management question

[student2008]

Anybody have any suggestions for this case study?? The patient was in a car accident.

While in the ICU, the patient continues to be hypotensive, ands is restless on the ventilator. Vitals and ABG’s are as follows:

BP 60/40 mm Hg

HR 160 bpm

Temperature 38.° C

pH 7.3

Pco2 46 mm Hg

Po2 104 mm Hg

Hco3 22 mmol/L

Settings on the ventilator were changed as follows: FiO2 90 %, SIMV Rate 6, Tidal Volume 800 mL

The client was given a bolus 500 ml bolus of NS. His fraction of inspired oxygen (FiO2) increased from 90% to 100%, tidal volume (Vt) was 800 ml, and SIMV rate was 6 with total respirations of 16 breaths/min. At this time, a positive end-expiratory pressure (PEEP) of 5 cm H2O was added, and he continued to receive pressure support of 7 cm H20. He was given several boluses of NS and continued to receive dopamine. The ventilator settings just outlined were continued. The following arterial blood gas values were obtained 2 hours after the ventilator settings were changed: pH 7.42, PCo2 46 mm Hg, Po2 75.2 mm Hg, HCO3 28.9 mmol/L.

After 5 days post-op, PEEP was increased to 10 cm H2O, and Vt was increased to 1000 ml.

BP 130/60 mmHg, HR 120 bpm, Temp 38.3C, pH 7.43, PCo2 46.2 mm Hg, Po2 86.8 mm Hg, HCO3 30.5 mmol/L

After these changes, the patient gradually stabilizes and he was weaned from the ventilator.

You are the charge nurse on the step down unit. You currently have a census of 23, with 8 total care patients and 2 ventilators. You have 4 seasoned nurses, 1 nurse who has been on the floor for 6 months and 1 nurse on orientation. You must make the decision of which nurse to assign this patient to. Each of the seasoned nurses has a ventilator and/or 1-2 patients who are total care. Which nurse do you assign this patient to?

The nurse you have assigned the patient to becomes very upset and does not want to care for anymore patients. How will you manage this situation?