Clinical Presentation A 79 year-old Hispanic male is admitted to the ICU from a SNF with new onset ALOC. The patient arr
Posted: Mon Oct 04, 2021 8:06 am
Clinical Presentation A 79 year-old Hispanic male is admitted to
the ICU from a SNF with new onset ALOC. The patient arrived from
the ER with a Foley catheter connected to a drainage bag that
contains cloudy, foul-smelling urine. Initial vital signs are: Temp
96.7º F; Radial pulse 1+ at 136 bpm; RR 36 and shallow; Pulse ox
88% on a non-rebreather mask; BP 86/44 (MAP 58).
Medical History Early dementia, CHF, CAD, MVR, DM II, renal
insufficiency
Preliminary lab test results:
o ABGs: pH 7.30 PaCO2 65 mmHg HCO3 32 mmHG PaO2 256 with 100%
Fio2 via non-rebreather mask.
o Serum lactate 5.9 mmol/L
o K 3.3
o BUN/Cr 58/1.9
o Glucose 298
o CRP 5 mg/L
o BNP 1347
o Troponin I 1.9 ng/mL
o CBC: H/H 9/27; WBC 21K; Platelets 95K
o Serum bilirubin 4.8 mg/dL
o Blood cultures show gram-positive cocci in cluster
Additional focused physical assessment findings:
o Neuro: GCS 10; PERLA, +gag reflex, admitted with ALOC
o Pulmonary: breath sounds diminished bilaterally with crackles
in anterior and posterior fields
o GI: hypoactive bowel sounds x4 quadrants
o Renal: urine output 20 mL/hr
o Skin: no breakdown, extremities cool to touch
o Cardiovascualr: S1, S2, grade 2 systolic murmur, +3 pitting
edema in lower extremities, +1 pedal pulses
Initial Medical Treatment
o 12 Lead EKG
o 2-D echo o Right subclavian triple lumen central line with
CVP
o CXR (confirming pulmonary edema and central line
placement)
o Intubation with the following vent settings: AC 20 VT 500 PEEP
5 FiO2 40%
o Arterial line in the right radial artery o norepinephrine
(Levophed) 2 mcg/min, to be titrated to keep SBP greater than 100
mm Hg.
o Propofol 10 mcg/kg/min and tritrate to sedation (patient’s
weight is 165 pounds)
Case Study question:
20. Based on new ABGs, the physician has increased the FiO2 and
the PEEP. What potential complications could the patient develop
that the RN would need to assess/monitor for?
the ICU from a SNF with new onset ALOC. The patient arrived from
the ER with a Foley catheter connected to a drainage bag that
contains cloudy, foul-smelling urine. Initial vital signs are: Temp
96.7º F; Radial pulse 1+ at 136 bpm; RR 36 and shallow; Pulse ox
88% on a non-rebreather mask; BP 86/44 (MAP 58).
Medical History Early dementia, CHF, CAD, MVR, DM II, renal
insufficiency
Preliminary lab test results:
o ABGs: pH 7.30 PaCO2 65 mmHg HCO3 32 mmHG PaO2 256 with 100%
Fio2 via non-rebreather mask.
o Serum lactate 5.9 mmol/L
o K 3.3
o BUN/Cr 58/1.9
o Glucose 298
o CRP 5 mg/L
o BNP 1347
o Troponin I 1.9 ng/mL
o CBC: H/H 9/27; WBC 21K; Platelets 95K
o Serum bilirubin 4.8 mg/dL
o Blood cultures show gram-positive cocci in cluster
Additional focused physical assessment findings:
o Neuro: GCS 10; PERLA, +gag reflex, admitted with ALOC
o Pulmonary: breath sounds diminished bilaterally with crackles
in anterior and posterior fields
o GI: hypoactive bowel sounds x4 quadrants
o Renal: urine output 20 mL/hr
o Skin: no breakdown, extremities cool to touch
o Cardiovascualr: S1, S2, grade 2 systolic murmur, +3 pitting
edema in lower extremities, +1 pedal pulses
Initial Medical Treatment
o 12 Lead EKG
o 2-D echo o Right subclavian triple lumen central line with
CVP
o CXR (confirming pulmonary edema and central line
placement)
o Intubation with the following vent settings: AC 20 VT 500 PEEP
5 FiO2 40%
o Arterial line in the right radial artery o norepinephrine
(Levophed) 2 mcg/min, to be titrated to keep SBP greater than 100
mm Hg.
o Propofol 10 mcg/kg/min and tritrate to sedation (patient’s
weight is 165 pounds)
Case Study question:
20. Based on new ABGs, the physician has increased the FiO2 and
the PEEP. What potential complications could the patient develop
that the RN would need to assess/monitor for?