Transcript
CHAPTER 16 </P></ANS></ANSSET></MCQSET>
Clinical Reasoning Checkpoint Answers
Ms. T. is an 82-year-old woman who was admitted to the hospital with fever and chronic diarrhea from a long-term care facility. She is diagnosed with a urinary tract infection. On admission, she was pleasantly confused, oriented to name only, and following commands. Twenty-four hours after her admission, she became agitated, increasingly confused, and pulled out her lines.
1. Is Ms. T. at risk for delirium? Why?
Answer: Yes, Mrs. T has several risk factors that place her at risk.
2. What are the risk factors for the development of delirium? What risk factors does the patient have?
Answer: Risk factors for the development of delirium include her infection; metabolic and electrolyte imbalances from her diarrhea; and acute renal failure as well as hypoxemia. Efforts to correct her physiologic status will take time; however, asking one of her friends or family members to sit with her and calm her through gentle conversation may be an effective intervention throughout Mrs. T’s stay.
3. What pharmacological treatment is indicated for delirium?
Answer: Benzodiazepines and haloperidol are medications that can treat delirium. It is important to have daily sedation goals for her and to assess her using valid tools to measure her degree of sedation. These medications should be titrated to achieve a specific sedation goal. Because prolonged use of benzodiazepines can contribute to the development of delirium, haloperidol is an anti-psychotic medication that is useful.
Clinical update: Ms. T.’s condition worsens as she is believed to have aspirated and developed pneumonia. Her chest X-ray now reveals bilateral interstitial infiltrates consistent with pulmonary edema and acute respiratory distress syndrome (ARDS). It becomes increasingly more difficult to oxygenate her. She is orally intubated and placed on mechanical ventilation. She requires 100% FiO2, PEEP, and neuromuscular blockade to maintain her oxygenation.
4. For patients such as Ms. T. who are receiving neuromuscular blockade, what nursing interventions would be indicated?
Answer: Management of airway, breathing, and circulation: Establish and maintain a patent airway (intubate); suction as needed; monitor ventilator settings for accuracy; evaluate oxygenation and ventilation through use of arterial blood gases and pulse oximetry. Keep a manual resuscitation bag valve mask at the bedside at all times. Monitor heart rate and rhythm, blood pressure, temperature, and peripheral pulses; monitor acid-base and electrolyte status. Assess cardiac and pulmonary systems for ill effects of immobility; monitor condition of skin and prevent breakdown; assure implementation of deep vein thrombosis prophylaxis. Management of pain, sedation, and level of neuromuscular blockade: Monitor level of paralysis with peripheral nerve stimulation train of four; monitor continuous airway pressure; institute monitoring to evaluate patient’s level of pain and sedation; administer pain and sedation medications while patient is receiving neuromuscular blockade.
Protect the patient’s eyes by closing them and covering with a soft, sterile eye pad: Use eye lubricants or artificial tears to keep them moist.
5. What complications are patients who are paralyzed with neuromuscular blocking medications at risk for developing?
ANSWER: Potential complications: Prolonged neuromuscular weakness; a synergistic effect that occurs when the agents are given with corticosteroids or aminoglycosides. Aminoglycosides, antibiotics, hypothermia, hyperkalemia, and hypercalcemia potentiate the effects of neuromuscular blocking agents. Prolonged muscle weakness is associated with elevated serum creatine kinase levels, muscle fiber atrophy, and muscle fiber necrosis; complications of immobility such as DVT, pulmonary embolisms, atelectasis, and pneumonia.
