1
Unit 3: Case studies in SVN Therapy: KEY
roster #
date:
Name:
2007
Case study #1
1.
Your patient is a 65 YO LAF who has a history of emphysema. She gets .5 mL of
Albuterol in 2.5 cc of normal saline Q 6 hours as maintenance for her disorder.
a.
What type[s] of breath sounds do you expect to hear if you were to listen
her chest before the treatment?
With her emphysema we can expect, expiratory wheezes, distant breath sounds as a
baseline.
b.
If the doctor was to change the order to Proventil 2.5 mg in normal
saline, what has changed? [The drug? The dose?]
Nothing has changed: same drug, same dose
c.
If the doctor was to change the order to Metaproternol .3 ml in 3 cc
normal saline, what has changed? [The drug? The dose?]
This is a different drug.
d.
If the doctor was to change the order to terbultaline sulfate .5 mL in 3-ml
normal saline, what has changed? [The drug? The dose?]
This is a different drug.
e.
What do all these drugs have in common?
f.
Are all these drugs indicated for her disorder?
All of these drugs are short acting Beta II bronchodilators
Yes, all are indicated for bronchospasm associated with her empysema
g.
h.
If not, which aren't indicated?
n/a
If she were to complain of increased thickness of her secretions would
the addition of ipratropium bromide be advantageous [better] for her?
A side-effect of ipratropium bromide [Atrovent] is potential thickening of
secretions, so this would not be advantageous for her
i.
j.
If not, what drug would you suggest?
We could add some acetylcystiene to the treatment to loosen secretions
How would you monitor this patient's response to the drugs in question
a-d?
Assess BBS and s/s of increased WOB for successful bronchodilation
We would assess the patient’s HR for possible cardiac side effects
Assess the sputum production for success of SVN
k.
How would you monitor this patient's response to the drug in question h
and I?
We would examine the sputum for consistency, we could ask the patient how her
cough has changed, is it easier to bring up sputum. We could listen to her BBS for
looser-sounding rhonchi
2.
Case study # 2
Your patient is a 15 YO BF who presents in the ER with wheezes, rhonchi and
crackles to all lobes. Her Sp02 is 89% on room air. She has a respiratory rate of 28
bpm and a heart rate of 100 bpm.
2
a.
b.
c.
What would you recommend for her?
I would start her on 1-2 lpm nasal cannula to get her Sp02 up to 90-92%
What else would you recommend?
I would start her on inhaled Beta II bronchodilator to treat the wheezing
How would you monitor her?
Assess BBS and s/s of increased WOB for successful bronchodilation
We would assess the patient’s HR for possible cardiac side effects
Assess the sputum production for success of SVN
The doctor orders .25 mL of Alupent in 3 cc normal saline. After she has been
getting this medication for 5 minutes her heart rate is at 88 bpm. Her Sp02 has
risen to 91%
d.
What do you think has happened that made the heart rate decrease?
e.
She was most likely tachycardiac due to increased WOB associated with increased
RAW from bronchospasm
Why has the Sp02 risen? Are you surprised?
Her Sp02 has increased because she is getting her pneumatic SVN with 02 and the
6-8 LPM is increasing her Sp02.
She is also having less WOB
f.
g.
What do you suggest doing at this point?
Continue the treatment
How would you monitor her at this point?
Re-assess HR, RR and BBS after the treatment is over. It would be useless
to check her Sp02 immediately after the treatment so we need to wait
about 15-20 minutes till she returns to baseline.
Four hours later, the doctor orders you to add .5 mg of Atrovent to the Alupent she
is getting.
h.
Is this combination safe?
This is a very safe combination of beta II and cholinergic blocker with excellent
bronchodilator effects and minimal cardiotoxic effects
i.
Is this combination effective for her disease?
If she has asthma, the combination is worth a try
If she has bronchitis, this might be helpful
The patient gets both medications and her heart rate stays stable and her Sp02
rises to 93%. Her breath sounds now show decreased wheezing and the rhonchi
are looser. The patient complains of a dry mouth.
j.
Why is she complaining of a dry mouth?
The Atrovent is causing the dry mouth
k.
What other side effects might she get with this combination of drugs?
l.
What type of drug might you suggest to treat the inflammatory portion of
her disorder?
HR increases could always happen, as could nausea and vomiting.
She could get blurred vision from the Atrovent.
If she has asthma, giving her steroids by inhalation would be helpful
Case study #3
3
3.
