Interpretation of Arterial Blood Gas in Critical Care Nursing Assessment Answer

Interpret this ABG for My Critical Care Nursing

The Arterial blood gas measurement is present, this needs to be assessed and then interpretation should be drawn accordingly. The pH which is present is lower than the normal range, along with pH, the level of pCO2 is also low. In addition to it, pO2 is increased and above the normal range. Oximetry level should be measured, in this sO2 and F02 Hb is above than normal range. The electrolyte value is measured, and all the levels of electrolyte are managed however sodium and chloride level is not in the normal range. The level of sodium is lower than the normal range, however, the level of Cl is above the normal range. When the oxygen level is assessed it has been observed that oxygen status is being assessed. The acid-base status should be assessed, in this, the base level is lower than the normal range, and the carbonate level is not under the normal range, however, it is lower than normal. The CO2 level is high and much more than normal (Chandran et al., 2021).

From the above assessment, it has been clear that pH is lower than normal, hence steps should be taken to bring it to the normal range. The level of oxygen is also affected, hence it should be controlled and it should be brought to normal range. When all these readings are assessed, it can be stated that the patient is diagnosed with metabolic acidosis. In metabolic acidosis, a clinical disturbance is mainly defined by pH which is less than 7.35, and also a low level of HCO3. The anion gap helps to determine the cause of metabolic acidosis. An increased level of anion gap is due to diabetic ketoacidosis, uremia, and salicylate toxicity. All these gaps need to be taken care of, and the kidney should be taken care of as it helps to improve enough acid from the body (Vahedian-Azimi et al., 2021). The several symptoms which are observed are an increase in heartbeat, fatigue, and confusion. In addition to it, urine tests and blood tests help to relieve the symptoms which are present. There are three types of respiratory acidosis and these are MUDPILES, SLUMPED, and DR. In this, the main goal of nursing care is to maintain a healthy balance of the acid-base level. The treatment mainly revolves around correcting the raising and the underlying cause of the blood pH with intravenous and oral sodium bicarbonate (Nanjayya et al., 2020).

As the sodium bicarbonate level is affected, it is necessary to keep bicarbonate ampules handy. The vital signs of the patient should be monitored along with it, and they must be present within the normal range. The intake and the output should be monitored as it affects renal function. Provide seizure or coma precautions and bed in a low position, use of side rails, and frequent observation. This protects the patient from any injury and it results in decreased convulsion and mentation. The heart rate and rhythm should be monitored. Acidemia may be manifested by changes in ECG configuration and the presence of Brady dysrhythmias as well as increased ventricular irritability such as fibrillation (signs of hyperkalemia) (Smeets et al., 2022). Life-threatening cardiovascular collapse may also occur because of vasodilation and decreased cardiac contractility. Observe for altered respiratory excursion, rate, and depth. Deep, rapid respirations (Kussmaul's) may be noted as a compensatory mechanism to eliminate excess acid; however, as potassium shifts out of the cell in an attempt to correct acidosis, respirations may become depressed (Bijapur et al., 2019).

ARDS - Type 1 Respiratory Failure

A 60-year-old presented to the ED, and he is complaining of regular chest pain on the right side of the chest. Along with it, there was also a cough and the chest pain was pleuritic and has been present since the last month. The cough was seen as yellow sputum along with hemoptysis, the patient has lost a huge amount of weight over the last 6 months and has also experienced swears. The patient is a regular smoker and smokes about one pack of cigarettes daily, which has affected his health. The patient's past medical state states that he has experienced some chronic shakes in the upper extremities and he has not sought any medical attention for it. At the time of admission of the patient, the patient's condition was not good, however, the patient was provided with ventilation help and this helped the patient to improve their condition (Diamond et al., 2023). As seen the patient cannot breathe adequately hence, ventilation support needs to be provided. The main goal of mechanical ventilation is acute hypoxemic respiratory failure, and it is required to provide adequate support toward a gas exchange. In addition to it, it also does not provide any harm to the lungs. The process of ventilation is required as it will help to support breathing while the lungs are recovering. Invasive ventilation is the positive pressure that is delivered to the patient's lung with the help of an endotracheal tube or also the tracheostomy tub (Shebl et al., 2023).

