Acute Respiratory Distress Syndrome

Patient Profile

Z.Q., 84-year-old Hispanic male, came to the emergency department (ED) 7 days ago with complaints of shortness of breath. His wife stated that he had a history of hypertension, depression, and chronic obstructive pulmonary disease (COPD). The admission chest x-ray revealed dense consolidation of the left lower lobe. An arterial blood gas (ABG) at that time showed: pH 7.60, PaCO₂ 29mm/Hg, HC0₃ 32mmol/L, and PaO₂ 75mm/Hg. Z.Q. quickly deteriorated and subsequently was intubated. He has been in the intensive care unit for 5 days.

Subjective Data

• Z.Q. and wife have been married 45 years and live with a daughter and 2 grandchildren
• Z.Q. and his wife speak both English and Spanish

Objective Data

Physical Examination

• Blood pressure 167/98, pulse 112, temperature102.0° F, respirations 14, oxygen saturation 72% on 6L via venture mask.
• Height 5 feet 6 inches, weight 75 kg
• Patient localizes to endotracheal tube (ETT) and is intermittently aroused, making several attempts to pull ETT
• Orally intubated #7.5 ETT, taped at 27 cm to lip
• Volume cycled ventilator at FIO₂ – 60%, in assist control mode of 14 breaths per minute, tidal volume 450, positive end-expiratory pressure PEEP5 cm H₂O
• Breath sounds decreased in bases with bilateral crackles that do not clear after suctioning
• Brown/yellow secretions returned with suctioning
• Peripheral pulses weak at 1/4 with capillary refill greater than 4 seconds
• 2+ pitting edema in the bilateral lower extremities

Newly Obtained Diagnostic Study Results

• Arterial blood gas (ABG) pH 7.31, PaCO₂ 58mm/Hg, HCO₃ 28mmol/L, PaO₂ 54mm/Hg, EtCO₂ 38 mm/Hg
• Chest x-ray reveals diffuse white out in middle and lower lobes; endotracheal tube present with tip well above the carina; left subclavian central venous catheter is located in the superior vena cava
• CT scan reveals alveolar opacities with increasing effusions in the gravity-dependent areas of the lungs

Complete the following Case study questions. Answers must be thorough and cited appropriately in APA format

Interpret Z.Q.’s latest set of ABGs.

Describe each of Z.Q.’s ventilator settings and the rationale for the selection of each.

After reviewing Z.Q’s ABG results, the provider increases the PEEP from 5 cm H₂O to 8cm H₂O. Why would this be necessary and what is the expected outcome associated with this action?

The provider decides to begin Z.Q. on IV dobutamine and milrinone. What is the rationale for using each of these medications?

Based on the assessment data, what are the nursing priorities for Z.Q.?

List three potential adverse complications with mechanical ventilation.

You are concerned about Z.Q.’s nutritional status and approach the provider for a dietary consult, thinking that Z.Q. is a candidate for enteral feedings with Pulmocare. What is your reason for making this recommendation?