The nurse cares for a 78-year-old female admitted to the med…
The nurse cares for a 78-year-old female admitted to the medical intensive care unit in respiratory distress. Nurses’ Notes 0900. Client was admitted to the ICU in respiratory distress after minimal response to high flow oxygen for a pulse oximeter reading of 83% in room air. Crackles heard bilaterally in lower lobes with diminished breath sounds in right middle lobe; S1S2 auscultated; bowel sounds positive in all 4 quadrants; skin warm dry and intact. VS T 99.8F(37.7C); HR 110; RR 30 bpm; B/P 168/90; pulse oximeter is 87% on 100% non-rebreather; pain-0/10. 0930. Client was intubated with #6 endotracheal tube and was placed on assist control mechanical ventilation, rate 14, Peep 5 mmHg, FIO2 60%. VS T 99.8F(37.7C); HR 110; RR 14; B/P 180/90; pulse oximeter is 96%. Client is restless. Laboratory Report Lab Results Reference range ABG pH 7.2 7.35-7.45 ABG P02 65 mm Hg 75-100 mm Hg ABG PC02 51 mm Hg 35-45 mmHg ABG HC03 28 mEq/L 22-26 mEq/L WBC 5,600 cells/mm3 4.5 – 10.5 x 103 cells/mm3 Platelets 250,000/ mm3 140,000 to 450,000/ mm3 Potassium(serum) 4.0 mEq/L 3.5 to 5 mEq/L Sodium (serum) 140 mEq/L 135 to 145 mEq/L Magnesium 1.5 mEq/L 1.5 to 2.1 mEq/L Lactate level 4.5 mEq/L 0.5 to 2.2 mEq/L Blood culture Gram negative cocci Negative Urine culture pending Negative Sputum culture pending Negative The nurse plans care for the client after beginning mechanical ventilation. Which of the following would also be included in the patient’s care plan? Select all that apply