Group 8: Brianna Hermann, Robert Rosgen, Alurea Bond, Soumida Vannasing, Carolyn Power, Julia
Larsen, Kylie Morrison, Laura Bacerra
1
Respiratory Case Study
Tuesday 1100: A 55-year-old client with a history of Chronic Obstructive Pulmonary Disease
(COPD) presents to the primary health care provider (PHCP) with complaints of a productive
cough for 3 days with fever, chills, and fatigue beginning in the last 24 hours.
His vital signs are:
BP 122/73 mmHg,
HR 102 BPM,
RR 26 bpm,
Temp 101.4°F (38.6°C),
SpO2 92% on room air,
Weight 105 kg (231.4 lb).
This clinic has capabilities for x-ray, rapid lab tests, and simple IV infusions. The client’s PHCP
hears coarse rhonchi in the client’s right lung and orders a chest x-ray, rapid flu test, and
COVID-19 PCR test. The x-ray shows right lower lobe infiltrates. The rapid flu test is negative,
the COVID-19 PCR test is sent out to the lab.
Based on assessment findings, which data are concerning factors? List each and explain
each.
Concerning Factor
Relevance
Productive cough x3 days with fever, chills,
and fatigue
Tachycardia is increased because the body is
trying to compensate by increasing the heart
rate to get more oxygen throughout the body.
Tachycardia
Temperature 101.4F
Low SpO2
Right lower lobe infiltrates
Coarse rhonchi
Temperature is increased & productive cough
with fever, chills, and fatigue is which could
indicate possible infection or a start of an
illness.
Lower lobe infiltrates and coarse rhonchi in
the lungs can be a sign of an infection present
in the lungs
Hx of COPD
High risk for illness (pneumonia), lower
oxygen saturations and higher tolerance for
CO2
Elevated respiratory rate
Increased WOB
Group 8: Brianna Hermann, Robert Rosgen, Alurea Bond, Soumida Vannasing, Carolyn Power, Julia
Larsen, Kylie Morrison, Laura Bacerra
2
Tuesday: 1200: The client is diagnosed with right lower lobe pneumonia and possible
COVID-19 and sent home on azithromycin, dexamethasone and an albuterol inhaler. The
client is instructed to isolate at home to prevent others from getting infected.
Thursday 0900: the client still has the cough with exporation of yellow sputum., fever, chills,
and fatigue and is now having body aches on and off and is short of breath intermittently. The
COVID results has come back positive.
What would you anticipate might happen next? What would the client need?
Anticipate the client being called to the primary care physician to be re-evaluated to
determine severity of intermittent shortness of breath. This could be achieved via telehealth as
well and the ordering of a mobile/portable x-ray of the chest to determine progression of
infiltrates within the lungs, this could be done to prevent spread of the virus. Also, instruct the
patient to maintain high fluid intake to provide adequate hydration and ability to expel mucus.
Instruct the client to take antipyretics for fever control and NSAIDs for pain PRN. Medication
reconciliation will also be anticipated. Use of expectorant and a humidifier to loosen secretions.
Friday 0830: the client’s spouse calls the PHCP because of “struggling to get out of bed, very
fatigued and feverish.” The client’s spouse reports a fever of 102.9°F (39.3°C). The PHCP
tells the spouse to take the client to the Emergency Department.
Friday 0845: In ED, rhonchi were heard throughout the lung fields, with wheezing noted
throughout.
Pale and lethargic.
Skin tenting on the sternum.
Nail beds are cyanotic.
BP 108/66 mmHg
HR 116 BPM
RR 30 bpm
Temp 101.8 °F (38.8°C)
SpO2 90% on room air
What are the priority needs for this client?
Priority Need
Oxygen
Fluids
Tylenol
Rationale
Increase oxygen and fluids d/t concern for
hypoxia, exertional dyspnea, ineffective
cough, possible ineffective airway clearance,
and decreased WOB
Group 8: Brianna Hermann, Robert Rosgen, Alurea Bond, Soumida Vannasing, Carolyn Power, Julia
Larsen, Kylie Morrison, Laura Bacerra
3
Antibiotics
Increase oxygen saturation
Suctioning
Correct signs of dehydration
Reduce fever and pain
Treat infection
Help clear airway
Friday 0900: The nurse assesses the client after an infusion of NS 1000ml and notes the BP is
90/60mm/hg and the SpO2 is 88% with crackles heard throughout all lung fields. The client is
on 4L NC (36% FiO2) as prescribed. The ED provider writes additional orders.
Orders:
Titrate O2 to maintain SpO2 >92%
CXR
Labs: ABG, CBC, CMP, blood cultures
Albuterol nebulizer 2.5mg x 3.
To meet the client’s needs the nurse must prioritize interventions and orders,
list in order of priority each intervention ordered above and the rationale.
Intervention/Order
1.
2.
3.
4.
Titrate oxygen
Albuterol nebulizer 2.5mg x3
Labs
CXR
Rationale
1. Quickest intervention and important to
ABC prioritization
2. Treatment for the patient’s difficulty
breathing and should be applied after
applying oxygen and open up their
airways
3. Obtain baseline labs, and obtain
cultures prior to starting broad
spectrum antibiotics
4. Should be done as a follow-up since
the patient is now presenting with
crackles in all lung fields
The nurse has titrated the supplemental O2, and the client is now on 100% non-rebreather
at 15 liters.
Group 8: Brianna Hermann, Robert Rosgen, Alurea Bond, Soumida Vannasing, Carolyn Power, Julia
Larsen, Kylie Morrison, Laura Bacerra
4
What actions should the nurse take next and why?
Actions
Reassess oxygen levels
Rationale
To see if intervention was effective or
worsening condition
Recruit help of RT (if not already present)
To manage treatment and administer albuterol
treatments/ invasive or emergent procedures if
needed
Assess ABGs, labs
To monitor perfusion and metabolic/
respiratory imbalances (acidosis, alkalosis)
Titrate oxygen levels down as tolerated
To prevent hyperoxygenation
Assess mental status
To detect for any signs of worsening
condition, intolerance of interventions
Position in high fowlers, encourage coughing
and deep breathing
Ease WOB and increase oxygenation
Notify HCP of worsening condition
Facilitate collaboration and new orders
Friday 0930:
The client’s SpO2 does not improve on the non rebreather and a decision is made to intubate
the client and initiate mechanical ventilation for worsening respiratory failure. The client is
placed on Assist Control (AC) mode of mechanical ventilation on the following settings:
A/C mode
VT 500 mL
FIO2 50%
RR 18
PEEP 5 cm
Initial ABG results are:
pH 7.30
pO2 65 mmHg
pCO2 58 mmHg
HCO3– 26 mEq/L
Based on the ABG results, what ventilator changes do you anticipate?
-
The ABG results reveal the patient is in respiratory acidosis, uncompensated.
Group 8: Brianna Hermann, Robert Rosgen, Alurea Bond, Soumida Vannasing, Carolyn Power, Julia
Larsen, Kylie Morrison, Laura Bacerra
5
-
We want to change the vent setting to assist the patient expel more CO2 to allow for the
pH to revert back to normal limits. Reassess q1h to determine if settings need to be
further adjusted.
-
These are the changes that we would anticipate to make:
- A/C mode
- VT 400mL : because of noncompliant lungs d/t COPD
- increase FIO2 100% : to assist the ventilation of the lungs
- RR 26 : to increase reduction in CO2
- PEEP 5. (improves oxygenation)
-
Mouth care q2h, moisturize lips and mouth, suction as needed.