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

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by kcvo kcvo Member

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guest042302019

guest042302019, BSN, RN

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

Agreed. I love going back and forth sharing these ideas. It really helps the thinking process so when the time comes and one has a patient that's not a piece of paper, a nurse will be able to understand whats going on and what to do. I bet years of experience goes into that quick, intuitive response as well.

Thanks for chit-chatting Mattnurse. And, thanks for the interesting situation OP. Hopefully, we haven't confused you too much.

I wish I could find a solid resource on O2 admin and a COPD patient. I did find this. Use of Oxygen Therapy in COPD | Doctor | Patient UK

Doesn't seem too bad.

kcvo

kcvo

25 Posts

I really appreciate for everyone's help.I have done my own work.However,I can't just write my answers on the internet.Cuz,other students may have seen this and copy my answers.So,this has been a difficult issue for me.But,I will try my best to share my own thoughts on this.

Here we go.Airway obstruction and respiratory distress are the most life threatening issue now.Decrease oxygen levels and increase levels of carbon dioxide,therefore,it indicates type II respiratory failure and respiratory acidosis with partial compensation.Expiratory wheeze indicates bronchospasm.

I will immediately sit the pt in High Fowler’s position.Stop feeding and take out food and suction sputum from her mouth.Because SaO2 88% on NP at 2L/min,therefore, increase flow rate to 4L/min. I will give PRN bronchodilators and corticosteroids as charted as well as antibiotics.

Edited by kcvo

guest042302019

guest042302019, BSN, RN

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

Airway obstruction is the most life threatening issue now.

Decrease oxygen levels and increase levels of carbon dioxide,therefore,it indicates type II respiratory failure.

Because SaO2 88% on NP at 2L/min,therefore, increase flow rate to 4L/min.

I guess I'm a bit conservative with the O2. There are people that would increase it. I think there are nursing interventions and other medical treatments that can be do before increasing O2. 88% isn't too bad with COPD patient. Why jump to 4? Why not 2.5 if you're dead set on raising O2. Titrate slowly. But, with MD approval.

I'd like to hear other opinions on this issue. Maybe GrnTea? Are you out there? :)

MattNurse

MattNurse, MSN, RN

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

Look at all your vitals too. You have a patient who has a heart rate 130's to 140's with pre-existing ischemic issues. The heart perfuses during diastole (relaxation). What do you think of when you look at a patient with low oxygen saturations, heart working over time, not relaxing much, and history of ischemia?

kcvo; Are you in North America w/ NANDA?

I would like to hear what other nurses do in regards to COPD and oxygen titration too.

kcvo

kcvo

25 Posts

hi,matt.i'm in nsw,australia. in our school,we only use nanda when we are asked to do a care plan. we will look at the nursing issues,goals,interventions and rationales.for this case study,we are asked to write a primary survey using the abcdefg algorithm then answer the questions.

MattNurse

MattNurse, MSN, RN

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

Do you find answers from American nurses helpful? I am sure the laws and standards of care are similar but different.

nerdtonurse?

nerdtonurse?, BSN, RN

Specializes in ICU, Telemetry. 3 Articles; 2,043 Posts

What I always did in school (and still do) is ask myself: What is going to kill my patient first?

There are COPDers who we're tickled pink to get them up to 88%. A crappy ABG is their norm.

The patient's been in the hospital a week, probably not terribly active, sudden onset respiratory distress. I'd evaluate for a PE.

Dixielee

Dixielee, BSN, RN

Specializes in ER. Has 38 years experience. 1,222 Posts

The O2 sat is not going to matter soon because your patient will stop breathing. With a resp rate of 45, heart rate of 144 (increased myocardial demand for O2 on patient with heart disease) and PaCo2 of 70 and HCO3 of 36, you can bet those respirations are very shallow. She is unable to speak in full sentences, she is not able to exchange what O2 she has because of her COPD and pneumonia. Forget the O2 sat and other labs. If you don't get her on Bipap now, she will completely crash and need intubation. That Co2 will not be compatible with life soon, regardless of how long she has been a retainer.

Edited by Dixielee

Cessna172

Cessna172

Specializes in ICU & LTAC as RN. FNP. Has 12 years experience. 135 Posts

There's some good replies, very interesting. My thoughts are, if you think her O2 sat is ok, then why is it ok? Here's my take on it, let me know your thoughts. If she was breathing room air or the 2L/nc, and if her resp rate was 20/min, then that 88% is super. But she's in acute resp failure' on top of her chronic condition and not moving much air. So she's working very hard to maintain that 88%. Her vitals are crazy and her CO2 is very high. The only real reason she's not more acidotic is because her kidneys are working overtime, see her bicarb. She's hypoxic and needs more oxygen, so put her on high flow O2 temporarily. Then do all that other stuff, nebs, etc. How much of that 2L O2 was actually reaching her few sparse alveoli if she is all bronchoconstricted? I don't know, maybe a little. I would not worry about shutting down her inspiratory drive, it will shut down by itself without oxygen and her fatigue won't help matters. Also, think about what happens with tissue hypoxia. Thanks.

Cessna172

Cessna172

Specializes in ICU & LTAC as RN. FNP. Has 12 years experience. 135 Posts

Almost looks like I copied you Dixielee, but my screen was open before your post showed up. Lol. Anyway, I agree, with you. Very well explained.

Bobby

Dixielee

Dixielee, BSN, RN

Specializes in ER. Has 38 years experience. 1,222 Posts

Almost looks like I copied you Dixielee, but my screen was open before your post showed up. Lol. Anyway, I agree, with you. Very well explained.

Bobby

Brilliant minds think alike :) I explained what would happened, you explained why.

nurseprnRN

nurseprnRN, BSN, RN

2 Articles; 5,114 Posts

i have "liked" the comments i find closest to being most appropriate. one cavil is that some folks seem to think that compensation will bring you into the normal range, e.g., if bicarb increases enough the ph will no longer be acidotic in chronic co2 retainers, or if co2 is blown off enough in metabolic acidosis, ph will no longer be acidotic. this is not accurate. compensation will almost reach the normal range, but not quite make it.

if she has a high bicarb, it's because she is a chronic co2 retainer-- it's not an acute compensation mechanism, so is not related to the present acute situation.

only one person has paid attention to the bronchospasm.why did she get acutely bronchospastic? something in her meal? new medication since she's been hospitalized, e.g., antibiotic for her pneumonia? this is the prime threat to life now.

it is perfectly acceptable to give a copd patient oxygen in an emergency situation. if her spo2 is normally around 92%, 88% is a big drop for her. you can cautiously titrate more oyxgen to her normal spo2, and keep watching her for signs of lost respiratory drive (vs., in this case, totally running out of gas).

prepare for intubation and icu transfer -- may not happen, but it sure could, and being prepared is always a good idea.