Question

R.B. is a 65-year-old female who presented to the emergency department (ED) via ambulance for acute shortness of breath. Her daughter called an ambulance after finding her mother with an increased respiratory rate and shortness of breath. Upon arrival to the ED, R.B.’s respirations were 40 and shallow with wheezing in the lower lobes and rhonchi in the upper lobes bilaterally. She had positive jugular vein distention and a heart rate of 128. After treatment with albuterol nebulizer via mask, her vital signs were temperature 96.8˚ F, pulse 98, respirations 18, blood pressure 148/84, and O₂ saturation 94% with 15 LPM via mask. Arterial blood gasses showed her pH 7.19, pCO₂ 90, PO₂ 92%, HCO₃ 38. R.B. was intubated for hypercapnia. After an echocardiogram showed an ejection fraction less than 50%, she had an emergency left heart catheterization done with two stent placements into the left anterior descending artery. A pulmonary artery catheter was placed and the initial hemodynamic readings show elevated left ventricular preload. R.B. is now being transferred to the ICU.

• 12 Lead ECG:ST elevation
• Troponin:41.94
• Lung V/Q scan negative for pulmonary embolis
• Urinalysis: Dark yellow and cloudy, protein 28 mg/dL, positive for casts, positive for red blood cells and white blood cells, positive for glucose and ketones

1. On arrival to the ICU, R.B. begins to thrash, kick her legs, and wave her arms. The portable transport ventilator alarms are ringing. What is the priority nursing assessment?

2.   During the assessment, it was noted that R.B. partially extubated herself and now must be reintubated. What equipment is needed?

3. After reinserting R.B.’s endotracheal tube, how is placement verified     
4. After R.B. is reintubated and sedated, you notice there is no waveform on the monitor for the pulmonary artery catheter. List the initial nursing trouble shooting interventions.

Answer 1

1 Since the patient is intubate the priority nursing assesment for this aggitated pateint is to check the ventillater alarm  for the patency and the position of the endotracheal tube and the oxygen saturation.The ventillater alarm will show the reason for the alarm and it should be rectifies as early as possible to maintain the oxygen saturation.

2.The equipment neede for the reintubation is same as that of the intubation.The article includeEndotracheal tube,buggie,laryngoscope,lubricant if needed,ambubag,syringe to inflate,ET holder to position the endotracheal tube,suction apparatus in good working condition,medications as adviced by the doctor to sedate the patient.

The placement can be verified by checking the bilateral lung sound by auscultation and the final verification should be done by doing an x ray chest .

The reasons fo the absence of wave form in the moniter can be due to the kink in the catheter,presence of blood clot and it can even due to the presence of air bubble and it could be due to the displacement of the catheter.So the nursing responsibility is to identify the reason for the issue ,inform the doctor and rectify it as needed like flushing the catheter to remove the air bubble and blood clot,remove the kink if it present and if at all needed position the cathater with the help of doctor.Even you can check the moniter settings also.