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Brief Patient History Mr. A is an 18-year-old 80-kg African American man admitted to the intensive...

Brief Patient History Mr. A is an 18-year-old 80-kg African American man admitted to the intensive care unit after emergency surgery for gunshot wounds to the abdomen. The surgical procedure was extensive and involved repair of a perforated bowel, splenectomy, and hemostasis. Mr. A’s mean arterial pressure (MAP) dropped below 65 mm Hg during resuscitation, and he received 9 units of packed red blood cells and 4 L of lactated Ringer solution intravenously (IV) to achieve hemodynamic stability. Clinical Assessment Within 24 hours of admission to the unit, Mr. A becomes extremely short of breath with an increase in respiratory rate of 44 breaths/min. Crackles, rhonchi, and bronchial breath sounds are heard bilaterally, whereas on admission, breath sounds were clear with a few crackles in the bases. Arterial blood gas (ABG) analysis reveals a PaO2 of 56 mm Hg, PaCO2 of 33 mm Hg, pH of 7.52, HCO3- level of 34, and O2 saturation of 84%. Mr. A was intubated and placed on synchronized intermittent mandatory ventilation (SIMV) with an FiO2 (fraction of inspired oxygen) of 60%, tidal volume (VT) of 400 mL, and 5 cm of positive end-expiration pressure (PEEP). Despite sedation, Mr. A becomes extremely restless, diaphoretic, and tachypneic at 36 to 44 breaths/min. His breathing is not synchronous with the ventilator, which is causing him to fight, or “buck,” the ventilator. The high-pressure alarm on the ventilator sounds frequently, and he steadily becomes more hypoxic. His FiO2 is increased to 80%, and PEEP is increased to 10 cm to keep his PaO2 above 60 mm Hg. Mr. A is started on a Norcuron (vecuronium) and Ativan (lorazepam) IV infusion. Diagnostic Procedures The current chest radiograph reveals complete opacity or a “white-out” appearance of the lungs. The chest radiograph in the emergency department was clear, and the chest radiograph immediately after surgery revealed bilateral patchy infiltrates that had a “ground-glass appearance.” ABG analysis: pH of 7.48, PaO2 of 60 mm Hg, PaCO2 of 65 mm Hg, HCO3- level of 28 mEq/L, and O2 saturation of 90% on an FiO2 of 80%. Current vital signs are blood pressure of 118/76 mm Hg, heart rate of 112 beats/min (sinus tachycardia), respiratory rate of 16 breaths/min, and temperature of 100.8F. Urine output is 30 mL/h, and peripheral pulses are palpable. Hematocrit is 24%, hemoglobin is 8 g/dL, lactate level is 3 mmol/L, and white blood count is 12,000/mcL. Medical Diagnosis Gunshot wound to abdomen; bowel resection Splenectomy Acute respiratory distress syndrome (ARDS) Patient-ventilator dyssynchrony Major Outcomes Expected for Patient: Maintain patent airway Maintain adequate ventilation Maintain adequate tissue and cerebral perfusion Prevent complications from mechanical ventilation, high FiO2, high PEEP, and neuromuscular blocking agents.

Discuss three interventions that should be initiated to promote optimal functioning, safety, and well-being of the patient?

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Discuss three interventions that should be initiated to promote optimal functioning, safety, and well-being of the patient?

  • Improve the perfusion in the pulmonary capillary system by increasing oxygen transport. Frequent changing of position helps to improve perfusion and enhances secretion.
  • Frequently assess patient condition, ABG values, hemodynamic status to evaluate the effectiveness of treatment and to prevent complications.
  • Suction the airway mucus to maintain open alveoli.
  • Check the patient vitals because the patient is on positive pressure ventilation which increases the cardiovascular risk.
  • Follow infection control practices to avoid Ventilator-Associated Pneumonia.
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