Page 86 - Critical Care Nursing Demystified

Chapter 2 CARE OF THE PATIENT WITH CRITICAL RESPIRATORY NEEDS 71

Nursing Diagnoses Expected Outcomes
Gas exchange impaired The patients ABGs will return to baseline with spe-
cific watch over the pO
2
Decreased cardiac output The patientʼs BP, HR, and pulmonary artery
pressures will remain within normal limits after
institution of PEEP therapy
Communication, verbal The patient will be assisted in making needs known
impaired by signing, writing, or other communication aids

Nursing Interventions
Assess for complications of PEEP, barotraumas, and pneumothorax to pre-
vent complications.
Assess for signs of increasing oxygenation in SaO and PaO for further
2 2
interventions.
Monitoring fluid management unless ARDS is due to shock.
Prone positioning using a Stryker frame; extra help or other turning devices
help increase secretion removal and prevent atelectasis. 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.
Monitor carbohydrate concentration of enteral fluids; they may increase
pCO retention.
2
Provide and monitor use of continuous sedatives and analgesics to help
decrease the work of breathing.

APPLYING IT
A A PP L
8 Jane Wallace is a 17-year-old high school student who was dropped off Ja
8 8
in front of her house after drinking at a weekend party. She passed out on
in fro
the way to her front door and the newspaper boy found her blue and
breathing shallowly in a snow bank 5 hours later. He initiated CPR after
calling 911 on his cell phone.
She was successfully resuscitated in the ECU after the emergency crew
initiated defibrillation and CPR at the scene. She was in ventricular fibrilla-
tion and required partial cardiopulmonary bypass to slowly warm her and
convert her to a normal sinus rhythm.
You are caring for her two days post incident in the ICU. She remains on
MV with an ETT on 50% oxygen with a V of 500 with a rate of 18, N FiO of
T 2
50% on IMV. Suddenly you note pressures on the MV start to trip off the high
alarm. When you suction Jane, you see that her clear secretions have changed