Page 93 - Critical Care Nursing Demystified

78 CRITICAL CARE NURSING DeMYSTIFIED

Assess the surgical incision site to observe for bleeding, infection, or crepitus.
Position the patient so the good lung is up, so it can help with lung expansion and
not be impeded by working against the weight of the patient and mattress.
Monitor chest tube for patency, bleeding, crepitus, and output.

Administer chemotherapy as needed to prevent tumor enlargement and me-
tastasis.

Teach the patient about radiation therapy and its potential side effects, so the
patient knows what is normal/abnormal.

Teach the patient to cough and deep breathe to prevent atelectasis.
Encourage the use of incentive spirometry every hour while awake to prevent
atelectasis.

CASE STUDY 1

8 Melissa Black is a 39-year-old asthmatic who has delayed coming into the
Emergency Care Unit (ECU). She is cyanotic with markedly diminished breath 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.
sounds. She is audibly wheezing and her inhalers are not working. After adminis-
tering O and getting the bed into a high Fowler’s position, an ABG is performed.
2
ABGs indicate the following: pH = 7.29, pCO = 50, pO = 50, HCO = 24. Serum
2 2 3
electrolytes show the following: Na 145, K 4.0, CL 110, and HCO 24.
+
+
3
QUESTIONS: What acid-base disturbance do these ABGs indicate? Does this pa-
tient have a normal anion gap? What would your next nursing actions be?

CASE STUDY 2

8 Mrs. F. M. is a spry 71-year-old retired nurse who served in Vietnam. She is ad-
mitted with a diagnosis of COPD, acute respiratory distress and relates a 50-year
history of smoking two packs of cigarettes per day. During the past week, Mrs. F. M.

states she has had flu-like symptoms such as fever; chills; a productive cough
with thick, brown purulent sputum; and chest pain when coughing. Mrs. F. M.
appears anxious and irritable, taking rapid, shallow breaths while breathing
through her mouth. She is also diaphoretic and has marked cyanosis around her
lips. Auscultation reveals moist crackles throughout both left and right lung fi elds.