Respiratory disorders

Case Study 23
1. Identify the four most important things to include in your assessment.
Determine a previous history (Hx) of pneumonia
Obtain complete VS with SaO2 on room air.
Perform a full physical assessment, especially a cardiovascular and pulmonary system
Identify the quality and presence pain upon cough, color and quantity of sputum

2. Which of these assessment findings concern you? State your rationale.
C.K.’s blood pressure, pulse, respirations, and temperature are elevated; SaO2 84% RA indicates patient is having hypoxemia
Decreased breath sounds in left lower lobe may indicate atelectasis and coarse crackles in the left upper lobe may indicate fluid accumulation.
Dusky nail beds indicate lack of O2 and tissue perfusion
Rust-colored sputum indicates respiratory infection.
Pain upon coughing presents inflammation or infection.
Allergy to antibiotics (need to identify the allergic response to antibiotic in detail because he will be starting antibiotic)
Medical history of CAD, MI and DM increases his presence illness

3. Review the orders and outline a plan of what you need to do in the next 2-3 hours.
Titrate O2 to maintain SaO2 over 90%.
Chest X-Ray now and in the morning
Metaproterenol sulfate 0.4% nebulizer treatment q3h
Obtain sputum for C&S
Blood culture for temperature over 102’F
IV of D5 ½ NS at 125ml/hr
Ceftriaxone 1g IV bid
VS with temperature q2h
CBC with differential and basic metabolic panel
Urinalysis (UA) with C&S
2100 Calorie ADA diet

5. What is the rationale for ordering O2 to maintain SaO2 over 90%?
The order means, the nurse would have to titrate the O2 flow rate to maintain the saturation, SaO2 above 90%.

6. What is a C&S test, and why is it important?
C&S means “culture and sensitivity”. It is a test used to identify the microorganism that causes the infection (culture) and to find a suitable antibiotic which is susceptible to kill the microorganism. A broad-spectrum antibiotic can only be prescribed before the C&S results are available. It is important because a more suitable antibiotic that is sensitive to the microorganism can be prescribed after the test result.
9. What would you expect the CXR results to reveal?
Chest x-rays may reveal areas of opacity which represent consolidation. When the lung is said to be consolidated, alveoli and small airways fill with dense material and it can be seen as white.

11. Which of the findings would best indicate that C.K is responding to therapy?
The answer is (b).
b. Cough productive of white sputum; temperature of 100.0’F; SaO2 98% on 2L NC

Case Study 29
1. Draw a picture of the pathophysiology of emphysema and label it.

Emphysema is a disease of the lung. In emphysema, the alveoli (small air sacs in the lungs that facilitate the exchange of carbon dioxide and oxygen) are damaged. Decreased alveolar surface area causes an increase in “dead space” and impaired oxygen diffusion. Therefore, carbon dioxide and oxygen is not exchanged in alveoli, and gradually lose their elasticity, becoming floppy, over-expanded, and collapse on exhalation. As a result, patients with emphysema have increasing difficulty moving air in and out of their lungs.

2. Are D.Z’s vital signs and SaO2 appropriate? If not, explain why?
Upon assessment, his vital signs are BP-162/84, P-124, R-36, T-102 and SaO2-88%. Pt. is having stage two hypertension and increased pulse rate (tachycardia) , respiration rate is 36, showing patient is having tachypnea.
The normal body temperature of a healthy adult person is 98.6’F and D.Z temperature, 102’ F shows that patient is also febrile due to disease process. Moreover, his SaO2-88% indicates that D.Z is having hypoxemia and the body is the depriving of O2.

