Page 72 - Critical Care Nursing Demystified

Chapter 2 CARE OF THE PATIENT WITH CRITICAL RESPIRATORY NEEDS 57

an elephant on the fragile mediastinum. The signs and symptoms of this com-
plication depend on how fast it develops. Things to look for in a potentially
lethal tension pneumothorax include a deviated trachea away from the affected
side; distended jugular veins; cool, clammy skin; a profound drop in BP and
tachycardia; cyanosis; and sharp pleuritic chest pain.

NURSING ALERT

If a nurse allows a patient to remain on MV and a pneumothorax results, the unre-
lieved pressure accumulation can cause a tension pneumothorax, which is a life-
threatening condition. If pneumothorax is suspected, the patient should be manually
ventilated with a BVM until a chest x-ray can rule out this condition.

The treatment for a tension pneumothorax and a pneumothorax greater
than 30% involves confirmation by chest x-ray and decompression of that side
of the chest with a chest tube. The oxygen level on the ventilator should be
increased before the procedure and analgesics should be administered.
Controlled Ventilation (CV) Compromise and Shock
MV upsets the hemodynamics in the chest and therefore potentially the body. Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
Because there is more positive pressure during inhalation, blood flow to the right
side of the heart (preload) can be decreased. Therefore, one of the most important
assessments a nurse can do right after institution of MV is monitor the blood pres-
sure and central venous pressure if there is a central venous catheter in place. A drop
in BP and a tachycardia along with a concurrent drop in urinary output indicate
circulatory compromise. If this occurs, the nurse must notify the health care pro-
vider. Initiation of fluids and a vasopressor (like Levophed) can be anticipated. If the
patient is dehydrated, a drop in BP can be even more profound. Initiation of fluids
prior to vasopressor therapy will make the medication more effective.

NURSING ALERT

The nurse must monitor the pulse and heart rate in a patient in whom MV has been
started. A drop in BP and an increase in heart rate can indicate decreased cardiac

output. A fluid challenge will help bring the patient’s blood pressure back to baseline

and prevent hypovolemic shock. If fluids do not bring up the blood pressure, adminis-
tration of pressors may be initiated.

Stress Ulcers
Being placed on MV is a very stressful event for the patient. The stress response
involves producing epinephrine, which causes increased stomach acid production.