a 67 year old female, presented to the emergency department (ED) with a 2-day history of increased shortness of breath and fever.

Past Medical History: Arthritis

Code Status: Full code

On arrival: Mary was placed on Airborne and Contact Precautions.

Vital signs: Temp 39.5C; HR 140 bpm; RR 35 breaths/min BP 81/49; and Sp02 75% on room air. Cardiac monitor: Sinus tachycardia.

Auscultation: Diffuse wheezes and decreased breath sounds to the lower lobes. The patient was placed on a non-rebreather oxygen mask at 15/Lpm.

Medications: Salbutamol 6-8 puffs was administered every 20 minutes times 3 with no improvement in work of breathing. Sp02 did increase to 88%.

Orders:

• Blood work: CBC, Lytes, Urea, Creatinine, lactate, ABGs (see results below)
• CXR completed: The x-ray showed diffuse bilateral infiltrates.
• Normal Saline (500 mL) bolus x 1 administered
• Hydrocortisone 100 mg IV x1 administered

Blood work results:

Patient Values; Sodium 135;Potassium 3.5;Chloride 100;Total C02 22;Urea 10.0 Creatinine 160 ;eGFR 50;Lactate 4.0;LKC 24;ERC 5.10;HB 134

Intensive CareAdmission

Mrs. Teal was admitted to the ICU and ABGs were drawn 40 minutes after the patient was initiated on mechanical ventilation.It was determined that the patient weighed 81 kg and was 163 cm in height. Mary was ventilated as shown below:

The patient continued to deteriorate. Vital signs: HR 140 bpm; RR 38 bpm; BP 78/46, and Sp02 90% on a Non-rebreather. Mary required intubation and ventilation. The RRT inserted a #7. 5 endotracheal tube (ETT), which was immediately followed by insertion of the central line by the physician. A post-intubation x-ray was done and the ETT and central line were noted to be in good position. A norepinephrine (8mg/ 250mL normal saline) infusion was started at 4 mcg/min for hemodynamic support.

ABGs 40 minutes after ventilation on the above settings:

pH 7.22

paC02 65

pa02 69

Sa02 0.90

Hc03- 22

1 Interpret the above ABG (pH 7.22, PaC02 65, Pa02 69, HCO3- 22) and discuss appropriate adjustments to the ventilator to correct the ABG

2 Describe the pathophysiology of ARDS. How do you know from Mary's ABG that she is experiencing ARDS?

3 Explore medical management (aside from mechanical ventilation) of a patient experiencing ARDS.What nursing interventions should be initiated to promote patient safety and positive patient outcomes? What diagnostic procedures, including rationale should be considered for the patient experiencing ARDS?

4 Discuss whether the patient's current ventilator settings meet lung protective ventilation strategies. Discuss any ventilator changes you would make to ensure lung protective ventilation is achieved

5 What are the effects of tissue hypoxia and resulting signs and symptoms on the following systems: CNS, pulmonary, cardiovascular, renal and GI?

Intensive Care10 days later

You are assigned to care for Mary Teals again. She now has a trach tube in place and has been slowly recovering from her ARDS. During your morning assessment, you note that her ventilator settings and ABGs are as follows:

ABGs:

pH 7.36

paC02 54

pa02 160

Hc03- 33

Mary's hemodynamic status has improved and she has been weaned off of the norephinephrine. Her Vital Signs now: Temp 37.4C; HR 110 bpm; BP 120/70; Sp02 100%; cardiac monitor shows sinus tachycardia.

6 Interpret the above ABG and discuss an appropriate adjustment to the ventilator

to correct the ABG

7 Mary Teal is in a different type of ventilation than when you previously cared for

her. Please compare and contrast between the two control variables and settings. Discuss the advantages and disadvantages of each

8 Discuss how you will assess if Mary is ready to wean?

9 Explore two potential weaning methods that could be attempted with Mary. Explain each weaning method

10 What and how will you monitor Mary to ensure she is tolerating her chosen weaning method?