Can anyone give me some ideas on this case study? thx

Updated | Posted
by kcvo kcvo Member

You are a new graduate nurse on your second rotation in a 30-bed medical ward. It is 0800hrs during a morning shift, and you have been allocated the care of a 70-year-old female, who has been on your ward for the last week, recovering from an acute infective exacerbation of chronic obstructive pulmonary disease (copd).

Past medical history: ischaemic heart disease (ihd) and severe copd (with type ii respiratory failure).

When assisting the patient with breakfast you notice she has become increasingly breathless, only speaking in single words, and not interested in eating. A set of observations are taken:

SAO2 88% on np at 2l/min

bp 160/90, hr 144

resp rate 45 b/min, and

Temperature 37.2. auscultation of the lung fields reveals wide spread expiratory wheeze bilaterally.

lab results:

abg

uec's

fbc

ph 7.33

na 144mmol/l

hb 155 g/l

pa02 55 mmhg

k 4.5 mmol/l

wcc 11 x 109/l

pac02 70 mmhg

cl 109 mmol/l

plt 400 x 109/l

hc03 36 mmol/l

urea 8 mmol/l

creat 90 µmol/l

Questions

1. Using the information given in the (above) case study start by prioritizing and justifying your immediate care of this patient?

2. You also need to interpret both clinical and lab results, and

3. what physiological processes may be responsible for the abnormal clinical or lab results?

JustBeachyNurse, RN

Specializes in Complex pediatrics turned LTC/subacute geriatrics. Has 12 years experience. 1 Article; 13,952 Posts

Well, since this is your assignment what do YOU think? What do you have is far? Show us what you have so far and we can help guide you in the right direction. How is the ABG? Are the ABG results consistent with the blood chemistries? What, if anything are abnormal with the labs? What is expected based upon these admitting diagnosis? As far as prioritization of care, I'll give you a hint...what is most life threatening right now? Think A B C and Maslows.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 42 years experience. 4 Articles; 20,908 Posts

First....you need to know the pathophysiology of copd, type ii respiratory failure (hypercapnic resp failure, co2 retainer) and what influences do they have on the body. What is the treatment? What is the standard of care?

What do you think about this patient? Are they in distress? What would you do next? What is abnormal about the abgs? What concerns you? What meds is this patient on? What would be your choice of o2? Does this patient have a co2 drive to breathe? What happens if they get high concentrations of o2? The patient is wheezing....What do they have ordered? What causes wheezing?

We are happy to help but I need to know what you are thinking first and what your train of thought is so I can lead you in the right direction.

guest042302019

guest042302019, BSN, RN

Specializes in Progressive, Intermediate Care, and Stepdown. 8 Articles; 466 Posts

1. using the information given in the (above) case study start by prioritising and justifying your immediate care of this patient?

assessment information

70 y/o female

admitted since last week

infective copd

hx of ihd, severe copd, type ii respiratory failure

today: increased breathlessness, single words when talking, no appetitite

vs: 88% 2l/min o2, 160/90, 144, 45, 37.2

lung fields: expiratory wheezing bilaterally

lab results:

[table=class: cms_table]

[tr]

[td]abg

[/td]

[td]uec’s

[/td]

[td]fbc

[/td]

[/tr]

[tr]

[td]ph 7.33 [/td]

[td]na 144mmol/l

[/td]

[td]hb 155 g/l

[/td]

[/tr]

[tr]

[td]pa02 55 mmhg [/td]

[td]k 4.5 mmol/l

[/td]

[td]wcc 11 x 109/l

[/td]

[/tr]

[tr]

[td]pac02 70 mmhg [/td]

[td]cl 109 mmol/l

[/td]

[td]plt 400 x 109/l

[/td]

[/tr]

[tr]

[td]hc03 36 mmol/l [/td]

[td]urea 8 mmol/l

[/td]

[td][/td]

[/tr]

[tr]

[td][/td]

[td]creat 90 µmol/l

[/td]

[td][/td]

[/tr]

[/table]

as the above posters said, knowing the pathophysiology will be useful in this situation. i didn't know type ii respiratory failure but looked it up. once you do, the labs could make more sense. look up copd. look up type ii respiratory failure. know medical treatment for each and why it pertains to each condition. there are several nursing interventions for copd and respiratory failure patient. what apply to this situation? what can you do right now to promote comfort, safety, and/or improve the patient's condition?

is there anything in this situation that immediately concerns you? what about this situation can you address, using nursing interventions, right now? ill give an example. eating appears to take a lot of energy away from the patient. hold off the eating unless vs and respiratory distress s/s are more stable. some folks say abcs (airway, breathing, circulation) first. are any of these affected? for instance, in copd. the word obstructive could ring a bell. if we have to be mindful of giving more o2 to a copd patient, what are other medical treatments available? what medications does the patient have? the website below was useful.

use of oxygen therapy in copd | doctor | patient uk

2. you also need to interpret both clinical and lab results, and

abgs are consistent with this situation. once you have determined if each is low or high, determine if the cause is respiratory or metabolic. then, is there compensation. has the respiratory or renal system compensated is some way in response to the cause? there are definite abnormals in the other labs. if you aren't sure what each lab pertains to then pair the lab value either with the body system or the pathophysiology of a condition. for instance, creatinine and urea pertain to the kidneys. same process for all labs.