The invasive method of ventilation will help to stabilize the patient with hypercapnic respiratory failure and hypoxemic respiratory failure. It also decreases the inspiratory work of breathing, along with it, it also redistributes the blood flow from the exercising respiratory muscle towards other tissue in the patient who is in shock. It also allows them to implement the lung-protective flow. The measurement of the arterial blood flow should be done and this will help to determine the step which needs to be taken. It will provide an idea of how much treatment is and what essential steps which need to be taken. The level of arterial blood gas level might be affected and providing this treatment will improve the condition to a great extent. The beneficial effects of this treatment are seen in the patient with respiratory acidosis, the knowledge of the arterial blood gas is an important application and it should be measured in the case of acute breathlessness (Summers et al., 2022). Synchronized intermittent mandatory ventilation (SIMV) is also a type of ventilation technique that needs to be followed at the time of respiratory failure. It is a type of volume control mode of ventilation, in this, the ventilator delivers a fixed set of several breaths with a fixed set of volume and at the same time, it allows spontaneous breaths. This mode of ventilation is typically used when the patients are unable to breathe adequately, this method will provide the required support to the patient. However, there is still one major concern and this is the increased work of breathing. One effective way to counteract this is to provide support to the SIVM.

 There are several contraindications of the SIVM and these should be taken care of effectively. Since this method enables the patient to partial mechanical assistance, the ventilator mode help to assist in the number of breaths and the patient's effort should be determined (Matthay et al., 2019). The maximum benefit of SIMV can only be determined when the patient can take a spontaneous breath. Just like any other mode of mechanical ventilation, SIMV only requires the respiratory therapist to regularly monitor the respiratory rate and the oversight of physicians. When the patient is prepared to begin the weaning process, the ventilator must be configured to the proper settings. Tidal volume, positive end-expiratory pressure (PEEP), respiratory rate, the percent of inspired oxygen (FiO2), and pressure support setting, if needed, are some of the parameters. It is recommended to have an arterial blood gas within 60 minutes of starting mechanical breathing and adjust the ventilator settings accordingly (Swenson & Swenson, 2019). Several complications have been observed due to this technique and these are atelectasis, acute respiratory syndrome (ARDS), ventilator-associated pneumonia (VAP), and barotrauma. All these complications need to be worked on and acted on. Another major complication was asynchrony, which is a mismatch between the patient demand and the ventilator supply, certain measures need to be taken care of and these are volume or pressure, ventilation rate, and flow (Fernando et al., 2021).

Sepsis and its Management

A 50-year-old patient was admitted to the emergency department after an accident, there were several massive abdominal injuries hence she was immediately transferred to the emergency department. When the patient arrived at ED she was unconscious and hypotensive, she was receiving oxygen support via her mask. Her breathing rate was recorded as 29 breaths per minute. The person has also experienced sinus tachycardia and the heart rate recorded was 150, BP was 80/45 mmHg. The patient was transported via stretcher for computed tomography, there was huge blood loss and fluid management was done. After the surgery the patient was hemodynamically stable, however, three days after the surgery the patient's level of consciousness started to deteriorate. Her skin was warm to the touch and it appeared to be flushed. The major reason for this is sepsis, which is mainly caused due to bacteria, fungi, and viruses in the blood (Gyawali et al., 2019). Due to this, the blood pressure of the patient starts to drop. The body's severe response to an infection is sepsis. It's a medical emergency that could endanger life. When an infection you already have sets off a series of events throughout your body, it results in sepsis. Sepsis-causing infections typically begin in the gastrointestinal system, urinary tract, skin, or lungs. Some of the common symptoms which are observed in sepsis are fever, low blood pressure, mental confusion, and fast heart rate.

Several treatments are present and these are the administration of intravenous fluid and the administration of antibiotics. Several factors put the patient at high risk, some are: if the patient is aged 65 years or above, people who have weak immune systems, people with any chronic medical condition such as kidney disease, lung disease, or cancer. In addition to it people with any recent hospitalization or illness. Several management techniques for sepsis need to be adopted; these are mentioned and described below (Mahapatra & Heffner, 2023). The first step which is adopted is to put the patient on a wide range of antibiotics, these antibiotics are highly important and help to treat any bacterial infection. There are several germ-causing bacteria and the consumption of antibiotics will help to treat them. In sepsis, it has also been observed that the patient becomes dehydrated hence, the level of liquid decreases. Due to this use of intravenous fluid starts so the level of blood can be maintained. A urine catheter should be placed for the patient however, it is not essential. Other than this vasopressor is also important, it narrows the blood pressure and increases the blood pressure.

 This medication can be used if the blood pressure is too low so blood pressure can be maintained (Gauer et al., 2020). Other than this several supportive cares is provided, this supportive care is necessary as it includes oxygen. Some people might not be able to breathe and require a machine for the breathing process. If the kidney of the person does not work well due to infection the person might require dialysis. Another very important technique that can be adopted is surgery. Surgery is highly important as it helps to remove any source of infection which is present in the body such as pus, or any infected or dead tissue.

