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Mr Howe Case Study
Mr Howe, a 68 year old man, was admitted this morning to the general medical unit suffering from infective exacerbation of chronic obstructive pulmonary disease (COPD). The nurses caring for Mr Howe have escalated his treatment by calling a Medical Emergency Team (MET) call that was triggered in response to a low oxygen saturation, despite changing his oxygen delivery system from nasal prongs (4 L/min) to Hudson face mask (8 L/min). The nurses also state that his respiratory rate has progressively increased over the past 2 hours. Mr Howe is also reporting some increasing breathlessness and right sided chest pain that increases on inspiration. He is able to speak in short phrases and is alert, orientated but agitated. You, as a critical care nursing student, attend this MET call as the nursing member of the rapid response team. On arrival you are informed by the nurse caring for Mr Howe that his vital signs are: RR 28 bpm, BP 100/60 mmHg, HR 130 bpm, SpO2 88% on oxygen at 8 LPM, Temperature 38 C
Question 1. Mr Howe is hypoxaemic. Explain the pathophysiology of, and relationships between V/Q mismatching, hypoventilation, infective COPD and his presenting clinical condition and how these lead to hypoxaemia. (14 marks)
Chronic obstructive pulmonary disease (COPD) is a blanket term used to describe the progressive deterioration of airflow with irreversible deterioration of respiratory function (Lee-Chiong & Brown, 2009). An exacerbation is a change in the usual course, characterised by dyspnoea and increased work of breathing triggered by a virus, bacteria or air pollutant (Sapey & Stockley, 2006; Tsoumakidou & Siafakas, 2006).
The acute infective state in Mr Howe causes an immune response which consequent...
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...he hypoxaemic and even more so the hypercapnic drive (Cretikos, Bellomo, Hillman, Chen, Finfer & Flabouris, 2008). Acid-base is the most protected homeostatic mechanism in a patient’s body and is altered by many different things, such as sepsis, with respiratory rate often compensating a change in the blood pH. Respiratory rate can also show the effect of some mediations such as opiates decreasing respiratory rate and conscious level (Cretikos et al., 2008).
In conclusion, while all vital signs are taught respiratory rate is the least accurately taken even though it’s the first to change in clinical deterioration. Many studies have been completed to show the impact of increased respiratory rate but it is not reflected in clinical practice. This shows that an accurate respiratory rate could minimise many preventable adverse effects from patient deterioration.
Additionally, some of the general diagnostic and pulmonary function tests are distinct in emphysema in comparison to chronic bronchitis. In the case of R.S. the arterial blood gas (ABG) values are the following: pH=7.32, PaCO2= 60mm Hg, PaO2= 50 mm Hg, HCO3- = 80mEq/L. R.S.’s laboratory findings are indicative of chronic bronchitis, where the pH and PaO2 are decreased, whereas PaCO2 and HCO3- are increased, when compare to normal indices. Based on the arterial blood gas evaluation, the physician can deduce that the increased carbon dioxide is due to the airway obstruction displayed by the hypoventilation. Furthermore the excessive mucus production in chronic bronchitis hinders proper oxygenation leading to the hypoxia. On the other hand, in emphysema the arterial blood gas values would include a low to normal PaCO2 and only a slight decrease in PaO2 which tend to occur in the later disease stages.
Mrs. Jones, An elderly woman, presented severely short of breath. She required two rest periods in order to ambulate across the room, but refused the use of a wheel chair. She was alert and oriented, but was unable to speak in full sentences. Her skin was pale and dry. Her vital signs were as follows: Temperature 97.3°F, pulse 83, respirations 27, blood pressure 142/86, O2 saturation was 84% on room air. Auscultation of the lungs revealed crackles in the lower lobes and expiratory wheezing. Use of accessory muscles was present. She was put on 2 liters of oxygen via nasal canal. With the oxygen, her O2 saturation increased to 90%. With exertion her O2 saturation dropped to the 80's. Mrs. Jones began coughing and she produced large amounts of milky sputum.
Noticeable indications of deterioration have been shown in numerous patients few hours prior to a critical condition (Jeroen Ludikhuize, et al.2012). Critical condition can be prevented by recognizing and responding to early indications of clinical and physiological deterioration ( kyriacosu, jelsma,&jordan (2011). According to NPSA (2007) delay in responding to deteriorating vital signs have been defined as an complication resulting in prolonged length of stay, disability or death, not attributed to the patient's underlying illness procedure along but by their health-care management ( Baba-Akbari Sari et al. 2006; Helling, Martin, Martin, & Mitchell, 2014). A number of studies demonstrate that changes or alterations in a patient’s
The circulatory system and respiratory system share a highly important relationship that is crucial to maintaining the life of an organism. In order for bodily processes to be performed, energy to be created, and homeostasis to be maintained, the exchange of oxygen from the external environment to the intracellular environment is performed by the relationship of these two systems. Starting at the heart, deoxygenated/carbon-dioxide (CO2)-rich blood is moved in through the superior and inferior vena cava into the right atrium, then into the right ventricle when the heart is relaxed. As the heart contracts, the deoxygenated blood is pumped through the pulmonary arteries to capillaries in the lungs. As the organism breathes and intakes oxygenated air, oxygen is exchanged with CO2 in the blood at the capillaries. As the organism breathes out, it expels the CO2 into the external environment. For the blood in the capillaries, it is then moved into pulmonary veins and make
To better understand how COPD affects an individual you should first know how the lungs function. When you breathe in air it first goes through your trachea then into your bronchioles. Once in the bronchioles the air goes to the air sacs called alveoli. In the alveoli, the gas exchange occurs with the capillaries. Gas exchange is when the oxygen enters the bloodstream and carbon dioxide enters the alveoli. During the breathing process, alveoli will inflate when inhaling and deflate while exhaling.
