Question

A pulmonary artery catheter is inserted to montior the pulonary artery wedge pressure(PAWP). An arterial line is inserted in the left radial artery for continuous blood pressure monitoring and an NG tube is inserted and connected to low intermittent suction. ASSESSMENT DATA Restless needs frequent reminding not to pull on the ET tube or NG Scattered crackles audible bilaterally tube Urine output over 2 hours is 50 mL of clear amber urine Bowel sounds slightly hypoactive audible in 4 quadrants Dressing dry, intact, Jackson-Pratt drain drainage unchanged. BP 100/46 mm Hg HR 124 beats/min PAWP 3mm Hg Respirations 24 breaths.min Temperature 102.1F Based on the data, which collaborative interventions will you anticipate for the client? Underline and provide rationale for the selections and rationales for NOT selecting an anwer Increase IV rate to 150 mL/hr Administer Lasix 40 mg IV . Administer norepinephrine (Levophed) infusion Give diltiazem (Cardizem) 15mg IV Infuse total parenteral nutrition at 70 mL/h Administer high-calorie entral feeding at 25 mL/h Obtain blood, sputum and urine specimens for culture

Answer 1

Q. No. 2. Answer : is 1st one that restraint hands with soft wrist restrains,

Because the clients oxygen saturation levels 90 %, so we should not give intramuscular blackade medications,

And we can not remain the client every time, because he may not in fully consciousness,

And family members should not allowed every time at ICU because it's an isolated area, to prevent spread of infections.

So we should do restraint to the clients hands, to prevent pulling of ET tube.

Q. No. 3. Answer : is suction is applied to the catheter while inserting into ET tube.

Q. No. 4. Answer : is 3rd one, that is maintain the head of the bed elevated at least 30 degree angle.

Because if the bed is in flat and not elevated there is a chance of aspiration of secretions and feeds what ever the giving through tube also, so by the elevation of head end we can maintain correct position to prevent aspiration.

When we can prevent aspiration automatically the ventilatory associated pneumonia we can preventable.

Q. No. 5. Answer :

* she can provide the oral care every 2 hours, to avoid getting oral infections.

* place in prone position for 4 hours in every shift, to prevent bedsores.

* she can check residuals and enteral feedings every 4 hours once. To maintain intake and out put chart.

* she can assess the breath sounds every 4 hours once, to check aspirations or any infectious sounds.

* suction ET tube as needed, to prevent aspiration.

* she will not educate family members and client about routine nursing care, because hospital administrative departments can look after regarding counseling.

* PCWP pulmonary capillary wedge pressure and arterial pressure from arterial line measured by pulmonologist and anesthesiologist respectively.