3. what physiological processes may be responsible for the abnormal clinical or lab results?

once you look the pathophysiology of the conditions above and look up the labs, this answer will fall into place. ask questions if you aren't sure about a lab value or its' connection with the conditions above.

overall, follow the nursing process. in this situation, you have plenty of assessment data. what are your nursing diagnoses? what is your plan? what are your interventions? what are you immediate goals? and, long term outcomes? what evaluations do you have once you have intervened?

nurseprnRN

nurseprnRN, BSN, RN

2 Articles; 5,114 Posts

oooh, we love this stuff.

just one thing: we don't do your homework for you so we won't be writing your prioritized care plan anytime soon. :D

however, we will point you in the right direction to do your own work. when you have, please let us know so we can see how much you learned, and maybe help you with some other points prn.

MattNurse

MattNurse, MSN, RN

Specializes in med-tele/ER. Has 39 years experience. 154 Posts

First stop feeding the patient and see if it improves the vitals. If not then:

ABC's.... I would crank up the oxygen, call a rapid response w/ those vitals. Get an EKG, get cardiac enzymes, put the head of the bed up. Call respiratory care. The patient is in compensated respiratory acidosis. The creatinine value you gave seems strange. But that case scenario you describes a very ill person that needs immediate attention, anyone with that tachycardic/tachypneic needs immediate intervention.

You don't list what kind of PRN meds you have available in your case study. The reason for calling respiratory is for a nebulizer treatment, you may want to give lasix if available too. Don't let people talk you out of giving oxygen to a COPD patient either.

Edited by MattNurse

guest042302019

guest042302019, BSN, RN

Specializes in Progressive, Intermediate Care, and Stepdown. 8 Articles; 466 Posts

ABC's.... I would crank up the oxygen, call a rapid response w/ those vitals. Get an EKG, get cardiac enzymes, put the head of the bed up. Call respiratory care. The patient is in compensated respiratory acidosis. The creatinine value you gave seems strange. But that case scenario you describes a very ill person that needs immediate attention, anyone with that tachycardic/tachypneic needs immediate intervention.

You don't list what kind of PRN meds you have available in your case study. The reason for calling respiratory is for a nebulizer treatment, you may want to give lasix if available too. Don't let people talk you out of giving oxygen to a COPD patient either.

Partially Compensated Respiratory Acidosis. pH is still 7.33 so patient hasn't compensated fully yet. Why rapid response?

The point of one posting homework here isn't to get a complete answer. By you giving them the answers, how does one learn?

COPD with increased 02 treatment equals death? I would be concerned about giving high flow O2. Turns of autonomic response to breathe with COPD pt with chronic hypercapnia levels.

MattNurse

MattNurse, MSN, RN

Specializes in med-tele/ER. Has 39 years experience. 154 Posts

It is respiratory acidosis w/ partial metabolic compensation.

[TABLE=class: cms_table_cms_table]

[TR]

[TD]ABG [/TD]

[TD][/TD]

[TD][/TD]

[/TR]

[TR]

[TD]pH 7.33 (partially compensated if 7.35-7.45 is normal)

[/TD]

[TD][/TD]

[TD][/TD]

[/TR]

[TR]

[TD]Pa02 55 mmHg

[/TD]

[TD][/TD]

[TD][/TD]

[/TR]

[TR]

[TD]PaC02 70 mmHg (elevated, so forms carbonic acids)

[/TD]

[TD][/TD]

[TD][/TD]

[/TR]

[TR]

[TD]HC03 36 mmol/L (elevated base, so compensation via the metabolic route)

[/TD]

[/TR]

[/TABLE]

Rapid response because patient has these vital signs:

SaO2 88% on NP at 2L/min

BP 160/90,

HR 144

Resp rate 45 b/min

I understand the CO2 effects and the whole issue with chemoreceptors, but you would die from hypoxia long before you die from hypocapnia. If you have a patient in acute respiratory distress give them oxygen, it would be more detrimental not to give them oxygen. Don't keep a patient on high flow O2 for a long period of time. But the case study presented here is a very sick person that needs lots of interventions. The first thing that is going to change in a patient who is doing poorly is their respiratory rate, someone with that rate needs more immediate help and getting extra help is important to teach students before the patient codes.

Hope this helps kcvo

guest042302019

guest042302019, BSN, RN

Specializes in Progressive, Intermediate Care, and Stepdown. 8 Articles; 466 Posts

Still not sure about the O2 administration and COPD situation. I'd love to have a reference about this issue. Google! Here I come! While every patient is a bit different, there must some general guidelines about this issue.