Chronic obstructive pulmonary disease or COPD is a group of progressive lung diseases that block airflow and make it hard to breathe. Emphysema and chronic bronchitis are the most common types of COPD (Ignatavicius & Workman, 2016, p 557). Primary symptoms include coughing, mucus, chest pain, shortness of breath, and wheezing (Ignatavicius & Workman, 2016, p.557). COPD develops slowly and worsens over time if not treated during early stages. The disease has no cure, but medication and disease management can slow its progress and make one feel better (NIH, 2013)
Carone M, D. C. ( 2007). Clinical Challenges In COPD[e-book]. (Oxford: Clinical Pub) Retrieved March 24, 2014, from (EBSCOhost).
An electrocardiogram (ECG) is one of the primary assessments concluded on patients who are believed to be suffering from cardiac complications. It involves a series of leads attached to the patient which measure the electrical activity of the heart and can be used to detect abnormalities in the heart function. The ECG is virtually always permanently abnormal after an acute myocardial infarction (Julian, Cowan & Mclenachan, 2005). Julies ECG showed an ST segment elevation which is the earliest indication that a myocardial infarction had in fact taken place. The Resuscitation Council (2006) recommends that clinical staff use a systematic approach when assessing and treating an acutely ill patient. Therefore the ABCDE framework would be used to assess Julie. This stands for airways, breathing, circulation, disability and elimination. On admission to A&E staff introduced themselves to Julie and asked her a series of questions about what had happened to which she responded. As she was able to communicate effectively this indicates that her airways are patent. Julie looked extremely pale and short of breath and frequently complained about a feeling of heaviness which radiated from her chest to her left arm. The nurses sat Julie in an upright in order to assess her breathing. The rate of respiration will vary with age and gender. For a healthy adult, respiratory rate of 12-18 breaths per minute is considered to be normal (Blows, 2001). High rates, and especially increasing rates, are markers of illness and a warning that the patient may suddenly deteriorate. Julie’s respiratory rates were recorded to be 21 breaths per minute and regular which can be described as tachypnoea. Julies chest wall appeared to expand equally and symmetrical on each side with each breath taken. Julies SP02 levels which are an estimation of oxygen
Person, A. & Mintz, M., (2006), Anatomy and Physiology of the Respiratory Tract, Disorders of the Respiratory Tract, pp. 11-17, New Jersey: Human Press Inc.
My colleague and I received an emergency call to reports of a female on the ground. Once on scene an intoxicated male stated that his wife is under investigation for “passing out episodes”. She was lying supine on the kitchen floor and did not respond to A.V.P.U. I measured and inserted a nasopharyngeal airway which was initially accepted by my patient. She then regained consciousness and stated, “Oh it’s happened again has it?” I removed the airway and asked my colleague to complete base line observations and ECG which were all within the normal range. During history taking my patient stated that she did not wish to travel to hospital. However each time my patient stood up she collapsed and we would have to intervene to protect her safety and dignity, whilst also trying to ascertain what was going on. During the unresponsive episodes we returned the patient to the stretcher where she spontaneously recovered and refused hospital treatment. I completed my patient report form to reflect the patient's decision and highlighted my concerns. The patient’s intoxicated husband then carried his wife back into the house.
Vijayan, V. K. (2013). Chronic obstructive pulmonary disease. Indian Journal Of Medical Research, 137(2), 251-269.
As we are well aware, being a patient at a hospital can prove beneficial or problematic. As it is with the most critical of patients, they require a closer level of surveillance and monitoring than those on other med-surg associated units. As the care of an ICU patient can escalate quickly, it’s critical to assess the needs of your patient in a timely manner. Looking at a ventilated patient who requires many different modalities, assessing the need for such ther...
Parker, Steve. "Chronic Pulmonary Diseases." The Human Body Book. New ed. New York: DK Pub., 2007.
Ascertaining the adequacy of gaseous exchange is the major purpose of the respiratory assessment. The components of respiratory assessment comprises of rate, rhythm, quality of breathing, degree of effort, cough, skin colour, deformities and mental status (Moore, 2007). RR is a primary indicator among other components that assists health professionals to record the baseline findings of current ventilatory functions and to identify physiological respiratory deterioration. For instance, increased RR (tachypnoea) and tidal volume indicate the body’s attempt to correct hypoxaemia and hypercapnia (Cretikos, Bellomo, Hillman, Chen, Finfer, & Flabouris, 2008). The inclusive use of a respiratory assessment on a patient could lead to numerous potential benefits. Firstly, initial findings of respiratory assessment reveals baseline data of patient’s respiratory functions. Secondly, if the patient is on respiratory medication such as salbutamol and ipratropium bromide, the respiratory assessment enables nurses to measure the effectiveness of medications and patient’s compliance towards those medications (Cretikos, Bellomo, Hillman, Chen, Finfer, & Flabouris, 2008). Thirdly, it facilitates early identification of respiratory complications and it has the potential to reduce the risk of significant clinical
This reflection of vital signs will go into discussion about the strengths and weaknesses of each vital sign and the importance of each of them. Vital signs should be assessed many different times such as on admission to a health care facility, before and after something substantial has happened to the patient such as surgery and so forth (ref inter). I learned to assess blood pressure (BP), pulse (P), temperature (T) and respiration (R) and I will reflect and discuss which aspects were more difficult and ways to improve on them. While pulse, respiration and temperature were fairly easy to become skilled at, it was blood pressure which was a bit more difficult to understand.