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ARDS Case Study (60 min)

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Mr. Martin is a 55 year old man who presents to his primary care provider (PCP) on a Tuesday with complaints of a productive cough for 3 days with fever, chills, fatigue beginning in the last 24 hours.  This clinic has capabilities for x-ray, rapid lab tests, and simple IV infusions. His PCP hears coarse rhonchi in Mr. Martin’s lungs and decides to take a chest x-ray. The x-ray shows right lower lobe infiltrates. His rapid flu swab is negative. Mr Martin’s vital signs were as follows:

BP 122/73 mmHg HR 102 bpm

RR 26 bpm Temp 38.6°C

SpO2 94% on room air Weight 105 kg

Mr. Martin is diagnosed with pneumonia and sent home on Azithromycin.  Two days later, on Thursday, Mr. Martin still has the cough, fever, chills, and fatigue and is now having body aches on and off and is short of breath intermittently. He calls his PCP concerned that the antibiotics are not working. His PCP agrees and changes his antibiotic to Amoxicillin.

On Friday, Mr. Martin’s wife calls his PCP again because he is struggling to even get out of bed and is very fatigued and feverish. She reports a fever of 102.9°F. The PCP tells him to come into the clinic.  He arrives at the clinic 20 minutes later.

Critical Thinking Check
Bloom's Taxonomy: Application

What nursing assessments should be performed at this time for Mr. Martin?

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Upon further assessment, Mr. Martin has rhonchi throughout his lung fields, with occasional expiratory wheezes. He appears pale and is lethargic. His skin is tenting on his sternum and his nail beds are pale. His vital signs are as follows:

BP 108/66 mmHg HR 116 bpm

RR 30 bpm Temp 38.8°C

SpO2 92% on room air

Critical Thinking Check
Bloom's Taxonomy: Analysis

What diagnostic tests would you anticipate the provider ordering?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What would be some priority interventions for Mr. Martin at this time?

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Mr. Martin’s PCP believes he is suffering from dehydration related to his fever and orders 1 L of Normal Saline to be infused in the clinic before sending Mr. Martin home. The nurse starts a peripheral IV and initiates the fluid bolus, which takes 1 hour to infuse.

Critical Thinking Check
Bloom's Taxonomy: Application

What evaluation information would you, as the nurse, want to obtain following the infusion of these IV fluids?

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Mr. Martin’s infusion completes after hours Friday, so the Medical Assistant removes his IV and tells him he can go home and to call the on-call team if he has any concerns.  Mr. Martin returns home and tells his wife he doesn’t really feel any better. For the next two days (over the weekend), Mr. Martin continues to be more and more fatigued. His wife finally calls the PCP on Sunday who says to bring him in first thing the next morning. 

On Monday morning, Mr. Martin arrives at his PCP who can immediately tell he has gotten much worse. He repeats a chest x-ray to find diffuse bilateral pulmonary infiltrates. Mr. Martin is sent straight to the Emergency Department (ED).

Critical Thinking Check
Bloom's Taxonomy: Analysis

What step of the nursing process was skipped? What impact might that have had on Mr. Martin?

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Mr. Martin arrives in the ED where providers confirm the diagnosis of bilateral pneumonia. 

Mr. Martin’s SpO2 is 88%, so he is placed on 4L NC (36% FiO2).  The provider writes the following orders, which are implemented by the nurse:

Keep sats >92%

Repeat CXR in 4 hours

Labs: ABG, CBC, BMP, blood cultures

Insert peripheral IV x 2

Give 1 L Normal Saline IV bolus now

Albuterol nebulizer 2.5mg

Mr. Martin’s blood gas results are as follows:

pH 7.30 pO2 75 mmHg on 4L NC (36% FiO2)

pCO2 58 mmHg SaO2 96% on 4L NC (36% FiO2)

HCO3 26 mEq/L

Critical Thinking Check
Bloom's Taxonomy: Comprehension

Interpret the ABG. Explain.

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Critical Thinking Check
Bloom's Taxonomy: Application

What is Mr. Martin’s PaO2/FiO2 ratio? Explain the results.

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Mr. Martin’s condition continues to deteriorate. He is placed on BiPAP and sent to the ICU. The next day he is still struggling to oxygenate and the family agrees to intubate him and place him on a mechanical ventilator. He is placed on Assist Control mode, FiO2 of 100%, Vt of 440  mL, PEEP of 5. After 1 hour, a blood gas is drawn, with the following results: 

pH 7.25 pO2 90 mmHg

pCO2 52 mmHg SaO2 99% on 100% FiO2

HCO3 28 mEq/L

Critical Thinking Check
Bloom's Taxonomy: Application

Interpret the ABG, including determining the PaO2/FiO2 ratio. What do these results indicate for Mr. Martin?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What, physiologically, is going on with Mr. Martin at this time?

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Mr. Martin is in the ICU for 14 days. He has multiple bronchoscopies to attempt to clear the fluid from his lungs. He was continued on high-dose IV antibiotics after his blood cultures revealed Strep A pneumonia. His PEEP is progressively increased until it is at the max of 14 cmH2O. He is placed on lung-protective ventilator settings (APRV) to prevent barotrauma and promote opening of the alveoli. He remained in severe ARDS despite all interventions.  He was too unstable to take to the OR for a trach and ended up going into Cardiogenic Shock. Despite all interventions, Mr. Martin passed away with his family by his side on the14th day in the ICU.

Critical Thinking Check
Bloom's Taxonomy: Analysis

What would you have done differently for Mr. Martin and when? Why?

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