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Case Study- Resp Distress

Nursing (Snead State Community College)

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Respiratory Distress
Clinical Reasoning Activity

Mark Peterson, 45 years old

Primary Concept
Perfusion
Interrelated Concepts​ (In order of emphasis)
•
Gas Exchange
• Infection
• Clinical Judgment
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
✓​ ​Management of Care 17-23% ✓
✓​ ​Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12% ✓
Psychosocial Integrity 6-12%
Physiological Integrity
✓​ ​Basic Care and Comfort 6-12%
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✓​ ​Pharmacological and Parenteral Therapies 12-18%

✓​ ​Reduction of Risk Potential 9-15% ✓

✓​ ​Physiological Adaptation 11-17% ✓

Part I: Present Problem:

Mark Peterson is a 45-year-old African American male with a new diagnosis of cardiomyopathy (40% EF), poorly
controlled type one diabetes mellitus, hypertension, and stage III chronic kidney disease. He is a one-pack-per-day smoker
who came to the emergency department (ED) with increased redness in his lower extremities, fever, and chills. He was
diagnosed with cellulitis and acute renal failure. He received his first dose of ceftriaxone 1 g IVPB in the ED. He has a
baseline creatinine of 2.8, and his current creatinine is 3.9. His WBC is 18.5. He was just admitted to the med/surg unit
where you will be the primary nurse caring for him. His initial set of VS: T: 99.8 F/37.7 C (o) P: 84 reg R: 22 (reg) BP:
148/88 O2 sat: 93% room air. He has fine bibasilar crackles in both bases posteriorly that do not clear with a cough.
Respirations do not appear to be labored, and he denies shortness of breath.

1.​ ​What clinical data do you notice that is RELEVANT and why is it clinically significant?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT Data: Clinical Significance:
​45 yr old African American M - With cardiomyopathy, the heart becomes enlarged and replaced
cardiomyopathy with scar tissue. It’s less able to pump blood through the body and
Uncontrolled diabetes maintain a normal electrical rhythm.
HTN - Uncontrolled HTN and diabetes can increase the risk of heart
Stage III chronic kidney dz attack, stroke, and decreased kidney function.
- Dx with HTN and smoking can lead to more severe forms of
Smoker (pack a day) hypertension that can progress to accelerated atherosclerosis.
Erythema in lower extremities - Elevated WBC, fever, and chills are indicative of an infection.
Fever on admission Cellulitis is a bacterial skin​ infection​ that may present with skin
Chills redness, warmth, and skin pain.
Cellulitis - Acute renal failure can present with hematuria, proteinuria,
Acute renal failure decreased eGFR, and elevated BUN and creatinine. Important to
Creatinine high (2.8 on admission, monitor labs.
3.9 now) - Bibasilar crackles with an unproductive cough can signify excessive
WBC high (18.5) fluid in the airway that is not being cleared out.
RR:22
O2 Sat 93% on RA
Fine bibasilar crackles bilaterally
Unproductive cough

Four Hours Later…

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It has been four hours since he was admitted. You notice that his O2 sat on room air has decreased from 95 percent to 88
percent, his respiratory rate has increased from 22 to 28 at rest, and he has coarse crackles halfway up bilaterally
posteriorly. You have a PRN order to titrate oxygen to keep O2 sat >92%, so you place a nasal cannula at 2 L/min which
improves his O2 sat to 94%. Two hours later, his respiratory rate has increased to 24, and his O2 sat is 90 percent. He now
requires 4 L/min per nasal cannula to keep his O2 sat greater than 92%.
His current VS are T: 99.6 F/37.6 C (o) P: 94 R: 28 BP: 156/90 O2 sat: 92% on 6 L/min per n/c. You contact the
primary care provider because of his increasing oxygen needs. He is feeling more short of breath. He has had 400 mL of
water but has not been able to void since admission to the floor. His bladder ultrasound (BUS) reveals 90 mL of urine in
his bladder.

1. What clinical data do you notice that is RELEVANT and why is it clinically significant? ​(Reduction of Risk
Potential/Health Promotion and Maintenance)
RELEVANT Data: Clinical Significance:
O2 sat is Low oxygen level is a common cause of
declining hypoxemic respiratory failure. Can indicate
rapidly excessive fluid in the lungs. L/T decreased gas
and exchange.
oxygen
demand
is rising
quickly Can indicate pulmonary hypertension.
Pulmonary artery vasoconstriction is likely
contributed to the V/Q mismatch and is one of
B/P is
the mechanisms of hypoxemia. May lead to
rising ARDS
Output In kidney failure, the inability to excrete fluid
is <30 ml can cause build-up in the blood vessels,
per hour resulting in pulmonary edema.

