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Respiratory Case Study Nurs. 3175

Impaired Oxygenation with a Secondary Infection Related concepts: Acid-base balance, infection, delegation, medication calculation and health promotion Medications to review: Albuterol, Formoterol, Cefuroxime & Methylprednisolone

Case Luann Yazzie is a 56-year-old who has lived her life around second-hand smokers. Her parents smoked in the home she grew up in, her first husband smoked before dying from complications of diabetes, and she works a card dealer in a Nevada casino which allows smoking. Although she has never smoked, Luanne learned a year ago that she had developed early symptoms of emphysema.

1. What symptoms does Luanne demonstrate that would indicate early signs of emphysema? Select all that apply. A. Increasing shortness of breath when climbing stairs. B. Production of dark yellow-green sputum. C. Wheezing with exhalation. D. Increased morning mucus production. E. Barrel chest. 2. Luanne comes to the clinic for increasing shortness of breath and worsening symptoms. The health care provider considers several pulmonary lab and diagnostic test. Match the diagnostic test on the left with the appropriate teaching on the right. g__ Arterial Blood Gas (ABGs) _d_ Oxygen Saturation _b_ Pulmonary Function Test (PFTS) _f_ Serum Hemoglobin Level (Hgb) _h_ Chest X-Ray _e_ Computerized Tomography (CT) _a_ Sputum Culture &

A. Be sure your sample is sputum from the lungs and not saliva. B. You will breathe forcefully into a machine to determine the volume of air in your lungs. C. A tube will pass into your lungs while you are asleep to visualize the structures and take samples of the tissue if needed. D. A clip will be placed on your finger to determine the oxygen level in

Sensitivity _c_ Bronchoscopy

your blood. E. You will lay still on your back and be placed in a large machine for scanning. F. A blood sample is taken from your wrist, and it can be painful. G. A blood test that helps your ability to carry oxygen in your blood. H. A test that can determine the shape of your expanded lungs.

3. Luanne’s provider prescribes a chest x-ray and pulmonary function test (PFT) which confirms that she is at a moderate (Stage 2) level of her illness with a forced expiratory volume in one second (FEV1) of 65% of normal. Luanne has many questions for the nurse about what this means. How should the nurse respond? A. The chest x-ray shows damage to the air sacs of your lungs. B. Your lungs are not functioning at full capacity any longer which explains why you are short of breath. C. Your disease has improved from when the symptoms started a year ago. D. This information needs to be explained by your provider.

Jan 25, 2020 1110

Triage Assessment  Temp. 97.2 F, HR 112, BP 122/75 (91), RR 16, O2 sat. 99% on room air.  Alert and oriented x 3  Lungs clear to auscultation throughout, no shortness of breath.  Bowel sounds active.  Denies pain or discomfort

4. The registered nurse reviews the assessment documentation by LPN/LVN and diagnostic findings. Which assessment inconsistencies require re-evaluation by the RN? Select all that apply. A. Temperature, heart rate and blood pressure. B. Respiratory rate and oxygen saturation. C. Orientation. D. Lung sounds.

E. Bowel sounds. F. Pain level. 5. For each assessment selected in question #4, determine why it would be important for the RN to re-evaluate. Respiratory rate/lung sounds and oxygen sat are important to reevaluate because if the patient has impaired breathing/gas exchange or hypoxia, they are at risk for respiratory exacerbations if not immediately treated, and if not treated, conditions can worsen and pt. can enter respiratory failure. If adventitious lung sounds are present, such as wheezing or stridor, there could be something blocking the airway and restricting bloodfow, that could cause the hypoxia and impaired respiration. 6. The health care provider has prescribed the following: Albuterol metered-dose inhaler 180 mcg (2 puffs) inhaled orally every 4-6 hrs. as needed (not to be exceed 12 inhalations/24 hrs. and Formoterol 12 mcg 1 capsule per aerolizer inhaler every 12 hrs. Luanne does not understand the need for two inhalers. How should the nurse explain the differences?

