Identify bundled prevention care strategies that should have been initiated upon admission to prevent this specific healthcare-associated pulmonary complication.

Questions:

1. Identify the likely acute pulmonary complication the patient is experiencing.

2. Explain the underlying pathophysiology (aka. cellular/tissue changes) and relate it to abnormal examination and diagnostic findings.

3. Identify bundled prevention care strategies that should have been initiated upon admission to prevent this specific healthcare-associated pulmonary complication.

4. Explain additional diagnostic testing, medical treatment, and nursing care to treat the patient and/or prevent future complications.

Scenario:

A 47-year-old male was struck by a car while crossing the street. Upon admission to the emergency department, he was alert and oriented. His injuries included pelvic fractures and open fractures of the left extremities with significant blood loss.

He required immediate orthopedic surgery and transfusion of blood products. The patient has history of hypertension and was taking Lisinopril/hydrochlorothiazide daily. He has no recent antibiotic use within the past year prior to hospitalization. The patient has been intubated and since his surgery 6 days ago.

This morning, the nurse notes he has had new onset of large amounts of purulent yellow/green pulmonary secretions.

Vital signs

• Temperature = 102.3° Fahrenheit

• Blood pressure = 110/72 mm Hg

• Heart rate = sinus tachycardia, 118 beats/min

• Respirations = 24 breaths/minute (ventilator rate set at 10 breaths/min, spontaneous rate of 14 breaths/minute)

• Oxygen saturation = 90% on mechanical ventilation with 35% fraction of inspired oxygen (Fi02)

Physical exam

• Alert and follows commands as able

• Increased bilateral rhonchi with diminished bases

• Abdomen soft, non-tender, non-distended with positive bowel sounds

• Indwelling Foley catheter with adequate amounts of clear, pale, yellow urine

• All incisions clean, dry, and well approximated without redness or drainage

Diagnostic results

• Complete blood count with white blood cell (WBC) differential = total WBC count increased, percentage of neutrophils increased, other results within normal ranges

• Chemistry = all results within normal ranges

• Chest x-ray = new onset bilateral infiltrates

• Sputum culture = positive for methicillin-resistant Staphylococcus aureus (MRSA)

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