Yvonne Ybarra 04/04/2020 Spring 2020 RSPT 1161 In order to properly dissect the clinical problem of post-operative hypoxemia, we need to understand what hypoxemia is in general. Hypoxemia occurs when the partial pressure of oxygen (O2) in the arterial blood (PaO2) is decreased to less than 60 mm Hg or 95%. In latent terms, there is not enough oxygen in the blood. There can be many causes to hypoxemia such as V/Q imbalances (COPD patients), anatomic/physiologic shunting (congenital heart disease/atelectasis), Hb deficiency (loss of blood), and even aging. I will be dissecting all the risk factors that are associated with the patient’s clinical problem of post-operative acute hypoxemia and apply the S.O.A.P methodology. Beginning to assess the patient, the patients BMI (body mass index) is 30, defining this patient as obese. Obesity is a risk factor for cardiovascular disease, diabetes, and hypertension. Adding to the obesity, the patient has had 25 pack years of smoking increasing her likelihood of COPD and future oxygen therapy for management of hypoxemia. The patient was a high risk for respiratory complications when having the surgery to begin with just based on the patient’s history of cigarette smoking. The patient had surgery to remove a large ovarian tumor which are usually removed because the tumor can cause pain, be a risk of infection, and be cancerous as well. To remove this ovarian tumor, a laparoscopy is done. An incision is done in the umbilicus and lower abdomen. This patient had an uneventful surgery. Looking at the complete blood count and noting that the patient’s hemoglobin was below normal values, we can see that the patient has had loss of blood due to the surgery. Oxygen binds to hemoglobin and is transported throughout the body in erythrocytes. The patients SpO2 is a good indicator if sufficient oxygen is being transported throughout the body. Initially, the patient had an SpO2 of 97% via NC at 2 L/min, SpO2 at 94% RA, and then it decreased to 92% RA by the evening the second postoperative day. There was a decline in the amount of oxygen being transported throughout the body after the removal of oxygen accompanied by the loss of blood. Upon assessing the patient, the second post-operative day, the patient’s vital signs such as the heart rate were above normal by 18 beats with normal ranges from 60-100 beats per minute making this patient tachycardic. The patient’s respiratory rate was at 26 breaths per minute (normal ranging from 12-16) making the patient tachypneic as well. The patients’ blood pressure was at 146/86 (normal 120/80 mm Hg or a range from 90/60-140/90 mm Hg) bringing the patient close to stage I hypertension that could be due to the patient’s obesity. The patient’s temperature was elevated, and the patient became diaphoretic because the hypothalamus was trying to regulate the temperature by initiating peripheral vasodilation. The body was also trying to compensate the fact that there was possible associated atelectasis by the elevation of the right hemidiaphragm. The elevation of the diaphragm was caused by the lower abdominal surgery the patient had. The closer the incision to the diaphragm, the greater the risk for postoperative atelectasis that lead to the post-operative acute hypoxemia. Signs and symptoms of atelectasis that the Yvonne Ybarra 04/04/2020 Spring 2020 RSPT 1161 patient encountered were crackles over the affected lung region which was the right lower lobe. As atelectasis progresses, the respiratory rate increases. The patient had pleuritic chest pain and developed a cough because of the collapsed alveoli. Based on the assessments and vital signs, the patient was short of breath, so the patient was breathing faster, and the heart was trying to pump faster to get more oxygen to the tissues. The PaO2 from the ABG showed that the oxygen wasn’t able to move from the lungs to the blood and the patient was hyperventilating blowing off the PaCO2. Overall, the patient had initially lost blood due to the surgery and due to many risk factors such as obesity, and history of cigarette smoking, the surgery was uneventful and the patient developed atelectasis causing even more difficulty with the transportation of oxygen throughout the body resulting in post-operative acute hypoxemia. Yvonne Ybarra 04/04/2020 Spring 2020 RSPT 1161 S (subjective): Patient has 25 pack years smoking history. Patient has had an inactive lifestyle, employed as a data processor. Claimed to have stopped smoking 2 weeks before surgery. Patient able to ambulate to bathroom unassisted second post-operative day. Patient complained of pleuritic chest pain on the right side and shortness of breath. O (objective): Obese appearance (BMI 30). SpO2 97% post-operation via NC 2 L/min (FIO2 of .28). VC 3.5 L (pre-op) 1.19 L (post-op) WBC 89000/ mm3 (within normal range), Hb 10.9 g/dL (below normal), Platelets 252,000 (within normal range). Post-operative second day VC increased to 1.92 L, SpO2 94% RA. Evening of post-operative second day, cough developed, SOB, and patient was diaphoretic. ECG demonstrated sinus tachycardia. Vital Signs: HR 118, RR 26, BP 146/86, and temperature 99.3 F. Crackles heard at right lung base upon auscultation. ABG (RA) after assessment and complaint: pH 7.48, PaCO2 34 mm Hg, PaO2 59 mm Hg, SpO2 92% RA. No tenderness, warmth, or redness on calves (depicting a normal circulation). After O2 administration (4 L/min NC) SpO2 increased to 95%. A (assessment): Elevation of right hemidiaphragm w/possible atelectasis and clear of infiltrates (CXR). Airway secretions (RLL) Respiratory Alkalosis (ABG) Tobacco addiction (Hx) VC increase (SMI) P (plan): Oxygen Therapy Protocol (4 L/min NC/ FIO2 of .36 with a bubble humidifier) Continued Lung expansion therapy (SMI) Offer smoking cessation and weight reduction programs. Continuation of PCA pump for pain and patient assessment. Yvonne Ybarra 04/04/2020 Spring 2020 RSPT 1161 Key Terms Post-Operative hypoxemia: after surgery, the partial pressure of oxygen (O2) in the arterial blood (PaO2) is decreased to less than 60 mm Hg could also be represented in oxygen fraction (PaO2/FIO2) less/equal to 200 torr. Pulmonary embolism (PE): blockage of a pulmonary artery by foreign matter (fat, air, tumor, or thrombus) arising from a deep vein. Atelectasis: collapse of distal lung parenchyma. Pleural effusion: abnormal collection of fluid in the pleural space. Pleuritic pain: pain (sharp, stabbing pain) located laterally or posteriorly and typically worsens when taking in a deep breath. Works Cited Johns Hopkins. Ovarian Masses. 2020. 6 April 2020. Konica Minolta Sensing, Inc. "orsupply." 2006. How to Read SpO2. 6 April 2020. Robert M. KacMarek, James K. Stoller, Albery J, Heuer. Egan's Fundamentals of Respiratory Care. ST. Louis: Elseviar, 2017.
