are not taking an oral temperature near an ETT because patient is inability to form a tight seal around the
thermometer by mouth due to ETT and the patient can be sedated too. By that it provides inaccurate measurement
that does not reflect body temperature.
14. You assess P.R.'s skin every 4 hours. Identify three treatment goals in relation to skin and positioning.
 Position the patient every 2 hours. To prevent skin breakdown in bedridden patient and allows good circulation.
 Make sure the skin is clean and dry. Clean the skin with a mild soap and warm water and rinse thoroughly. Gently pat
dry.
 Overlays on mattress. To improve circulation and help prevent pressure ulcers (bed sores).
15. What four strategies will facilitate the expected outcome of maintaining skin integrity?
 The four strategies which helps in good skin integrity are change patient’s position and provide back care every 2
hours of shift. Instruct a well-balanced protein-rich food and maintain the patient's fluid status.
16. That afternoon, a powerful storm causes a power failure. What do you do?
 The RN must be aware of the structure and operation of backup electrical power sources.Portable oxygen cylinder and
resuscitation equipments and emergency drugs must be kept ready for emergency

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GROUP C

1. Describe the pathophysiology of acute respiratory failure (ARF). Brief only.

2. What assessment findings would you expect P.R. to exhibit?

 Bronchodilator medicines and corticosteroids to reverse some types of airway obstruction.

F _4. Assign an experienced NAP to take vital signs every 2 to 4 hours.

T_5. Perform a respiratory assessment once per shift.

T_7. Keep a resuscitation bag at the bedside.

_ T____8. Monitor the cuff pressure of the ETT every 8 hours.

F _10. Change the ventilator tubing every 12 hours.

10. What are your nutritional goals for P.R.?

• Feeding must be tailored as per the patient's requirement and tolerance.

 In ETT in place patients, first remove any dentures.

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