A. They both work to expand your lungs and improve your ability to breathe. B. One will help your breathing; the other will repair the damage to your lungs. C. One is short-term for immediate relief and the other is for long-term control. D. One opens your airways, and the other decreases the inflammation.

Luanne is managed well on the two inhalers for over a year. One morning she awakens feeling more short of breath than usual. She goes to work but has to leave early since her breathing is more difficult and the cough is getting worse despite the use of her albuterol inhaler every 1-2 hours. She goes to the urgent care on the way home.

Nursing Note Feb. 3 2021 1130

Temp. 100.4 F (38 C), HR 110, RR 24, BP 156/89 (111), O2 sat. 92%

1140

States feeling increased shortness of breath. Lung sounds diminished throughout with expiratory wheezes. Sputum yellow. ABGs drawn. O2 placed at 2 L/nasal cannula – O2

1230

Sats. 98% Chest x-ray shows right lower lobe consolidation consistent with pneumonia. Laboratory Report

Arterial Blood Gas pH PO2 PCO2 HCO3 SaO2

Normal Ranges 7.35-7.45 80-100 35-45 22-26 95-100

Results 7.33 75 47 27 92 Room air 7. Please fill in the normal ranges for the arterial blood gas and indicate if the results are high or low. 8. The nurse reviews Luanne’s physical and diagnostic assessments. What assumptions can be made? A. Luanne’s current medications are ineffective for her worsening COPD. B. Luanne has a secondary infection that’s impairing her ability to breath. C. Luanne requires intubation with mechanical ventilation. D. Luanne is unable to compensate for her acid base imbalance. 9. The health care provider prescribes albuterol per small volume nebulizer (SVN). Luanne asks the nurse how it’s different from the metered dose inhaler (MDI) she takes at home. How should the nurse respond? A. Them MDI is less portable to use. B. The SVN uses compressed air to distribute the medication into your lungs. C. The SVN provides oxygen during delivery of the medication. D. The MDI is lower dosage and less potent. 10. The nurse is instructing Luanne on how to use the nebulizer, what should be included in the instructions? Select all that apply. A. Fully exhale before taking the medication. B. Rinse your mouth after use. C. Firmly place your lips around the mouthpiece. D. Take normal breaths during administration. E. You may feel your heartbeat increase with administration. F. Let me know if you feel lightheaded or dizzy. 11. What else could the nurse suggest that would be helpful for Luanne’s recovery? Select all that apply. A. Increase fluid intake. B. Ambulate around the block twice each day.

C. Complete the full dose of antibiotics. D. Consume at least 2000 calories each day. E. Avoid smokey environments. Luanne is discharged after her oxygen saturation increased to 94% on room air. She was started on an oral antibiotic and told to get rest and not to return to work for 7 days. She returned to work after 2 days since she was feeling better and could not afford to take 7 days off of work. After a week the shortness of breath has returned. Her son notices that she seems mildly confused. He takes her to the emergency department. The triage nurse takes her vital signs and performs a focused assessment. Vital Sign Record Time March 10 1039

BP (MAP) 100/58 (72)

HR 108

RR 26

O2 Sat. 89% RA

Nurse Note: Brought in by son per private vehicle. Oriented to name and place only. Crackles in the right lower lobe, inspiratory/expiratory wheezes. Moist cough. Some use of accessory muscles. States having a hard time breathing.

12. What should be the nurse’s next action? Place in order of priority. _a__, _b__, _c__, _e__, __d_. A. Raise the head of the bed. B. Apply oxygen at 2L/nasal cannula. C. Complete a more comprehensive assessment. D. Notify the health care provider. E. Encourage pursed lip breathing. 13. Luanne’s son asks why she is so confused. How should the nurse respond? A. The medications that your mom is taking can sometimes cause confusion. B. She may have had a stroke, and we’ll run some tests. C. She’s probably just tired of being sick. D. Her oxygen levels are low which can cause confusion. Laboratory Report Arterial Blood Gas

