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.