Resuscitation is a highly critical step that needs to be adopted, in which adequate oxygen levels should be maintained. Although there is no standard present, some basic steps need to be followed as this will ensure quality control. The blood glucose level is also affected in sepsis, hence, it should be controlled and worked on (Polat et al., 2017).

Out-of-hours Hospital Cardiac Arrest Temperature Management Treatment Plan

A patient aged 55 years old arrived at a 10-bed rural ED and needed emergency medical services (EMS). The patient fell hard on the ground at home and she was unresponsive cardiopulmonary resuscitation (CPR) was performed immediately. The emergency medical services arrived at the scene almost immediately and continued with CPR, along with it an automated external defibrillator (AED) was also provided to the patient. After a cycle of CPR, AED was delivered along with a defibrillator shock and this has helped in spontaneous circulation. When the patient arrived at the ED, the vital signs of the patient were as follows: BP was 135/70 mmHg, the heart rate recorded was 50 beats per minute, and the temp was 36.9 ℃. Along with it, the oxygen saturation level was 92%, while the Glasgow Coma scale score was 3. It has been observed that the pupillary response was absent in the patient.

In this case, it has been mentioned the importance of out-of-hospital care, the recent evidence which is present states that the target temperature should range between 32 to 36 ℃. This temperature should be maintained for at least 24 h in the adult patient. This is a highly important step and it needs to be followed regularly. Once cardiac arrest happens the heart stops beating. Once the heart stops beating, the healthcare provider then uses a cooling device to lower the body temperature for a short period. TTM is highly recommended in cardiac arrest because it has been known to improve the survival rate and along with it neurologic functional outcome after cardiac arrest is also managed (Coppler et al., 2017). The first line of emergency treatment for cardiac arrest is immediate CPR, this helps to reset the heart rhythm and is also known as defibrillation. Multiple methods of cooling have been described and these are the use of an ice bag, infusion of cold saline, use of the cooling blanket, and other than this intranasal cooling devices or intravascular cooling devices. Out of all the options which are present cold saline is been proposed to be a favored option for the induction of TTM. The major reason for its presence is low cost, ease of patient transport, and universal availability (Tisherman et al., 2017).

When the patient is out of the hospital there is no special equipment present, since there is no specialized equipment present the people should know the basic techniques so immediate intervention can be provided and the patient's life can be saved. This technique is aimed to avoid any instance of hyperthermia on the brain, there is a part of the brain which is known as the hypothalamus which helps to adjust the body temperature to maintain an optimal environment to carry out body function. An adequate step needs to be followed, these steps are necessary as they will help in adequate function. It also helps to decrease neurological disability in the cardiac arrest patient (Aneman et al., 2022). Moderate therapeutic hypothermia is highly recommended and it helps in improving the neurological outcome. The adults might go to ICU if timely assistance is not provided. Neuromonitoring is mainly based on the minimum invasive technique in this brain oximetry and imaging test is being used. It is an essential technique that needs to be followed. The relationship between neurological damage and thermoregulation is highly complex. Hypothermia at the time of hypoxia-ischemia needs to be followed via the following different mechanisms. The major goal is to achieve the target temperature which is 32℃- 36℃. This temperature should be achieved as quickly as possible. In most cases, this can be achieved within 3-4 hours of initiating the process of cooling (Moler et al., 2019).

References

Aneman, A., Frost, S., Parr, M., & Skrifvars, M. B. (2022). Target temperature management following cardiac arrest: A systematic review and Bayesian meta-analysis. Critical Care (London, England), 26(1), 58. https://doi.org/10.1186/s13054-022-03935-z

Bijapur, M.B., Kudligi, N.A., & Asma, S. (2019). Central venous blood gas analysis: An alternative to arterial blood gas analysis for ph, pco₂, bicarbonate, sodium, potassium and chloride in the intensive care unit patients. Indian Journal of Critical Care Medicine : Peer-Reviewed, Official Publication of Indian Society of Critical Care Medicine, 23(6), 258–262. https://doi.org/10.5005/jp-journals-10071-23176

Chandran, J., D'Silva, C., Sriram, S., & Krishna, B. (2021). Clinical utility of arterial blood gas test in an intensive care unit: An observational study. Indian Journal of Critical Care Medicine: Peer-Reviewed, Official Publication of Indian Society of Critical Care Medicine, 25(2), 172–175. https://doi.org/10.5005/jp-journals-10071-23719

