Question

Introduction

For this critical/evaluative essay, read both scenarios and answer the questions that follow. Your viewpoint and purpose should be clearly established and sustained. Your assignment should be a continuous piece of writing that allows for a sustained viewpoint with logical order and organization.

The assignment should follow the conventions of Standard English (correct grammar, punctuation, and spelling). A title and reference page are required. Your assignment should be double spaced using New Times Raman and a 12 point font.

You must include at least five (5) references including three (3) evidence based, peer-reviewed resources to support your ideas.

Part I

Sam is a 20 years old and has been admitted to the hospital for a large bowel obstruction. Sam was diagnosed with Cystic Fibrosis at the age of 2. Cystic Fibrosis is a genetic disorder that affects not only the respiratory system but also the gastrointestinal system. Sam’s parents are very worried about him at this time. During surgery he had 4 liters blood loss and was admitted to the ICU where you work. He was intubated at time of admission

Assessment:

Vital Signs: B/P 90/45, HR 116, T 98.9, RR 16

            Weight 150 pounds, Height: 6 foot

Neuro: Lethargic but opens eyes to voice

Respiratory: Lungs diminished in bases bilaterally

Vent: SIMV TV 650, FiO2 70%, RR 16, PEEP 5

ABG: pH 7.30, PaCO2 46, Bicarb 22, PaO2 70

PaO2/FiO2 ratio 150

Cardiac: Heart tones normal

GI: Bowel sounds absent

GU: Foley in place with 40ml/hr, Urine yellow and clear

Lab Values prior to surgery: NA 137 meq/L, K 3.9 meq/L, CL 100 meq/L, Mg 2 meq/L, WBC 12,000 mm³, H/H 15 g/dl and 42%, Lactic Acid 20 mg/dl,

CXR: Ground glass appearance in lower lobes

1. What is the genetic component of Cystic Fibrosis and how is it diagnosed?
2. How can genetic testing be used to make predictions?
3. Explain the pathophysiology of Cystic Fibrosis. How does it affect the respiratory system? How does it affect the GI system?
4. Sam is in the early stages of ARDS. What manifestations do you see that would indicate this finding?
5. What is the Pathophysiology of the three stages of ARDS?
6. What are your top three nursing priorities with rationale at this time?
7. How might the lab values change after 4 units of PRBC are given?
8. Use ADPIE to write a plan for Sam for the next 12 hours.

Part II

It has now been 24 hours since Sam has been intubated and in the ICU. His parents are at his bedside. Both Sam and his parents are practicing Buddhists. Sam has a living will that states he does not want to be on the ventilator longer than 4 days without improvement. Sam’s parents have asked to have the sedation to be discontinued because of their religious beliefs.

Assessment:

            Vital Signs: B/P 80/40, HR 120, T 102, RR 20, Pulse Ox 88%

Ventilator: Vent: Assist Control (AC), TV 550, FiO2 90%, RR 20, PEEP 15

ABG: pH 7.30, PaCO2 46, Bicarb 24, PaO2 60

PaO2/FiO2 ratio: 150

Neuro: Patient is sedated

Resp: Lungs with rhonchi bilaterally in all lobes

Cardiac: CO 3.5, CVP 3, SVR 800 dynes/sec/cm-5,

GI: Bowel sounds absent, NG tube to low continuous suction        

GU: Foley in place with Urine output <20 ml/hr

Lab Values: Lactic Acid 40 mg/dL, Potassium 5 meq/L, Sodium 140 meq/L, Platelets 50,000, Creatinine 4 mg/dL, WBC 20,000 mm^3,

Doctor’s Orders:

Begin Dobutamine at 3 mcg/kg/min (IV bag is supplied with 500 mg Dobutamine mixed in 250 ml D5W).

Begin Levophed at 1.5mcg/kg/min (IV bag is supplied with 1000 mg Levophed in 500 ml D5W).

1. Sam is now in septic shock. What information can you use to come to this conclusion?
2. Calculate the Mean Arterial Pressure (MAP), and ml/hr for the Dobutamine drip and Levophed drip
3. What are your top three priorities, with rationale, at this time?
4. Discuss one ethical dilemma you identify in relation to Sam’s parents request. Use either beneficence or non-maleficence to justify our answer.