Normal Ranges (fill in)

pH

7.35-7.45

March 3 (state if results are High or Low) 7. 33

March 10 – 1100 (State if results are H or L 7.25

PO2 PCO3 HCO3 SaO2

80-100 35-45 22-26 95-100

75 47 27 92 Room air

71 51 28 90 2 L/NC

14. Provide a rationale for each of these abnormal findings in Luanne: A. Tachypnea: increase CO2 due to trapping in lung, and the patient is tring to compensate by breathing faster to expel air out of the lung B. Respiratory Acidosis: pH reduces, CO2 increases C. Adventitious Breath Sounds: bronchitis = inflammation, thick mucous in lungs, obstructed airway 15. The nurse gathers information and begins to prepare an SBAR telephone conversation for the HCP. Complete each section of the communication form. (Situation, Background, Assessment, Recommendation) S- Luanne has had SOB for a week, and was brought to the ER by her son due to confusion B- Luanne is 56, with a history of living with smokers. She was diagnosed with emphysema last year and prescribed 2 inhalers for treatment. She also had pneumonia, and was prescribed an oral antibiotic for treatment. A- Her vitals are as follows: BP 100/58, HR 108, RR 26, O2 SAT 89%, and she is A&Ox2. Crackles were heard in the right lower lobe, accompanied with inspiratory and expiratory wheezes. Her cough is moist with use of accessory muscles and SOB. R- We could use a nasal cannula at 2Lpm to reduce her SOB, and will continue to monitor her O2 saturation and respiratory rate. Put her in a high fowlers position to promote ease of breathing, and continue assessment of respiratory status as well as LOC q1-2h until she is stable. HCP Prescriptions March 10 1039

1. Admit to the medical surgical unit. 2. Medications:  Cefuroxime 750 mg IVPB every 8 hrs.  Albuterol 2.5 mg every 3-4 hrs. and prn per small volume nebulizer (SVN).  Methylprednisolone 125 mg IV every 12 hrs. 3. IV fluids normal saline at 100 mL/hr.

4. Titrate O2 to maintain saturations 93-95 % 5. Portable chest x-ray, STAT. Call results 6. Sputum for culture 7. Respiratory therapy consultation for chest physiotherapy 8. Incentive spirometry every 1 hr. 9. Diet as tolerated Before initiating the orders, the nurse performs another focused assessment on Luanne. Vital Sign Record Time March 10 1039 1100 1120

BP (MAP) 100/58 (72)

HR 108

RR 26

O2 Sat. 89% RA

98/56 (70)

110

26

91 % 2 L/NC

97/52 (67)

110

26

91 % 2 L/NC

16. With the current vital signs and assessment data, place the Top 3 Priority prescriptions/orders in the order the nurse should initiate them. _b__, __c_, __a_. A. Cefuroxime B. Albuterol C. Methylprednisolone D. IV fluids normal saline E. Increase O2 to maintain saturations 93-95% F. Portable chest x-ray G. Sputum culture H. RT consultation I. Incentive spirometry 17. Luanne’s O2 is increased to 3 L/NC. She’s received a treatment of albuterol per small volume nebulizer (SVN) and chest physiotherapy (CPT) from the respiratory therapist. Her IV fluids have been initiated at 100mL/hr. How will the nurse know if the treatments have been effective? Select all that apply. A. O2 sat. is 92% B. Respiratory rate is 24 breaths per minute C. She is coughing up yellow-green phlegm. D. Heart rate is 112 beats per minute.

E. Blood pressure is 102/60 (74). Over the next 24 hours, Luanne’s condition improves. Nurse’s note March 11 at 1830: States “feeling better” O2 weaned off with saturation >93%. Ambulated to the bathroom with a steady gait and mild shortness of breath. Anticipate discharge later today. Report to oncoming shift. O2 Titration Record Time 1339

HR 100

RR 18

Sats 95 % 3L/NC

1500

105

22

93% 2L/NC

1820

110

24

92% 1L/NC

Action O2 decreased to 2 L O2 decreased to 1L O2 removed

18. The night nurse reviews the oxygen titration record. What evaluation can be made? A. The nurse made the appropriate decision about titration. B. The client has become oxygen dependent. C. The HCP needs to be urgently notified. D. The client is not ready to without oxygen....