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طوارئ

1. Mr. M is a 60-year-old man admitted with heart failure presenting with shortness of breath, restlessness, tachycardia, and hypoxemia not responding to oxygen therapy who required intubation and mechanical ventilation. 2. Arterial blood gas results of hypoxemia, respiratory acidosis, and metabolic alkalosis are consistent with the need for mechanical ventilation. 3. Weaning criteria to consider for extubation include hemodynamic stability, oxygen saturation over 90% on low oxygen, normal chest x-ray, and normalized labs. 4. Treatment for heart failure includes medications like ACE inhibitors, beta blockers, and mineralocorticoid receptors as well

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0% found this document useful (0 votes)
33 views9 pages

طوارئ

1. Mr. M is a 60-year-old man admitted with heart failure presenting with shortness of breath, restlessness, tachycardia, and hypoxemia not responding to oxygen therapy who required intubation and mechanical ventilation. 2. Arterial blood gas results of hypoxemia, respiratory acidosis, and metabolic alkalosis are consistent with the need for mechanical ventilation. 3. Weaning criteria to consider for extubation include hemodynamic stability, oxygen saturation over 90% on low oxygen, normal chest x-ray, and normalized labs. 4. Treatment for heart failure includes medications like ACE inhibitors, beta blockers, and mineralocorticoid receptors as well

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bestmsaas
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Faculty of Nursing

Cairo University
Emergency Department
2023/2024

CASE SCENARIO No (1)

Mechanical ventilation
Under supervision

Dr.Hoda salah eldeen


Names:
1 -Abdalrahman kamel Mostafa 12-Israa Fangri Ahmed
2 -Alia Nsr kamal ali 13-abdalla Raja Dhafir
3-Shorouq Ahmed Fathi 14-Shereen Hassan Youssef
4-abda Rahman Muhammad 15-Sherif Gamal Ramadan
5 -Omar Abdal-haleem 16-Fatima Al-Zahra
Mohammed 17-Ali Ahmed Ghallab
6 -shrouk Wafiq Sami Hassan 18-Abdul Hameed Ayman
7-Kamal Mohammed Mohammed 19-Karim Muhammad Faraj
8-Safaa Mahmoud abdal-alem 20-Alaa Nessim Soliman
9-Shorouq Abdul Sadiq Hanafi 21-Farahat Mohamed
10-Shorouk Ali Mustafa
11-Sabreen Hassan Ahmed Ali
CASE SCENARIO No (1)

Mr. M. is a 60-year-old man who has been admitted to the intensive


cardiac care unit with a diagnosis of heart failure. On admission, Mr.
M. had shortness of breath, restless, and tachycardia, and not
responding to oxygen therapy, and O2 Sat. was 70%, then he was
intubated and mechanically ventilated. Arterial blood gases (ABGs)
showed PaO2, 70 mm Hg; PaCO2, 50 mm Hg; HCO3, 30 mEq/L; and
pH, 7.29 and confusion. On physical examination, his vital signs are as
follows: RR, 32 breaths/min HR, 126 beats/min; and BP, 100/64 mm Hg.
Now he has a Glasgow Coma Scale score of 12, and During assessment
of breath sounds, the nurse hears coarse crackles in both bases with
some audible expiratory wheezing. The current ventilator settings are:
FiO2, 0.45; no rate; PEEP, 5 cm H2O; RR, 20; and tidal volume, 500
mL, with A/C mode.

1. What are the main signs and symptoms associated with the
diagnosis of heart failure?
❖ Associated with the patient :
• shortness of breath, restless
• tachycardia
• not responding to oxygen therapy.
❖ General signs and symtomps of heart failure:
• Shortness of breath with activity or when lying down
• irregular heart rate
• Fatigue and weakness
• Swelling in the legs, ankles and feet
• heart palpitations
• Reduced ability to exercise
• protruding neck veins( jugular vien)
• Persistent cough or wheezing with white or pink blood-tinged
mucus
• Swelling of the belly area (abdomen)
• Very rapid weight gain from fluid buildup
• Nausea and loss of appetite
• Difficulty concentrating or decreased alertness
• Chest pain if heart failure is caused by a heart attack
2. What are findings from Mr. A.’s assessment is
consistent with the criteria of mechanical ventilation?
• PaO2, 70 mm Hg( normal range: 80-100 mm Hg)
• PaCO2, 50 mm Hg( normal range: 35-45 mm Hg)
• heart failure.
• shortness of breath
• tachycardia
• not responding to oxygen therapy
3. Interpret the labs results for Mr. A.?
Partially compensated respiratory acidosis
ABG RES NORMAL COMMENT
ULT RANGE
SAO2 70 95_100 hypoxia
PAO2 70 80-100 hypoxemia
mm Hg
PAC 50 35-45 Respiratory acidosis
O2 mm Hg
HCO 30 22-26 metabolic alkalosis
3 meq/liter
PH 7.29 (7.35- acidaemia
7.45)
4. Compare the mode of mechanical ventilation for Mr.
M. with other modes of mechanical ventilator?
A/C SIMV CMV pcv psv CPAP BIPAP
mode
-Pt. always -Most -Ventilation is -PCV mode PSV mode -All -Is a
receives a commonly completely in there is augments breaths are spontaneous
mechanical used mode provided by RR, The patient’s patient breathing mode
breath, the inspiratory spontaneous triggered in which two
either Spontaneous mechanical pressure breaths and cycled. levels of
timed or breaths and ventilator level, and with -Positive pressure
assisted mandatory with: inspiratory– positive pressure is (hi/low) are set.
-Ventilator breaths A preset tidal expiratory pressure applied -Better
provides If pt. has volume (I:E) ratio boost through synchronization,
the patient respiratory Respiratory must be during inspiratory more options
with a drive, the rate selected. inspiration and for supporting
preset tidal mandatory Oxygen used to i.e. assisting expiratory spontaneous
volume at breaths are concentration control each phases of breathing, and
a preset synchronized -Client does plateau spontaneous the potential for
rate with the pt’s not breathe pressures in inspiration. respiratory improved
-Client can inspiratory spontaneously. conditions, cycle. monitoring
initiate effort -Client can such as -CPAP
breathe . not initiate ARDS, in requires
breathe which intact
compliance respiratory
is decreased drive
and the risk patient
for ability to
barotrauma maintain
is high. tidal
volume.

