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Location: Surgical Intensive Care Unit (SICU)

This 55-year-old woman was admitted to the Emergency Department (ED) after being struck by a motor
vehicle, while crossing a busy downtown intersection. On arrival to the ED, the patient was alert and
oriented times three, receiving 100% oxygen per non-rebreather mask and vital signs were BP 80/56, HR
130, RR 28-32, and SpO2 88%. Her cardiac rhythm was Sinus Tachycardia. She had one peripheral 20ga
IV catheter with 1000mL 0.9%% NS infusing wide open. The paramedics stated eyewitnesses reported
the woman had landed on the windshield of the car after being thrown into the air by the impact. On
admission to the ED, the patient was electively intubated and oxygenated on on 100% oxygen. She was
typed and cross matched for four units of packed red blood cells (PRBC). In addition, multiple x-rays and
CT scans were obtained. These studies revealed no head trauma or cerebral bleed. However, the extensive
studies did reveal bilateral pulmonary contusions, kidney contusions, a perforated bowel and a left open
humerus fracture. Despite multiple transfusions and fl uid resuscitation, the patient was unable to sustain
a systolic blood pressure greater than 90mm Hg. The patient was transferred to the Operating Room for
an emergent exploratory laparotomy and repair of her humerus fracture. After surgery, the patient was
transferred to the Surgical Intensive Care Unit. She is receiving mechanical ventilation. She has a right
nasogastric tube to low wall suction draining a small amount of pink tinged drainage. She has a urinary
catheter with bloody urine. Despite frequent blood transfusions, the patient remains hemodynamically
unstable. A left femoral arterial line and pulmonary artery catheter were inserted for more accurate
hemodynamic and blood pressuring monitoring. The patient has advanced directives on the chart.

Healthcare Providers Orders:

Hourly vital signs
Pulmonary artery readings every hour; call surgical resident if pulmonary capillary wedge pressure
(PCWP) greater
than 18mmHg
Hourly intake and output; call surgical resident if urine output less than 30mL/hour
Continuous pulse oximetry; call surgical resident if less than 88%
Ventilator settings: Vt 600, RR 10, PEEP 10cm, FiO2 70%, mode assist control ventilation
IV 0.9% NS at 150mL/hour
Document Peak Airway Pressure (PAP) every hour; call surgical resident if PAP greater than 45cm H2O
ABG, CBC, Electrolytes, BUN, Creatinine, Magnesium, Calcium, Glucose, PTT, PT, Lactic Acid level on
Hgb, Hct, Blood glucose, potassium level every four hours
ABG with each ventilator change and prn
Metronidazole 500mg IVPB every 6 hours
Ciprofl oxacin 400mg IVPB every 12 hours
Portable Chest x-ray and 12-lead ECG on admission to SICU
Daily morning portable Chest x-ray while on mechanical ventilator support
Nasogastric tube to low wall suction and irrigate with 30mL normal saline every four hours
Dry sterile dressing to abdominal wound daily
Morphine 2mg IVP every hour prn for pain
Daily morning weight
Methylprendisolone 125mg IV every 6 hours

Omeprazole 40mg IVPB daily

Imipenem-Cilastatin 500mg IVPB every 6 hours
Learning Objectives :
1. Identifi es the direct and indirect causes of acute respiratory distress syndrome (ARDS) for this patient
2. Utilizes the appropriate underlying principles associated with refractory hypoxemia in planning and
implementing care of the trauma patient with ARDS (APPLICATION).
3. Correlates ventilatory changes with changes in cardiac, neurologic and pulmonary assessment findings
4. Analyzes the event history, assessment fi ndings and arterial blood gas results to anticipate the
complications associated with ARDS (ANALYSIS).
5. Formulates and implements an individualized plan of care for the patient experiencing ARDS
6. Communicates effectively with the family of the dying patient (APPLICATION).

Questions to Prepare for the Simulated Clinical Experience:

1. What clinical fi ndings support a diagnosis of Acute Respiratory Distress Syndrome (ARDS)?
2. What are the pathophysiologies of Acute Lung Injury and Acute Respiratory Distress Syndrome?
3. What is refractory hypoxemia and how would the nurse recognize it?
4. What is positive end expiratory pressure (PEEP), and what is its role in mechanical ventilation?
5. What are potential adverse effects to be alert for when caring for a mechanically ventilated patients
with PEEP?
6. What is bi-level ventilation?
7. What is tidal volume, and how is optimal tidal volume calculated for a patient on a mechanical
8. What is a PaO2/FiO2 ratio used to determine?
9. What are benefi ts of rotational sleep surface therapy?
10. Describe drug action, side effects and dosage requirements for norepinephrine and desmedetomidine.
11. What would the nurse need to assess to determine a sedation score based on a Sedation Agitation
12. What are nursing responsibilities when caring for a dying client?
13. What is the nursing responsibility for post mortem care?

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