P.R., a 61-year-old woman who has no history of respiratory disease, is being admitted to your unit with a diagnosis of

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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 Sa O2 of 53%. Her ventilator settings are
synchronized intermittent mandatory ventilation of 12 breaths/min
(BPM), tidal volume (V T ) 700 mL, Fi O2 0.50, positive
end-expiratory pressure (PEEP) 5 cm H 2 O.
1. Describe the pathophysiology of acute respiratory
failure (ARF).
2. What assessment findings would you expect P.R. to
exhibit?
CHART REVIEW:
Arterial Blood Gases
pH 7.28
PaCo2 62 mm Hg
HCO3 26 mmol/L
PaO2 48 mm Hg
SaO2 53%
3. The arterial blood gas (ABG) results drawn in the
emergency room before intubation are sent to you. Interpret P.R.'s
ABG results.
4. List eight interventions that would be implemented for
P.R. and the rationale for each.
5. After the insertion of the endotracheal tube (ETT), how
is correct placement verified?
6. Describe each of P.R.'s ventilator settings and the
rationale for the selection of each.
CHART REVIEW:
Arterial Blood Gases
pH 7.30
PaCo2 52 mm Hg
HCO3 22 mmol/L
PaO2 70 mm Hg
SaO2 88%
7. ABGs are redrawn after P.R. is on mechanical
ventilation for 1 hour. What ventilator changes do you anticipate,
based on your interpretation of these values? (Select all that
apply, and explain your rationale.)
a. Increasing the PEEP to 10 cm
b. Increasing the rate on the ventilator to 16
breaths/min
c. Increasing the tidal volume to 850 mL
d. Changing to continuous mandatory ventilation
8. 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.
_____ Administer mandatory muscle-paralyzing agents to keep the
patient from “fighting the vent.”
_____ Check ventilator settings at the beginning of each shift and
then hourly.
_____ When suctioning the ETT, each pass should not exceed 15
seconds.
_____ Assign an experienced NAP to take vital signs every 2 to 4
hours.
_____ Perform a respiratory assessment once per shift.
_____ Empty excess water as it collects in the ventilation tubing
back into the humidifier.
_____ Keep a resuscitation bag at the bedside.
_____ Monitor the cuff pressure of the ETT every 8 hours.
_____ Keep ventilator alarms silenced when in the room to maintain
a quiet environment.
_____ Change the ventilator tubing every 12 hours.
9. 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?
CASE STUDY PROGRESS
As P.R.'s nurse, you are concerned about meeting her needs
for fluids, nutrition, oral hygiene, and skin integrity.
10. Discuss five indicators that would help you assess
fluid status.
11. What are your nutritional goals for P.R.?
12. Describe interventions that you could use to assist in
meeting P.R.'s nutrition goals.
13. 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.
14. What is the rationale for not taking an oral
temperature near an ETT?
15. You assess P.R.'s skin every 4 hours. Identify three
treatment goals in relation to skin and positioning.
16. What four strategies will facilitate the expected
outcome of maintaining skin integrity?
17. That afternoon, a powerful storm causes a power
failure. What do you do?