2. What additional information or clinical data do you need to collect to ensure that you make a correct
clinical judgment?​ (Management of Care)
Onset of these symptoms, home medications, compliance with these medications, last follow up with cardiologist,
duration of symptoms, pain scale, radiation of the pain, BG level, CXR, lab tests, allergies.

3. What is your interpretation of relevant clinical data? What problem (s) may be present?​ (Mgmt. of
Care/Physiologic Adaptation)
Elevated RR, declining oxygen saturation, and an increasing demand of oxygen can indicate a back up of fluid into the
lungs in association with a rising b/p L/T pulmonary hypertension. Decreased urinary output, excessive fluid build up.
New onset of SOB.

4. In your response to interpreting relevant clinical data, what nursing priority (ies) will guide your plan of
care?
(Mgmt. of Care)
Nursing PRIORITY: Impaired Gas Exchange
PRIORITY Nursing Rationale: Expected Outcome:
Interventions:

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1. Position the HOB elevated, 1. Upright position can increase thoracic .

in a Semi-Fowler’s position
as tolerated.
2. Maintain oxygen
administration device as
ordered, attempting to
maintai oxygen saturation
at >92%.
3. Assess RR, depth, effort,
use of accessory
muscles, nasal flaring,
and abnormal breathing
patterns.
4. Assess the lungs for areas
of decreased ventilation
and auscultate presence of
adventitious sounds.
5. Monitor pt behavior and
mental status for onset of
restlessness, agitation,
confusion, and extreme
lethary.
6. Monitor effects of position
changes on oxygenation
(ABGs, venous oxygen
saturation, and pulse
oximetry)
capacity, full descent of diaphragm, 1. Maintains optimal gas
and increase lung expansion. exchange AEB unlabored
2. Supplemental oxygen may be required respirations @12-20 bpm,
to maintain PaO2 at an acceptable oximetry results WNL,
level. blood gases WNL, an
2. Accessory muscles, nasal flaring, baseline HR for pt.
abnormal breathing patterns, and
2. Pulse oximetry will remain
increased RR can be associated with
at 92% or greater.
hypoventilation which affects gas
exchange leading to hypoxia. 3. Pt achieves and maintains
clear lung fields and
3.. Any irregularity of breath sounds remains free of signs of
indicates impaired gas exchange. respiratory distress.
Crackles and wheezes may alert the 4. Pt verbalizes
nurse to an airway obstruction. Which understanding of oxygen
may l/t hypoxia. and other therapeutic
4. Changes in behavior and mental interventions.
status can be early signs of impaired
gas exchange.Cognitive changes may
occur with chronic hypoxia.
5. Putting the most compromised lung
areas in the dependent position
potentiates ventilation and perfusion
imbalances.

Part II: How Will You Respond Now? Reflect and Evaluate

You communicate your concern of increasing oxygen needs, and 90 mL

of residual urine using SBAR to the primary care provider. She orders a
stat portable chest x-ray, complete blood count (CBC) and basic
metabolic panel (BMP) and arterial blood gas (ABG).

You now collect the following clinical data:

Current VS: P-Q-R-S-T Pain Assessment:
T: 9​ 9.8 F/37.7 C (oral) P​rovoking/Palliative:
P: ​94​ (​regular) Q​uality: Denies
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R: ​32 (regular) R​egion/Radiation:

BP: ​144/90 S​everity:
O2 sat:​ 90% 6 L/min n/c T​iming:

Current Assessment:
GENERAL Appears tense, no grimacing, appears anxious
APPEARANCE:
RESP: Breath sounds course crackles half way up bilat. Posterior, tachypneic, slightly-labored resp.
effort
CARDIAC: Flushed complexion, warm & dry, no edema, heart sounds regular with no abnormal beats,
pulses weak, 2+ equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill
NEURO: Awake, alert & oriented to person, place, time, and situation (x4)
GI: Abdomen flat, soft/nontender, bowel sounds audible per auscultation in all four quadrants
GU: Bladder non-distended, non-tender, has been unable to void since admitted four hours ago, 90
mL per BUS
SKIN: Erythema bilateral lower extremities, feet to mid-calf. The redness has not progressed beyond
outlined edges, skin warm to touch with 2+ non-pitting edema bilat.

1. What clinical data do you NOTICE that is RELEVANT and why is it clinically significant?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT Data: Clinical Significance:

Course crackles half way up Pt is still having difficulty breathing despite the oxygen therapy. The fluid build
bilaterally and fast, labored up is getting worse.
breathing

Skin assessment shows some warm,
erythema bilaterally on the feet and
legs with edema
Cellulitis is warm, redness and swelling due to bacterial infection, typically
found on the legs but could be anywhere
This could also just be due to the heart decline and poor renal function which
will cause an increase in fluids in the body resulting in edema, especially in the
lower extremities.