Coppler, P.J., Dezfulian, C., Elmer, J., & Rittenberger, J.C. (2017). Temperature management for out-of-hospital cardiac arrest. JAAPA: Official Journal of the American Academy of Physician Assistants, 30(12), 30–36. https://doi.org/10.1097/01.JAA.0000526776.92477.c6

Diamond, M., Peniston, H.L., & Sanghavi, D. (2023). Acute respiratory distress syndrome. StatPearls. Available from: https://www.ncbi.nlm.nih.gov/books/NBK436002/

Fernando, S.M., Ferreyro, B.L., Urner, M., Munshi, L., & Fan, E. (2021). Diagnosis and management of acute respiratory distress syndrome. CMAJ: Canadian Medical Association journal = journal de l'Association medicale canadienne, 193(21), E761–E768. https://doi.org/10.1503/cmaj.202661

Gauer, R., Forbes, D., & Boyer, N. (2020). Sepsis: Diagnosis and management. American Family Physician, 101(7), 409–418.

Gyawali, B., Ramakrishna, K., & Dhamoon, A.S. (2019). Sepsis: The evolution in definition, pathophysiology, and management. SAGE Open Medicine, 7, 2050312119835043. https://doi.org/10.1177/2050312119835043

Mahapatra, S., & Heffner, A.C. (2023). Septic shock. StatPearls. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430939/

Matthay, M.A., Zemans, R.L., Zimmerman, G.A., Arabi, Y.M., Beitler, J.R., Mercat, A., Herridge, M., Randolph, A.G., & Calfee, C.S. (2019). Acute respiratory distress syndrome. Nature Reviews. Disease Primers, 5(1), 18. https://doi.org/10.1038/s41572-019-0069-0

Moler, F.W., Silverstein, F.S., Nadkarni, V.M., Meert, K.L., Shah, S.H., Slomine, B., Christensen, J., Holubkov, R., Page, K., Dean, J.M., & THAPCA trial investigators (2019). Pediatric out-of-hospital cardiac arrest: Time to goal target temperature and outcomes. Resuscitation, 135, 88–97. https://doi.org/10.1016/j.resuscitation.2018.12.012

Nanjayya, V.B., McCracken, P., Vallance, S., Board, J., Kelly, P.J., Schneider, H.G., Pilcher, D., & Garner, D.J. (2020). Arterio-VENouS Intra Subject agreement for blood gases within intensive care: The AVENSIS study. Journal of the Intensive Care Society, 21(1), 64–71. https://doi.org/10.1177/1751143719840259

Polat, G., Ugan, R.A., Cadirci, E., & Halici, Z. (2017). Sepsis and septic shock: Current treatment strategies and new approaches. The Eurasian Journal of Medicine, 49(1), 53–58. https://doi.org/10.5152/eurasianjmed.2017.17062

Shebl, E., Mirabile, V.S., & Sankari, A. (2023). Respiratory failure. StatPearls. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526127/

Smeets, T. J.L., van de Velde, D., Koch, B. C.P., Endeman, H., & Hunfeld, N. G.M. (2022). Using residual blood from the arterial blood gas test to perform therapeutic drug monitoring of vancomycin: An example of good clinical practice moving towards a sustainable intensive care unit. Critical Care Research and Practice, 2022, 9107591. https://doi.org/10.1155/2022/9107591

Summers, C., Todd, R.S., Vercruysse, G.A., & Moore, F.A. (2022). Acute respiratory failure. Perioperative Medicine, 576–586. https://doi.org/10.1016/B978-0-323-56724-4.00039-3

Swenson, K.E., & Swenson, E.R. (2021). Pathophysiology of acute respiratory distress syndrome and COVID-19 lung injury. Critical Care Clinics, 37(4), 749–776. https://doi.org/10.1016/j.ccc.2021.05.003

Tisherman S.A. (2017). Targeted temperature management after cardiac arrest: When, how deep, how long?. Journal of Thoracic Disease, 9(12), 4840–4843. https://doi.org/10.21037/jtd.2017.11.20

Vahedian-Azimi, A., Rahimi-Bashar, F., Pourhoseingholi, M. A., Salesi, M., Shamsizadeh, M., Jamialahmadi, T., Gohari-Moghadam, K., & Sahebkar, A. (2021). Effect of the specific training course for competency in doing arterial blood gas sampling in the intensive care unit: Developing a standardized learning curve according to the procedure's time and socioprofessional predictors. BioMed Research International, 2021, 2989213. https://doi.org/10.1155/2021/2989213

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