Unit 5 SVN
case studies
By Elizabeth Kelley Buzbee
AAS, RRT-NPS RCP
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Mrs. Mosby is a 45 year old who
presents in the ER with c/o [complaints
of ] SOB [shortness of breath]. She is
wearing a pulse oximeter on her finger
that says 99% How do you assess her?
answer
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Collect VS [vital signs] to assess her
dyspnea
Interview her to discover her history of
recent exposures or underlying lung
disease
Observe her for retractions, and other
signs of increased WOB
Listen to her breath sounds
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Her HR is 120 bpm and her respiratory rate is
31 bpm.
She is a waitress who came into the ER after
a kitchen fire. She has no history of lung
disease and does not smoke.
She has nasal flaring and mild supraclavicular
retractions and mild intercostal retractions.
She has inspiratory and expiratory wheezing
in all lobes
What do you suggest?
answer
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A bronchodilator to treat the wheezing
Remove the pulse ox, it is unhelpful at
this point
Assess her HbC0 with a co-oximeter
reading and get her started on
supplementary 02 at 100% NRB to
washout the CO.
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Her HbCO is 5% so the doctor orders a
NRM to washout to Carbon Monoxide
The doctor also orders Atrovent
[Iprotropium bromide ] You suggest?
answer
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Atrovent [iprotropium bromide] is a
Cholinergic blocker. You might be better
starting with the Beta II first because
that stimulates bronchodilator rather
than blocks bronchospasm.
You could keep the iprotropium bromide,
but add Albuterol
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The doctor orders .25mL of 5%
Alupent [ Metaproterenol ] in 3 ml of
normal saline.
You suggest?
answer
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Agree, this is the correct dose, and this
is a Beta II agonist
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What other inhaled drug might be
helpful with the inflammation one sees
with thermal damage and chemical
irritation
answer
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Inhaled or IV steroids might be helpful
in this case
Case study # 2
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Your patient is a 4 year old LAF who is
admitted to the ER with respiratory
distress. You suggest:
answer
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Assess her VS
Assess her 02 status by pulse oximeter
Assess her breath sounds
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Her VS shows a respiratory rate of 29
bpm [slightly respiratory rate for age]
Her HR is 135 again slightly high
Her Sp02 is 98%
On auscultation, you hear scattered
rhonchi to both lungs
What do you suggest?
answer
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Continue to monitor her for hypoxemia
but for now no 02 is indicated. She has
no s/s of respiratory distress now—but
something brought her to the hospital
Continue to assess
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The doctor orders an X-Ray that shows
areas of consolidation in the Right
Middle Lobe. He orders 2 cc of 10 %
Acetylcysteine. Why?
answer
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He wants to mobilize the secretions by
breaking up the chemical bonds of the
mucus
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You suggest what else might be
necessary for this patient?
When you administer this aerosol, you
will use what kind of device?
answer
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She needs a Beta II bronchodilator
with the mucolytic which irritates the
lungs
Both of these drugs can be given with a
pneumatic aerosol generator SVN
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When you add this drug to the SVN you
notice that is smells like rotten eggs
and that it seems to have an oily sheen.
What is going on?
answer
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Nothing, Acetylcysteine smells like
rotten eggs and it has a sheen
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When you administer this drug, the
child starts to breath faster and her
heart rate increases.
What do you do?
answer
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Listen to her breath sounds.
Assess her pulse ox for increased
hypoxemia
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Her breath sounds have scattered
inspiratory and expiratory wheezes
Her Sp02 has dropped from 95% to
89%
You suggest?
answer
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Stop the treatment and give her a Beta
II drug alone
Give the TX with 02 and the Sp02
should go back up.
Continue to monitor
Consider another mucolytic
Case study # 3
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Your patient is a 35 year old WM with a
history of AIDS. He is admitted to the
ER with increased respiratory distress
What do you suggest?
answer
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Get VS
Assess 02 status with Sp02
Listen to breath sounds
Get sputum culture to send to lab
because AIDS patients get infections
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His Sp02 is 89% on R.A
His respiratory rate is 31 bpm
He is retracting and flaring
You hear diffuse crackles
The doctor asks you to help collect the
sputum using whatever tools you have.
You suggest:
answer
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We could give him a combination of
Albuterol and Acetylcysteine to
mobilize secretions without stimulation
of bronchospasm
We could also give him hypotonic or
hypertonic saline to cause him to cough,
but we need to monitor him for
wheezing triggered by the hypertonic
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The doctor performs a bronchoscopy
and obtains sputum that is sent to the
lab.
The lab diagnosis is a PCP infection of
the lung.
You suggest?
answer
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Pentamidine to control the parasitic
infection
If the pentamidine causes
bronchospasm you would like some Beta
II drug ordered PRN
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What SVN do you select to deliver this
drug? And why?
answer
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The Respirgard II, because it has
bacteria filters in the exhalation line to
protect the RCP
It has baffles to reduce the particle
sizes to less than 1 micron to enter the
alveoli where it is needed
Case study # 4
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Your patient is a newborn who presents
with increased respiratory distress. He
is tachypnic and tachycardia.
You suggest:
answer
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Assess hypoxia with pulse oximeter
Assess breath sounds
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The Sp02 is 89% and the doctor orders
a heated hood at 30% for the baby
whose respiratory rate decreases. The
Sp02 rises to 93%
You listen to breath sounds and hear
diffuse wheezing and inspiratory stridor
You suggest:
answer
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Give Beta II bronchodilator for
wheezing
Give racemic epinephrine for stridor
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How do you administer the Beta II
bronchodilator?
answer
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Via the pneumatic SVN
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How do you administer the racemic
epinephrine?
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Via the pneumatic SVN
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The doctor orders a nasal wash on this
child because she suspects he has RSV
pneumonia.
What do you suggest?
answer
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Administer 6 grams of Ribavirin in 300
ml sterile water to run over 18 hours
for three days. If the nasal wash is
negative for RSV, we can just stop the
TX, but we have to start within 24
hours of symptoms, otherwise Ribavirin
is useless
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How do you administer this drug?
answer
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Via the SPAG unit into the baby’s
heated hood.
Case study # 5
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Your patient comes into the ER in great
respiratory distress. This 22 year old
has a long history of severe asthma.
You suggest?
answer
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Assess VS
Assess Sp02
Assess breath sounds
If she is wheezing, and if she can handle
it offer a PERF
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Her respiratory rate is 34 bpm, her
heart rate is 130 bpm
Her Sp02 is 88% on 2 lpm nasal cannula
started by the EMT
Her breath sounds show diminished
breath sounds in the Right middle lobe
and scattered expiratory and
inspiratory wheezes to all other lobes.
Her exhalation is prolonged
She refuses to even try the PERF
You suggest?
answer
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She needs more 02, increase her from 2
lpm to 5 or 6lpm
Start her on 2.5 mg Albuterol now
Disregard the PEFR, it will only confirm
what we already know—she is in
bronchospasm
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After the 2.5 mg of Albuterol, and
getting a steroid IV started, the
doctor orders another TX in 30 minutes.
It does no good.
He decides to start continuous
treatments. You set up what?
answer
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A “Heart” SVN with a deeper medication cup
will hold enough bronchodilator for a
continuous TX.
She needs an arterial blood gas [ABG] to
assess her C02 for her ventilatory status
Continue to monitor Sp02, VS and breath
sounds. Get serial ABGs because if her C02
rise in 15 minutes she needs to be intubated