Hospitals
... at 10ml/kg which seems a little high due to her COPD. The mode CMV means that every breath the patient receives will be a controlled breath only. The rate is how many times in one minute she is getting her controlled breath. The FiO2 is the percentage of oxygen the patient is receiving, and the PEEP is the positive pressure that is staying in the air sacs at the end of exhalation to increase her oxygenation. The vital signs obtained in the ICU were a heart rate of 90 (60-100), respiratory rate of 16 (12-20), temperature of 98.5F/36.9C (97.7-99.5F/36.5-37.5C), and blood pressure was barely 90 systolic (120/80) (Oakes, 1-4,1-5). The blood gases were difficult to obtain from her so they immediately proceeded with arterial line placement. This patient needed to have multiple amounts of blood drawn for blood gases. An arterial line is an arterial blood monitoring system consisting of a catheter inserted into an artery and connected to pressure tubing, a transducer, and a monitor. The device permits continuous direct blood pressure readings as well as access to the arterial blood supply when samples are needed for analysis (Schrefer, 105). Her arterial line was placed in the right femoral artery. While in the ICU the patient was started on numerous drugs. She was started on Ipratropium bromide (Atrovent) administered four times a day (Q4). Atrovent is a bronchodilator used in patients with COPD, chronic bronchitis, and emphysema (Spratto, 641). She also received Levalbuterol (Xopenex) four times a day (Q4) which is also a bronchodilator. Her additional medications included Lovenox 40 mg which decreases the chance for her to develop a pulmonary embolism (Spratto, 416). Reglan 10 mg was prescribed which helps her with gastroesophageal reflux (Spratto, 782). Zithromax 500 mg was given for acute bacterial exacerbations of COPD due to hemophilus influenzae (Spratto, 107), and Versed 1 mg was prescribed for sedation to help her relax (Spratto, 794). A complete blood count was retrieved from the lab and revealed her to have a white blood cell count at 16.6 (5,000-10,000) which is increased due to an infection which is most likely her pneumonia. The red blood cell count was 5.20 (4.5-5.2) which is normal and means that she is not producing too little of too many red blood cells. She is not anemic or polycythemic at this point. Her hemoglobin is 14.2 (12-16), and her hematocrit is 43.1 (36-48%). Hemoglobin is a complex protein-iron compound in the blood that carries oxygen to the cells from the lungs and carbon dioxide away from the cells to the lungs, thus releasing carboxyhemoglobin to be excreted (Schrefer, 581). Both of these values are within normal range which means she is experiencing no acute blood loss. The platelet count is also within normal range at 316 (150,000-400,000), which means she is not having complications of inflammation or anemia. The neutrophil count is at 80 (40-75%) which is high and is most likely due to her pneumonia infection. Her Bands are borderline at 2 (3-5%). The lymphocytes are at 9 ( 20-45%) which is low and indicate a chronic infection. The monocytes at 7 (2-10%) are normal which could rule out a viral infection. Her sodium count is at 139 (135-145), and her potassium is at 4.1 (3.5-5.0) meaning that she is not dehydrated. The BUN is the end product of metabolism and at 8 (8-25) it is on the low side. A clinical decrease is indicative of hepatic failure or could also mean that she is simply on a low protein diet. Her glucose level is high at 141 (60-110) which means she could have adrenal insufficiency. Her Albumin level is normal at 3.7 (3.5-5.0). Finally, the calcium is high at 8.8 (4.5-5.8) which indicates she is experiencing diarrhea, or a vitamin D insufficiency (Oakes, 5-2, 5-3, 5-4, 5-5, 5-6, 5-7, 5-8). A chest x-ray showed marked hyperinflation, as well as hyperlucency in the lungs. Hyperinflation and hyperlucency are results from bronchial constriction, such as in asthma, COPD, or emphysema (Wilkins, 325). They simply mean that there is an increased amount of air in the lungs. The physicians impression of the x-ray was fairly severe emphysema, and also noted was that her endotracheal tube was in good position. Her urinalysis revealed a pH of 5.0 (4.5-8.0) which confirms that her infection is not urinary because her value is normal. A pH value greater than 7 could indicate a bacterial infection (Oakes, 5-8). The patient was stabilized in the ICU, so on February 10th, 2005 the patient was transferred from the intensive care unit to the long term care facility via ambu bag at 100% FiO2. The patients breath sounds at the time were diminished. It was noted that she was awake and alert. While in the long term care facility it was decided the patient would receive a trach due to the prolonged ventilation needed. On February 23rd, 2005 the procedure called a percutaneous tracheostomy was performed. A tracheostomy is an opening through the neck into the trachea through which an indwelling tube may be inserted (Schrefer, 1284). The actual procedure was performed at the bedside. It began at 09:00 and was complete by 09:20. Her position was supine on 100% FiO2. The patient’s vital signs revealed a pulse of 98, respiratory rate of 16, blood pressure of 102/81, and a temperature of 98.2F/36.7C. Versed 2 mg was given before the surgery for sedation, and fentanyl 75 mcg was given as a preanesthetic medication (Spratto, 482). The physician used a size 8 tracheostomy tube and placed the patient on the following ventilator settings: The tidal volume was 500, CMV of 16, FiO2 at 30%, and a PEEP of 3. On February 24th , 2005 I saw my patient. She responded to me, but seemed a little tired. Her heart rate at that time was 84, blood pressure110/61, and a SpO2 of 100%. An SpO2 is measured with a pulse oximeter. A pulse oximeter is a device that measures the amount of saturated hemoglobin in the tissue capillaries (Schrefer, 1056). I gave her a breathing treatment with a Unit dose of Atrovent and 1.25 Xopenex. Her treatment went well because her vital signs were unchanged. Her breath sounds were clear, but diminished as I auscultated her. Her percussion note was slightly hyperresonant due to her air trapping and COPD. She had normal fremitus throughout as I palpated her. While waiting on her treatment to finish, I observed the settings on the ventilator. She was on a mode of CMV, and her set rate was 16. She was on 30% FiO2 with a PE...