Page 73 - Critical Care Nursing Demystified

58 CRITICAL CARE NURSING DeMYSTIFIED

Patients can develop stress ulcers unless placed on prophylactic medications to
prevent ulcers.

Ventilator Dyssynchrony
The experience of being intubated and placed on a mechanical ventilator with loss
of respiratory control causes many patients to fight these uncomfortable conditions.
Catecholamines are liberated when patients struggle, which causes the vital signs
to elevate, increasing the work of breathing and therefore metabolism and oxygen
demand. To decrease the energy expenditure and decrease metabolism, patients
may need antianxiety medications like benzodiapezenes (Versed or Ativan).
Diprivan (Propofol), a short-acting IV drip general anesthetic agent, can also be
used to help with rapid sedation. If the results of this do not decrease the work of
breathing, the patient may be chemically paralyzed with neuromuscular blockers.

NURSING ALERT

Neuromuscular blockers do not cross the blood-brain barrier, so although patients
may look at peace and restful, they can feel pain and discomfort. Therefore, a strong
pain medication like morphine sulfate should be administered to aid in comfort and
alleviate distress. 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.

APPLYING IT
The MV patient you are caring for suddenly appears to be in distress. You
note the heart rate increasing alarmingly and the blood pressure falling
dangerously low. You see neck veins distending, and breath sounds on the
right side are markedly diminished from your last assessment. The trachea
is deviated to the left. What do you think is happening? What would be
your FIRST nursing action?

✔ ANSWER
When there is unrelieved pressure that develops from a pneumothorax, the
mediastinum is freely moveable. Pressure builds up on the affected side and
pushes the trachea away from it. Because the heart and great vessels are
kinked, no blood flow can enter the heart. This is the cause of the decreased
breath sounds, elevated neck veins, and shock (HR up and BP down) this pa-
tient is experiencing. These are classic signs of a tension pneumothorax and
you must act quickly. Take this patient off the ventilator and support him with
the bag-valve mask (BVM); call a Code Blue. He needs emergency decompres-
sion of this pressure and a chest tube will probably be inserted.