Nursing Interventions for a 69-year-old Client with Acute Respiratory Distress and Altered Mental St

Vital Signs

A 69-year-old client in the medical intensive care unit has been diagnosed with acute respiratory distress and altered mental status. The client’s medical history includes asthma, hypertension, and diabetes. She is intubated and receiving multiple vasopressor medications for hypotension. At 1200 hours: The client’s ventilator alarm sounds with the high-pressure alarm, and is found to be agitated, unresponsive to commands, demonstrating extreme facial grimaces localized to pain, and restless, with excessive movement of extremities noted.

Vital signs include:

Heart rate 125 beats/min (100 beats/min at 0800),

Respiratory rate 35 breaths per minute,

BP 150/99 mm Hg (120/75 mm Hg at 0800), and

SpO2 85% (down from 100% at 0800). At 1205 hours:

BP increases to 185/110 mm Hg, with a mean arterial pressure of 135 mm Hg.

 

The monitor displays sinus tachycardia at a rate of 140 beats/min. The client is prescribed medication infusions of norepinephrine (10 mcg/min), fentanyl (75 mcg/hr), and lorazepam (2 mg/hr).

Fill in the matrix below.

Then write up your rationales for each, in paper format, utilizing the case study. Based on the 1200- and 1205-hour assessments and nursing notes, use an X to identify “Indicated” (appropriate or necessary), “Contraindicated” (could be harmful), or “Nonessential” (makes no difference or not necessary) nursing interventions to manage the client’s current condition.

Intervention Indicated Contraindicated Non-essential Suction as needed Provide additional oxygen Increase norepinephrine drip to 15 mcg/min Increase fentanyl drip to 150 mcg/hr Increase lorazepam drip to 4 mg/hr Assess mental status