⚫It may
be used as
a weaning
mode(mask
CPAP
5. What weaning criteria should be considered before
extubation of Mr. M.?
❖ Readinas Criteria
• Hemodynamically stable, adequately resuscitated, and not
requiring significant vasoactive support
• Sa02 greater than 90% on FiO2 less than or equal to 40%;
PEEP less than orEqual to 5 cm H20
• Chest x-ray reviewed for correctable factors; treated as
indicated
• Metabolic indicators (serum pH, major electrolytes) within
normal range
• Hematocrit greater than 25%
• Core temperature greater than 36°C and less than 39°C
Adequate management of pain/anxiety/agitation
• No residual neuromuscular blockade (NMB)
• ABGS normalized or at patient's baseline

6.What are the medical treatments for patient with heart


failure?
The main treatments are medication :

• ACE inhibitors
• angiotensin-2 receptor blockers (ARBs or AIIRAs)
• beta blockers
• mineralocorticoid

-devices implanted in the chest to control heart rhythm / surgery


In many cases, a combination of treatments will be required.

-Treatment will usually need to continue for the rest of your life.
7.What are the nursing care plan needed for that patient?
❖ Actual Nursing diagnosis:
• Excess fluid volume
• Decrease cardiac output
• Impaired spontaneous ventilation
• Ineffective airway clearance
• Ineffective breathing pattern Potential nursing diagnosis
• Impaired verbal communication
• Impaired physical mobility
• Disturbed sleeping pattern
• Fatigue
• Anxiety
❖ Potential nursing diagnosis
• Risk for ineffective protection
• Risk for infection
• Risk for impaired oral mucus membrane
• Risk for imbalanced nutrition; less than body requirement
• Risk for pressure ulcer/ bed sore
• Risk for constipation
• Risk for deficient fluid volume
• Risk for aspiration
• Risk for fall
Nursing diagnosis Excess fluid volume related to heart failure as evidence by
presence of crackles , shortness of breath , restlness ,
tachycardiaand decrease BP
Objective • Demonstrate stabilized fluid volume with balanced
intake and output
• breath sounds clear/clearing,
• vital signs within acceptablerange,
• stable weight
• absence of edema.
Assessment • Monitor urine output, noting amount and color
• Monitor and calculate 24-hour intake and output
(I&O)balance
• Weigh daily. Frequently monitor blood urea
nitrogen, creatinine, and serum potassium,
sodium, chloride, andmagnesium levels.
• Assess for distended neck and peripheral vessels.
Inspect dependent body areas for edema (check for
pitting edema )
• Auscultate breath sounds, noting decreased
and/oradventitious sounds (crackles, wheezes)
• Monitor BP and central venous pressure (CVP)
• Evaluate urine output in response to diuretic therapy
• Assess the need for an indwelling urinary catheter.
• Assess for the presence of peripheral edema.
Intervention • Weigh the patient daily and compare to the
previous measurement.
• Monitor for distended neck veins and ascites
• Follow a low-sodium diet and/or fluid restriction
• provide oral care q2hr.
• Change position frequently.
• Maintain bed in semi-Fowler’s position
• Administer medications as indicated.
• Monitor chest x-ray(Reveals changes indicative of
resolution of pulmonary congestion).
Health teaching
• Weigh yourself every morning on the same scale when
you get up.
• Reduce salt intake and avoid fatty foods
• Try to stay away from things that are stressful.
• Your provider may refer you to cardiac
rehabilitation program. There, you will learn how to
slowly increase
• Teach exercise and how to take care of your heart disease

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