Ventilator Management - Nursing Case Study

Pathophysiology

• Primary mechanism: Ventilation support - Mechanical ventilators assist or replace spontaneous breathing by delivering oxygen-rich air to the lungs while helping remove carbon dioxide. This maintains optimal blood oxygen levels and prevents respiratory acidosis.

• Secondary mechanism: Positive pressure application - Unlike normal breathing that uses negative pressure, ventilators apply positive pressure. They push air into the lungs, keeping them inflated, which helps in oxygenation and ventilation, especially in patients with impaired respiratory mechanics.

• Key complication: Ventilator-associated pneumonia (VAP) - Prolonged use of ventilators can lead to infections like VAP due to bacteria entering the lungs through the breathing tube. Regular oral care, elevation of the head of the bed, and timely removal of ventilator support can help prevent VAP.

Patient Profile

Demographics:

78-year-old male, retired school teacher

History:

• Key past medical history: Mild Chronic Obstructive Pulmonary Disease (COPD), no history of hospitalizations

• Current medications: Spiriva (tiotropium), Ventolin (albuterol)

• Allergies: No known drug allergies

Current Presentation:

• Chief complaint: Difficulty breathing

• Key symptoms: Mild shortness of breath, occasional coughing

• Vital signs: Blood pressure 130/85, pulse 75, respiratory rate 18, oxygen saturation 94% on room air, temperature 98.6 F

Section 1

Change in Patient Status:

The nursing staff noticed a slight change in the patient's status during the early morning rounds. There was an increase in his respiratory rate, now at 22 breaths per minute, and a drop in his oxygen saturation to 90%. Additionally, he reported a new onset of mild chest discomfort. On auscultation, the nurse noted decreased breath sounds in the lower lobes bilaterally. The nurse immediately informed the healthcare provider about these changes, who ordered a chest X-ray and arterial blood gas (ABG) analysis.

New Diagnostic Results:

The chest X-ray revealed some infiltrates in the lower lobes, suggesting a possible lower respiratory tract infection. The arterial blood gas (ABG) results showed a PaO2 of 72 mmHg, PaCO2 of 45 mmHg, and a pH of 7.35, indicating a mild respiratory acidosis. These findings, coupled with the patient's symptoms, led the healthcare provider to contemplate the possibility of an early-stage ventilator-associated pneumonia (VAP). He ordered a sputum culture to confirm the diagnosis and determine the appropriate antibiotic therapy. The provider also prescribed a chest physiotherapy to help mobilize the secretions and optimize the lung function.

Section 2

Response to Interventions:

The patient was started on chest physiotherapy and broad-spectrum antibiotics pending sputum culture results. Over the next 24 hours, the patient's respiratory rate decreased to 18 breaths per minute and his oxygen saturation improved to 94% on room air. The chest discomfort he had previously reported was no longer present. However, the nursing staff noted that the patient seemed generally fatigued and less responsive than usual. His temperature was slightly elevated at 38.2°C (100.8°F), which could be indicative of an ongoing infection.

New Complications:

Upon reassessment, the nurse noted crackles in the lower lobes on auscultation, a potential sign of fluid accumulation or worsening infection. The healthcare provider was immediately informed of these findings. Given the patient's increased temperature, fatigue, and new lung sounds, the provider suspected that the patient might be developing sepsis secondary to the suspected ventilator-associated pneumonia. He ordered a complete blood count (CBC) and blood cultures to investigate further. The provider also requested that the nurse closely monitor the patient's vital signs and level of consciousness, as these could provide important clues about the progression of the patient's condition.

Section 3

Change in Patient Status:

Over the next 12 hours, the nurse observed that the patient's fatigue was worsening and he was becoming increasingly less responsive. His skin was warm and flushed. His vital signs were recorded as: blood pressure 110/70 mmHg, pulse 102 beats per minute, respiratory rate 20 breaths per minute, and temperature 38.8°C (101.8°F). The patient's oxygen saturation had dropped to 90% on room air, causing concern about his respiratory status.

New Diagnostic Results:

The results from the complete blood count (CBC) revealed an elevated white blood cell count of 14,000 cells/mcL, indicating a possible infection. The blood cultures were pending. Based on these findings, the healthcare provider decided to adjust the patient's antibiotic therapy. In addition, the provider ordered a chest x-ray to further assess the patient's respiratory status. The nurse was instructed to administer supplemental oxygen to maintain the patient's oxygen saturation above 92% and to continue monitoring his vital signs and level of consciousness closely.

Section 4

New Diagnostic Results:

The results from the chest x-ray came back showing signs of early pneumonia in the patient's right lower lobe. Additionally, the blood cultures confirmed the presence of Streptococcus pneumoniae, a common cause of community-acquired pneumonia. This, in combination with the patient's elevated white blood cell count and fever, was indicative of an ongoing bacterial infection. The healthcare provider decided to change the antibiotic regimen to amoxicillin-clavulanate, a more targeted therapy for this type of pneumonia.

Response to Interventions:

After 24 hours of the new antibiotic therapy and supplemental oxygen administration, the patient's condition showed signs of improvement. His temperature dropped to 37.2°C (98.9°F), his respiratory rate lowered to 18 breaths per minute, and his oxygen saturation levels increased to 94% on a 2L nasal cannula. However, the patient still appeared fatigued and was minimally responsive. The healthcare provider instructed the nurse to continue the current management plan, while closely monitoring the patient's consciousness level, vital signs, and response to the antibiotic therapy. The nurse also reiterated the importance of regular incentive spirometry use to the patient to help improve his lung function.

Section 5

New Complications:

On the third day of the new antibiotic therapy, the patient seemed more fatigued and complained of difficulty in breathing. His oxygen saturation dropped to 90% on the same 2L nasal cannula. The nurse observed increased work of breathing and noted a decrease in the patient's incentive spirometry performance. The patient's heart rate increased to 110 beats per minute and his blood pressure was 140/90 mmHg. Auscultation revealed decreased breath sounds in the right lower lobe. The nurse quickly reported these changes to the healthcare provider.

The healthcare provider ordered a repeat chest x-ray and ABG test to understand the sudden changes in the patient's condition. The nurse made sure to maintain the patient's comfort during this time, monitoring his vital signs closely, and providing supplemental oxygen to maintain his oxygen levels. The nurse also prepared the patient for the possibility of needing a higher level of respiratory support, such as bilevel positive airway pressure (BiPAP), if his condition did not improve. The nurse knew that these new complications could indicate a worsening of the patient's pneumonia and that prompt intervention was crucial for the patient's recovery.