3. Describe a plan for implementing these physician’s orders.
First of all, the nurse would administer Albuterol 2.5 mg plus ipratropium 250 mcg nebulizer treatment STAT, and maintain SaO2 of 90%. Then, implement the followings.
ABG draws in the AM
CBC with differential now
Basic metabolic panel (BMP) now
Chest X-ray q2h
IV of D5W at 50ml/hr
ECG monitoring
Diet as tolerated
Out of bed with assistance

4. Identify three independent nursing actions you would try to improve D.Z’s oxygenation.
As a nurse, I would demonstrate the followings and observe the patient’s return demonstration.
Deep breathing, “huff” coughing
Breathing exercises to reduce air trapping diaphragmatic breathing pursed lip breathing
Insentive Spirometry

5. Indicate the expected outcome for D.Z that is associated with each of the medications he is receiving.
Patient D.Z is receiving the following medications.
Methylprednisolone 125 mg is corticosteroids and prevents inflammation in the lungs.
Doxycycline 100mg and Azithromycin 500 mg are antibiotic and those medications will kill the bacteria in the lungs.
Advair 2 puff (inhalation) BID will open up the constricted bronchioles and eases SOB. We need to teach him the side effects of this medication such as tachycardia and nervousness.
Heparin 4000 units is the blood thinner which will prevent DVT during hospitalization.
Enalapril 10 mg is the ACE inhibitor used for hypertension.
Albuterol 2.5 mg/ ipratropium 250mcg nebulizer is the breathing treatment to improve breathing.
6. Since D.Z is on azithromycin (Zithromax), what nursing actions need to be added to the plan of care? Select all that apply.
a. Monitor IV site for inflammation or extravasation
b. Assess liver function studie and bilirubin levels
c. Obtain a hearing test prior to initiating therapy
e. Place D.Z on intake and outout

10.
Did you know that if you have COPD, the foods that you eat can have an affect on your breathing. Foods high in carbohydrates produces large amounts of carbon dioxide. When carbon dioxide is increased in the body the blood becomes acidic. If your blood becomes too acidic messages are sent to the brain to increase respiration and urination to eliminate this build up of acid. Your body's natural buffer system in the form of increased bicarbonate production kick in to bring you back to a state of homeostasis. When you have COPD the anatomy of the lungs has changed in such a way as to decrease the body's ability to eliminate carbon dioxide. Over time the body resets the baseline CO2 (carbon dioxide) to a higher number due to the lungs inability to properly eliminate it effectively. This in turn causes the bicarbonate to reset as well to bring the body's blood pH back to normal. Foods high in carbohydrates increase the amount of CO2 in an already deficient system, therefore making expiration more difficult.

If you have been diagnosed with COPD have your doctor recommend a registered dietitian that can help you to devise a meal plan with the proper nutrition to offset increased CO2. Do not try to do this yourself because carbohydrates provide fuel for the body and should not be completely eliminated from your diet. For example, complex carbohydrates are a good source of fiber which is necessary for proper bowel function. Simple and complex carbs also provide a lot of minerals and vitamins that are necessary for proper cell function. Fats produce the least amount of carbon dioxide while providing a great source for energy. Proteins are great for maintaining respiratory muscle strength along with proper exercise. Adequate water intake is also necessary in diluting the thick sputum that goes along with COPD. Coarse breath sounds from congestion are often confused with wet breath sounds from pulmonary edema which is more related with a condition known as congestive heart failure. Some foods also affect other factors that goes along with COPD such as how they affect medications taken such as blood thinners, and some foods need to be increased to provide better bone strength as with calcium depletion that occurs with steroid use.

More importantly when making changes to your diet increase your meal to approximately six small meals a day. Merely trying to eat with end-stage COPD requires a lot of oxygen expenditure. Preparation of smaller, but more frequent meals aids in meeting the nutritional requirements that is imperative to normal body function. Ask your doctor for advice at your next appointment so that you can enjoy a greater quality of life.

11. Identify four strategies that might improve his caloric intake.
To improve D.Z’s caloric intake, the nurse would provide,
Small, frequent meals
Liquid supplements
High calorie, high protein in soft foods (Consult with nutritionist)
3L/fluid per day
Use of bronchodilators before meals

difficulty breathing, coughing and severe chest pain, which can make it difficult for you to eat and may result in you losing weight. In addition, because of the difficulty breathing, your body spends more energy breathing to get enough oxygen. This, too, can cause you to lose weight rapidly. You need to maintain an adequate calorie intake, as well as nutrient intake, so your nutritional status doesn't deteriorate and you can prevent any possible complications associated with malnutrition.