Joseph Hale, 27 years old was admitted to the ICU of a community hospital after running a red light in his car and colliding with another car. He is being transferred to the operating room to evacuate a left parietal subdural hematoma. His concomitant injuries include a flail chest with pulmonary contusions, for which he is being mechanically ventilated, and a fractured left femur. Currently, he is receiving propofol 45mcg/kg/min. He responds to noxious stimuli by withdrawal. He withdraws all his extremities from noxious stimuli except his left leg, and his pupils are equal and reactive to light.
His ventilator settings are Assist Control with a rate of 18, tidal volume (TV) 800, FiO2 50%, PEEP 5. Lung sounds are diminished on the left with scattered rhonchi on the right. He has a left chest tube in place and has bilateral equal chest expansion.
Some of his other assessment findings are BP 109/71, HR 111/min, RR 18, Temp 100.6, urine output 20-30mL/hr, pH 7.28, pCO2 56, p)2 sat 97%, Hgb 10 and Hct 30.
In addition to the propofol and ventilator settings some of his post-op orders include insertion of a central line, IV antibiotics, morphine sulfate 2 mg q 2 hr for pain, Foley catheter to gravity drainage, nasogastric tube to low continuous suction, maintain left leg in immobilizer.
On hospital day 6, Joseph became increasingly unstable. His chest x-ray revealed pulmonary contusions and pneumonia on the left as well as the fractured ribs. He began to meet the criteria for ARDS with diffuse bilateral infiltrates and refractory hypoxemia. His ventilator settings at this time are FIO2 100%, TV 800, Assist control 24, and PEEP 7. His propofol has been increased to 55 mcg/kg/min but he was becoming increasingly restless.
Other findings included BP 80/50, HR 120,m RR 28, Urine output 18-20mL/hr, temperature 10-1.4, pH 7.11, pO2 109, pCO2 54, WBC 32,000, Hgb 8, Hct 28.
Before answering questions review Normal ABG results. Regarding ventilator settings, just know as his condition becomes more unstable the settings on his ventilator will increase. The first 8 questions are related to Septicemia and this Case study.
1) What Joseph’s possible sources of infection?
2) What is SIRS?
3) Has Joseph developed severe sepsis or septic shock? Why or why not?
4) Are there indications that Allen is in danger of developing failure of other organs?
If yes, what are the indications.
5)Why is severe sepsis a costly illness?
Why is it likely to become more costly?
This is a thought provoking question, answer may not be in your book, why do you think sepsis is so costly. Critically think your way through to this answer.
6)How does elevating the head of the bed for a ventilated patient decrease the incidence of ventilator-associated pneumonia (VAP)?
7) What interventions would you include in the evidenced based care of a central venous catheter?
8) Why is shaving a surgical site preoperatively no longer indicated?
9) List 5 populations that are high risk for developing TB.
10) What are the typical symptoms you would see in a patient with TB.
11) How would tuberculosis be diagnosed.
12) List 4 medical treatment options and 4 nursing care interventions.
13) How could a community education program help in the prevention and treatment of TB.
14) Explain how septicemia might develop as a complication of TB and tell how that would change your plan of care.
