So I'm in 3rd semester and just did my ICU rotation; thus my ICU specialty paper & care plan is due in a week. I am working on it and just want a little 'guidance' or just someone to bounce ideas/concepts around. ALSO because I kinda want to understand my pt's condition better too.
SOO:
73yo F.
Has been in the ICU for over a week now.
She came into the ED w/ dx of status epilepticus, confusion and dementia.
HX: 2 CVAs (one 10 yrs ago and other ~ 4 yrs ago), HTN, DM t2, CHF.
Her husband has been taken care of her (she's total care, nonverbal, immobile and bedbound) for 10+ yrs @ home.
She's on a ventilator: mode is AC, PEEP of 5cm, FiO2 28%, Tidal volume 300 and rate is 8min. Nurse said that "those are weanable values/settings BUT when they attempted to wean her a few days ago, she went into SVT. Thus, they had to put her bck on the vent & neurology came up & eval her and said that she has "Onidine's Syndrome" and its unlikely that she will be able to come off resp. support.
She does have an OG tube for nutrition too.
And also has VAP & MERSA.
Her ABGs:
pH: 7.528
pO2:101.6
pCO2: 38.9
HCO3: 31.7
BE: 8.3
O2 sat: 98.6%
Labs:
There's QUITE a lot of labs so I'm going to list the abnorm. ones and let me know if you want the others:
WBC: 12.8
RBC: 3.42
Hgb: 9.2
Blood glucose: 169
Hct: 31.4%
CO2: 34
BUN/Creat ratio: 25
lactic: 2.2
Tot. Protein: 8.2
A/G Ratio: 0.9
CBC w/ diff:
EOS: 0.45
GRAN: 7.93
Imm GRAN: 0.07
NOW my assessment:
Neurological: Pt. wasNonverbal.Level of Consciousness: Sedated. Pupils reactive to light bilaterally, movement is sluggish. Unable to assess further r/t sedation and condition.
Psychological: RASS Score= -3 moderate sedation. Eye opening/movement to voice w/out eye contact.Unable to assess further r/t condition and sedation.
Cardiovascular: Peripheral pulses present and steady bilaterally in all extremities. Good capillary refill in all extremities. Apical HR-84bpm, rhythm is regular without murmurs or irregular beats.S1 & S2 audible.1+ non-pitting edema noted in RUE and LUE. Rhythm: Normal Sinus Rhythm
GU: Foley catheter. Foley patent, collection bag has 300mL of clear, light-yellow urine.
Output during shift: 500mL
GI: Bowel sound active x4 Quadrants. No distension or apparent tenderness upon palpitation.OG tube in place and patent. Continuous TPN is running @ 30mL/hr.
Integumentary: Warm, Diaphoretic. L arm-multiple surface abrasions (may be r/t the LUE edema). Mepilex Sacral pad-prophalytic precautions- clean, dry and intact. Double lumen subclavian central line on R side of chest
Respiratory: Intubated with 7mm ET tube, 23cm at the lip. R & LUL clear and diminished. RLL=clear & diminished. LLL=crackles.
Musculoskeletal: No movement in all extremities.
SO…I really don't even know what to do with the information.
WHAT I DID DURING MY SHIFT: suctioned her et/vent, checked placement of OG Tube and admin a water bolus, admin insulin and checked BG, turned on the percussions on her rotation/proning sport bed, sedation, PO care and PO suctioning.
I would really appreciate some questions or anything to jog some thinking. Im drawing a blank honestly.
Regarding her abg. I think it is a metabolic alkalosis. They are trying to compensate and make her a little acidotic on the respiratory side. Trying to increase her co2 by having a small tidal volume and low respiratory rate on the vent. She has too much base in her system needs acid. Seems a bit cruel to compensate by not giving her the minute volume she probably needs/wants. Hopefully well sedated. I might be thinking of this all wrong. Someone please correct me if needed. Dusting cobwebs from my RT days.
Your priority is safety and multidisciplinary supportive care. I have attached some good links.
Do add restraints to prevent removal of ett/lines and releaseq2 hr and ROM q2hrs to maintain function and prevent contractures.
I'm going to suggest that you focus on the recommendations to prevent VAP (oral care and subglottal suctioning HOB 30degrees).
I am going to guess that your pt was on lung protective ventilation and permissive hypercapnia for an Acute lung injury. I agree that the pt has a metabolic alkalosis (bicarb of 31.7 and PaC02 of 38.9 BE of 8.3) as compensation for a primary respiratory acidosis.
Did she have a corneal reflex or gag or cough? Did they turn off the sedation and did she wake up? Was her resp. rate above the vent? Any purposeful movements ? Did she breathe spontaneously at all during the breathing trial?
The SBT most likely taxed her sick heart due to LV dysfunction and a low ejection fraction to the point that she went into SVT. A strict I&O and presence or absence of signs of overload such as JVD and copious frothy secretions is part of the assessment.
She is also high risk for skin breakdown, malnutrition and DVT and stress ulcers. We use a standardized care plan for vent pts to cover these interventions.
Did her cultures grow MRSA or did she have a positive nasal swab?
Specializes in Geriatrics, In-Home Care, Community Based Nursing.
We just did our acute respiratory module in lecture too. I need to do a little bit of digging into my understanding of her respiratory situation (like with the ventilator and her specific settings because I don't know what 'normal' vent settings are or what her settings are related to my assessment and findings.
"I would say the VAP & MERSA treatment anddddd skin/fluid/dvt/aspiration precutions/prevention?"
You're absolutely right. Trust yourself, you pulled those out without any help. You mentioned sz precautions in your first post, make sure you know what those are and what to do in case your patient has one. The only other thing I can think of is that she's high risk for sepsis. It's a new core measure and if you haven't heard a lot about it you will.
The guidelines section gives you a good baseline normal. "Normal" is individual for each patient and will vary depending on their response and ABG's. For example, FiO2 is titrated based on their PaO2, tidal volume and rate are titrated based on PaCO2. The goal is to use the minimum settings necessary to reach the targeted response to minimize complications and over-correction.
I don't see permissive hypercapnia based on the lack of hypercapnia. Her PaCO2 is normal (within 35-45). There's really not enough information to determine what is going on, other than I would call it metabolic alkalosis. Was she on suction? Was she administered any diuretics? Does she have a hx of COPD?
Shagce1
200 Posts
Regarding her abg. I think it is a metabolic alkalosis. They are trying to compensate and make her a little acidotic on the respiratory side. Trying to increase her co2 by having a small tidal volume and low respiratory rate on the vent. She has too much base in her system needs acid. Seems a bit cruel to compensate by not giving her the minute volume she probably needs/wants. Hopefully well sedated. I might be thinking of this all wrong. Someone please correct me if needed. Dusting cobwebs from my RT days.