FA is a 69-year-old female who was admitted to the acute care hospital two days ago as a result of a massive CVA with possible brain stem infarct. Because she was also experiencing secondary ventilatory failure, she was intubated and placed on full ventilatory support via mechanical ventilator. She was placed in the neuro intensive care unit and stabilized.
Currently, she is on the ventilator at the following settings:
Mode: volume control-assist/control
Rate: 14 breaths per minute
Tidal volume: 450 mL
PEEP: +5 cmH2O
Her present vital signs are: respiratory rate 14 (ventilator rate), temperature 100.4 F. Her SpO2 is 95%. Her rating on the Glasgow Coma Scale is 5. In addition, the nurse and respiratory therapist both report that they have been suctioning her frequently for moderate amounts of thick dark yellow mucus.
Use the Blood Pressure and Auscultation Tabs to complete the physical assessment.
Blood Pressure: /