St.

Paul University Philippines

Tuguegarao City, Cagayan 3500

School of Nursing and Allied Health Sciences

College of Nursing

NCM 112 - RLE Requirements

Case Scenario: Respiratory Disorders

History

A 65 years old former garage mechanic presents with a chief complaint of increased
shortness of breath and a change in the quantity and color of his sputum for the past week.
The sputum is usually scant and clear. However, recently it has become yellow and
continues all day. He has had trouble raising sputum in the past year. He has become
progressively short of breath over the last five years. He is now dyspneic at rest. He denies
asthma, childhood respiratory problems, allergies and any occupational exposures.

Physical Examination

 Obvious respiratory distress with prominent use of accessory muscles.

 Temperature 99.5; Blood pressure 140/90; pulse 110; respiratory rate 28.
 Head/neck reveal distended neck veins throughout expiration.
 Chest reveals increased A-P diameter; reduced chest wall excursion; lungs
hyperresonant to percussion; diaphragms low and immobile; auscultation reveals a
prolonged expiratory phase with diminished breath sounds and generalized rhonchi.
 Heart reveals PMI in epigastrium; heart sounds distant with regular rhythm and no
murmurs.
 Extremities reveal trace pitting edema of the lower extremities.

Laboratory and Diagnostic Studies

 Chest x-ray reveals hyperinflation of lungs with an increase in the retrosternal space;
low, flattened diaphragms; hyperlucent lung fields with paucity of vascular markings in
the periphery but prominent hila and narrow heart silhouette.
 EKG reveals low voltage; right axis; peaked P waves and clockwise rotation.
 WBC 8,500 with normal differential and Hgb 14.7 gm.
 ABG's:
PFT 0100 (RA) 0300 (2 LPM) 0800 (2 LPM) 0800 (RA)
Ph 7.38 7.37 7.42 7.42
Pa02 44 60 62 60
PaC02 58 63 44 36
HC03 (calc) 31 32 30 24

 Spirometry
FEV1 at 0100=0.5 L (predicted 2.9 L); at 0800=0.7 L. 
FVC at 0100=Unobtrusive . (predicted 3.9 L); at 0800=1.7 L.

Questions for Case Analysis:

1. What type of acid-base disturbance occurred in the Emergency Room?

The acid base disturbance occurred in the emergency room is Chronic respiratory acidosis.

2. What is the PA02?

PAO2 (at 0100) =

150-(1.2x 58) = 80

3. What is the A-a gradient and what does it tell you?

PAO2-PaO2 = 80-44 = 36

The Aa gradient indicates abnormal gas exchange.

A-a gradient values of < 15 mm Hg are considered normal. Increased A-a gradient 
of higher than 15 mm Hg suggests an abnormal gas exchange. The A-a gradient
is 36 mm Hg, so it indicates abnormal gas exchange.

4. Give at least two mechanisms of hypoxemia in this situation.

Mechanisms of hypoxemia in this situation includes Hypoventilation and V/Q abnormality

5. What does the elevated HCO3 tell you?

An elevated bicarbonate in your blood can be from metabolic alkalosis, a condition

that causes a pH increase in tissue. Metabolic alkalosis can happen from a loss of
acid from your body, such as through vomiting and dehydration.

Renal effort to compensate for Respiratory acidosis.

The process is chronic

6. What does the spirometry result mean?

Hospital Course

Arterial blood gases are drawn in the Emergency Room and oxygen (2 LPM) by nasal prongs
is started.

Gases are repeated at 0300. You commence bronchodilators and begin

trimethoprim/sulfamethoxazole.

A gram stain of sputum reveals many Polymorphonuclear leukocytes and some alveolar
macrophages.

At 0800, the patient feels better, can raise some sputum and is able to sleep.

7. Why begin trimethoprim/sulfamethoxazole?

Pharmacologic treatment of trimethoprim/sulfamethoxazole aims to treat acute exacerbation

in COPD that are commonly caused by the organisms Streptococcus pneumonia, Moraxella
catarrhalis, Viruses and Hemophilus influenza.

8. Why did the PaC02 increase at 0300? Should any therapy be altered to diminish the
hypercapnia? Should the patient be intubated?
Hypoxic stimulus to increase ventilation abolished by oxygen administration

9. Note that the hypoxemia originally presented is easily corrected. What does this suggest
as the mechanism of the hypoxemia?

Hypoxemia due to V/Q abnormality rather than shunt

A review of old records reveal the followings:

PFT 1978 1980 1983

FEV1 1.3 L 1.1 L 0.82 L (pred 2.9 L)
FVC 3.0 2.9 1.96 (pred 3.95 L)
RV 3.1 3.4 5.0 (pred 1.6 L)
TLC 6.1 6.9 6.9 (pred 5.57 L)
DCO 10 ml/min/mmHg 20 (pred 20)

10. How does this patient's average yearly decline in FEV1 compare to the normal decline?

Patient's decline in FEV1 is approximately 100 ml/yr. while the normal decline is 30 ml/yr.

 
11. Is this patient more like the classic pink puffer (type A) or blue bloater (type B) with
COPD? What are the differences in lung physiology between these extremes?

The patient is more like the classic pink puffer (type A emphysema).

Pink Puffer (type A emphysema):

 Hyperinflation with
 decreased diffusion capacity,
 greater physiologic dead space and
 work of breathing.

Blue Bloater (type B chronic bronchitis):

 Greater physiologic shunt resulting in Hypoxemia and

 early pulmonary hypertension.

12. What are the mechanisms of slowing of forced expiration in emphysema? Chronic
bronchitis? Asthma?

The mechanisms of in the slowing of forced expiration in Emphysema is loss of elastic

recoil (pel), in Chronic Bronchitis it is the increased airway resistance from increased
mucous glands and secretions while in Asthma is the increased airway resistance from
mucosal inflammation/edema and smooth muscle constriction.
 

13. Why is the thorax expanded in emphysema?

It is because of the Unopposed outward recoil of the chest wall from loss of inward recoil of lung (decreased
Pel)
14. Develop a Nursing Care Plan for the patient

ASSESSMEN NURSING PLANNING INTERVENTION RATIONALE EVALUATION

T DIAGNOSIS
Objective: Risk for After 4 hours
Blood heart failure of nursing
pressure as evidenced intervention
140/90 by low the patient
oxygen will be able
Pa02: 44, 60, levels and to:
62, 60 high blood
pressure.
PaC02: 58,
63, 44, 36

Pa02 44 60 62 60
PaC02 58 63 44 36
https://www.cardio.com/blog/copd-and-heart-failure-what-are-the-symptoms-and-how-are-they-related#:~:text=COPD%20and%20Right
%2DSided%20Heart,condition%20known%20as%20pulmonary%20hypertension.