Radiology Reports:
Radiology: Chest X-Ray
Results: Clinical Significance:
Normal cardiac mediastinal silhouette. Patchy This means that it is not the cardiomyopathy causing the problems but
opacities throughout lungs that may represent an infection or pulmonary edema due to his heart problems
infection or pulmonary edema.

Lab Results:
Basic Metabolic Panel (BMP)
Na K Gluc. BUN Creat
Current: 132 4.8 345 71 4.3
6 Hours ago: 135 4.4 241 62 3.9
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Complete Blood Count (CBC)

WBC HGB PLTs % Neuts Bands
Current: 18.8 8.2 305 91 0
6 Hours ago: 18.5 8.1 298 86 0

RELEVANT Lab(s): Clinical Significance:

Untreated hyperglycemia can lead to serious complications such as diabetic coma, fatigue,
Glu 241-345 headahce, blurred vision, N&V, confusion, ketones in urine, increased complications in the
heart, nerves, kidneys, and eyes.
BUN 62-71 Elevated BUN and creatinine levels is in relation to the patients chronic kidney disease. An
elevation in these labs can cause SOB, confusion, edema, feeling dehydrated, neuropathy,
Create 4.3-3.9 muscle cramps, and high blood pressure.
Elevated WBCs can indicate infection.
WBC 18.8-18.5
Pt may be experiencing anemia secondary to chronic kidney disease. No/decreased
Hgb 8.2-8.1 production of erythropoietin.

Neut 91-86%
Increased levels of neutrophils can lead to a physical state called neutroplilic leukocytosis.
This is a normal immune response to an event such as infection, injury, inflammation, and
some medications.

Arterial Blood Gas (ABG)

pH pCO2 pO2 HCO3 O2 sat
Current: 7.6 25 70 26 90

RELEVANT Lab(s): Clinical Significance:

pH:7.6 Elevated. associated with lung problems. Combined with the decreased pCO2 levels, can
pCO2: 25 indicate decreased alveolar ventilation.
HCO3:26 Decreased. Can signify the impaired oxygen exchange in the alveoli.
O2 Sat: 90 WNL
Sign of impaired gas exchange and hypoxia.

2. What is your INTERPRETATION of relevant clinical data? What problem is present?​ (Mgmt.
of Care/Physiologic Adaptation)
Primary Problem: Pathophysiology of Problem in OWN Words:

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An increase of fluid in the body that backs up into the lungs which leads to ineffective breathing
and gas exchange that occurs in the alveoli. Which results in decreased oxygenation.
Respiratory distress
r/t pulmonary edema

3. What nursing priority (ies) will guide your plan of care that determines how you will
RESPOND? ​(Mgmt. of Care)
Nursing PRIORITY: ​BREATHING DEMAND AND
INTERVENTIONS!

PRIORITY Nursing Interventions: Rationale: Expected Outcome:

Place patient with proper body alignment for Breathing is the main focus for this pt. He is Pt will continue to be
maximum breathing patterns. having fast, labored and ineffective breathing stable at 90% O2 Sat
Utilizing incentive spirometer. due to an increase of fluid built up inside his on the NC at 6L, but if
Encourage diaphragmatic breathing. lungs. Need to monitor the O2 sat, lungs sounds not an increase WILL
Provide respiratory medications and oxygen, and respiration rate consistently to ensure that HAVE to happen to
per doctors orders. the pt is not going into distress ensure proper
Encourage patient to mobilize own secretions A sitting position permits maximum lung oxygenation.
with successful coughing. excursion and chest expansion.
Encourage or assist with ambulation as per Techniques promotes deep inspiration, which Maybe with proper
physician’s orders. increases oxygenation and prevent atelectasis. anti-hypertensives and
Provide reassurance and reduce anxiety. Diaphragmatic breathing relaxes muscles and monitoring the pt can
increases the patients oxygen level. be stabilized
Bronchodilation helps to open airway passages.
Facilitation of secretions can help clear the Pt will void the
airway. residual urine inside
Ambulation can furhter break up and move the bladder and will
secretions that blocks the aiway. avoid dialysis for now
Anxiety increases dyspnea, RR, and work of with the proper
breathing. internventions

Use Reflection to THINK More Like a Nurse!

What did you learn that you can apply to future patients you care for? Reflect on your current strengths and weaknesses
this case study identified. What is your plan to make any weakness a future strength?
What Did You Learn? What did you do well in this case study?

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I learned a lot about how comorbidities all Deciphering the lab values and what they mean in relation to
connect with each other and can cause further the pts worsening health status
damage and other health problems

What could have been done better? What is your plan to make any weakness a future strength?

I struggle with describing the patient issues and Although case studies are very time consuming, working
wording in a manner that made sense. This patient had through these issues help lead me to a better understanding of
a lot going on. some disease processes.

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