Patient is a quadriplegic 34 YO WM with a history of recurrent pneumonia. He
presents in the ER with rapid shallow breathing. On auscultation, you hear
scattered rhonchi, rales and wheezes with decreased breath sounds in the basal
lobes. The doctor orders .75 mL of racemic epinephrine.
a.
Do you agree?
No, I don’t agree
b.
What is this drug best used for?
Treating upper airway occlusion associated with croup or recent removal of artificial
airways
c.
What are the side effects of this drug?
HR increase, BP increase, paleness of the face where the medicine touches it, nausea
& vomiting and rapid tolerance
d.
What do you suggest for this patient instead?
1. He needs a Beta II drug like albuterol 2.5mg
2. He needs a mucolytic
e.
Why?
1. for bronchospasm
2. to loosen secretions
f.
How would you monitor this patient?
assess HR, RR, Sp02, and BBS before the treatment is starts;
reassess these parameters in the middle and at the end of the treatment
remember that the Sp02 will rise from the 6-8 LPM of the pneumatic SVN,
so will be higher than in might in 15-20 minutes.
The doctor changes the order and when you give the treatment with the new drug,
you see that the Sp02 rises from 88% to 95%. He gets sleepy and hard to arouse.
g.
What has happened?
There is a chance that this patient has long-standing hypoxemia and chronic
hypercapnea [high C02] he has suffered 02 induced hypoventilation
h.
What would you do at this point?
Stop the treatment, stay with the patient till he wakes up,
Resume giving his these drugs with compressed air instead of 02
After correcting this situation, you continue the treatment and after 3 minutes of
the treatment you see that the HR has risen from 98 bpm to 106 bpm .
i.
What has happened?
j.
He is having a reaction to the Beta II drug,
What do you do at this point? Monitor HR closely and if it rises to over 118 stop
the treatment and suggest that we change the patient to levalbuterol like Xopenex.
Case study #4
Patient is a 2 year-old black infant with suspected RSV pneumonia. He got
symptomatic the night before and in the ER, he is tachypnic and his Sp02 is 88%
on room air.
a.
How would you monitor him at this point?
Listen to his bilateral breath sounds: is there stridor or wheezing
Observe him for s/s of increased WOB [intercostal retractions? Nasal flaring?]
4
b.
c.
Is his skin pink? Is he sweaty?
Listen to the sound of his cough- are secretions sounding loose?
What do you suggest for treating the infection?
Starting him on 6 grams of Ribavirin in 300 ml of sterile water will treat
RSV pneumonia if he’s been sick for a day or so
What type of nebulizer would you use to deliver this drug?
SPAG
Before you start this medication, you listen to the baby’s chest and you hear
diffuse scattered inspiratory and expiratory wheezes to all lobes.
d.
At this point you recommend what steps?
Recommend inhaled beta II bronchodilators for the wheezing
e.
How would you monitor the patient’s response to this new drug?
HR, RR, observe for s/s of increased WOB [retractions? Flaring?] and BBS
The baby is started on both drugs and at midnight of the second night he is in the
hospital, you note that the infant has loud inspiratory stridor.
f.
What has happened now?
He has croup now along with the other respiratory infection
g.
What drug do you suggest to treat this disorder?
Racemic epinephrine .05 mg/kg IBW
He needs to be put into a mist tent
Case study #5
Your patient has a history of AIDS and he is suffering from PCP pneumonia. His
breath sounds show diffuse inspiratory and expiratory crackles with some
wheezes.
a.
How would you monitor him?
HR, RR, observe for s/s of increased WOB [retractions? Flaring?] and BBS
b.
What do you suggest for treating his PCP pneumonia?
Inhaled Pentamidine
c.
What are the hazards of this drug?
Wheezing and fatigue are most likely
d.
What steps would you take to minimize these hazards?
e.
Explain how the delivery of Pentamidine differs from the delivery of
Albuterol or Atrovent:
a. Length of Tx?
Get an order for PRN short acting Beta II bronchodilator
More than 20 minutes to get every drop of the drug
b. Patient breathing pattern?
Normally we ask the patient to breath normally and take a deep breath every
few breaths, but with this drug we need to get the patient to take as deep a
breath in each time, hold it and then exhale completely and take another maximal
inspiration
c. Area of the lung where Pentamidine belongs if it is to do its job?
It needs to be in the alveolar in the periphery of the lungs
5
d. Precautions the RCP takes protect herself while delivering this drug
Wear a face mask to avoid breathing this drug