From what I understand, keeping a COPDer around 88% to 92% is optimal, anything above could be fatal.

I think there are other interventions aside from O2 administration that could helps since Pox is at 88% as it is. Some medications. Don't want to give it away for the OP. :p I'm no expert though.

MattNurse

MattNurse, MSN, RN

Specializes in med-tele/ER. Has 39 years experience. 154 Posts

I always get concerned when you are at the 88-89% o2 saturations. kcvo look at the oxyhemoglobin dissociation curve in all of your en-devours.

I totally agree with you Floridatrail2006 about how hard it is to manage a patient on oxygen w/ chronic hypercapnia and COPD. Carbon dioxide narcosis certainly can be fatal if managed incorrectly.

The reason I responded with call a rapid response because the case study said: "You are a new graduate nurse on your second rotation in a 30-bed medical ward." If you are presented with this patient at 8:00 am during breakfast of day shift on your second day of work, I would say call a rapid response.

I have been a nurse for longer period of time and might manage the patient differently then a new grad. I don't think I gave all the answers to the OP either. kcvo, you should spend time looking up everything we discussed here. Look for an article in the databases or in your med surg book related to carbon dioxide narcosis, try to see why there is differing opinions. Look up the drugs that you might want to give to this patient. Look up cardiac enzymes, EKG's, activity intolerance.

guest042302019

guest042302019, BSN, RN

Specializes in Progressive, Intermediate Care, and Stepdown. 8 Articles; 466 Posts

I love talking about this stuff. It really makes you think. It's important to bring up the oxygen-hemoglobin curve. Although, it may confuse OP even more.

Had to whip out my A&P book for this. Nice review. Says, "Carbon Dioxide levels are responsible for regulating respiratory activity under normal conditions. As you mentioned, COPDer with chronic hypercapnia, chemoreception reverses. p02 becomes the stimuli to breath. I guess I'm repeating what we've said already. Anyway. Beating a dead horse.

If it were me, I would be conservative with the O2 as patient is already on 2L/min. I mean, patient is at 88%. Not terrible for COPD patient. Elevate HOB, call respiratory for treatment (probably a prn albuterol). See how patient does after treatment.

Call doc to relay ABGs, and current condition. Give steroids (prednisone) if ordered or ask doc what he/she thinks. More frequent VS, physical assessments. Continuous Pox/hear monitor orders. I wonder if a prn BP med would be indicated. But, I imagine if one gets the pulse0x down and patient is relaxed, it may lower. I would still consider it. Maybe a hyrdralizine or equivalent. Whatever is prn. Just my thoughts.

MattNurse

MattNurse, MSN, RN

Specializes in med-tele/ER. Has 39 years experience. 154 Posts

I love talking about this stuff. It really makes you think. It's important to bring up the oxygen-hemoglobin curve. Although, it may confuse OP even more.

Had to whip out my A&P book for this. Nice review. Says, "Carbon Dioxide levels are responsible for regulating respiratory activity under normal conditions. As you mentioned, COPDer with chronic hypercapnia, chemoreception reverses. p02 becomes the stimuli to breath. I guess I'm repeating what we've said already. Anyway. Beating a dead horse.

If it were me, I would be conservative with the O2 as patient is already on 2L/min. I mean, patient is at 88%. Not terrible for COPD patient. Elevate HOB, call respiratory for treatment (probably a prn albuterol). See how patient does after treatment.

Call doc to relay ABGs, and current condition. Give steroids (prednisone) if ordered or ask doc what he/she thinks. More frequent VS, physical assessments. Continuous Pox/hear monitor orders. I wonder if a prn BP med would be indicated. But, I imagine if one gets the pulse0x down and patient is relaxed, it may lower. I would still consider it. Maybe a hyrdralizine or equivalent. Whatever is prn. Just my thoughts.

Ultimately the patient can be in respiratory distress for so many reasons. You might see the doc even prescribe morphine for anxiety too and possibly nitro paste & beta blocker combo for the HTN/tachycardia. I have had this patient so many times.

My guess is you would see orders from the doctor along these lines.

1/2" nitro paste

2mg IVP morphine will help w/ anxiety

Titrate O2 to >90%

metoprolol tartrate 50mg take down the BP & HR

albuterol 0.083% stat

lasix 20mg IVP stat

In most cases I see methylprednisolone IVP rather then prednisone, although I do believe I saw an article last year that said IVP and PO steroids have same efficacy.

More times then not you will get do all of these interventions and be able to titrate the oxygen back to baseline in an hour or 2.

I would elevate the head of the bed.

Use anxiety reduction methods to calm the patient.

Encourage purse lipped breathing.

Reduce activity.

Look at the patient

what is there capilary refill?

How is the color of their skin/mucus membranes?

OP ultimately you have so many nursing diagnoses in your case study. Anxiety, activity intolerance, ineffective gas exchange, infection, fluid overload possibly.

You know the patient has a weak heart, poor respiratory effort.