5

RESPIRATORY CASE STUDY

Mrs. C is a 75 year old married woman with severe oxygen and

corticosterioid-dependent chronic obstructive pulmonary disease
(COPD). She arrived in the emergency room because of
increasing shortness of breath, increased purulent sputum and
difficulty breathing at rest. She wears home O2 at 2L.
Laboratory Data:
indicates infection
White blood cells – ​20,000 → high →
Hemoglobin ​ ​10.9 gm → mild anemia
Platelettes ​ ​165,000 HOW

ABG on 2L NC:
​pH 7.3 → acidotic
YETIS
780
​PO2 60 mmg Hg → LOW
35-45
​PaCO2 55 mm Hg → high
​HCO3 27 mEq/L 22-26
→
high
​POX 84% → low > 92%
1. How do you analyze these results?
① acute anemia during COPD exacerbation
Hypoxemiais tlowllegb
→

MBC possibly in compensated respiratory

acidosis due to acidotic pit , high Cozt slightly
high to use kidneys to compensate
HCO} →
trying low platelets
Bacterial infection
causingand consolidation in the
Chest X-Ray – Patchy infiltrate
posterior basal segment of the right lower lobe. Cardiomegaly
noted.
Physicial Assessment:
AAOX3, Respirations labored. Use of accessory muscles.
 Patient sitting in the tripod position and utilizing pursed lip
breathing. Lung sounds diminished bilaterally with course
crackles in the right middle lobe and right base.
VSS: BP 154/86, RR 32, Pulse 124 bpm proem consolidation.

2. What is Mrs. C. Experiencing? resp distress , resp acidosis

.
.

trim mine
troms 3. What factors contributed to the development of this
system
corticosteroid condition in Mrs. C? severe Oz dependence, COPD
dependence4. What are the pathophysiologic effects and clinical
manifestations supporting this diagnosis?
5. Why is Mrs. C utilizing the tripod position and pursed lip
breathing?
infection dueto increased ABC
possible pneumonia
+ radiology report labored breaths
coz release causing
4) inadequate oxygenation
+
constriction
muscles
of accessory Positioning rlt broncho
&
volume is deer > Moormall 30%3
use
forced expiratory
.

signifies sounds t crackles → fluid

in
lungs
BIL diminished lung
→ blows off excess coz to stabilize
chest
g) pursed lip down
forward
Tripod → forces diaphragm+ reduce work of breathing
&

Provider Orders:
BIPAP (Bilevel Positive Airway Pressure) 15:2, FiO2 60%
Ciprofloxacin 500 mg IV Q8h
Methylprednisolone (Solu-Medrol) 125 mg Q8h
Ipratropium/albuterol nebulization Q2h PRN
6. What is BIPAP?
7. What nursing interventions are appropriate for a patient
utilizing BIPAP?
8. What are the indications for each of these medications?
9. Which of these treatments are the most important in
returning her to her usual level of respiratory function?
Bipap machine pushes air into lungs at mask connected
to a
⑥ air
ventilator supplies pressurized
into air
.
ways Opens
.

with
positive air pressure
.

lungs
⑦ Pt education regarding keeping Bi PAP on face +
cardiac
why device
is being used continuous Oz saturation
. &

ventilation
monitoring
via Bi PAP → provide pos pressure
⑧ Oxygen
-

infection
ciprofloxacin → antibiotic pneumonia
to treat

corticosteroid to decrease inflammation

methyl pred → Betaadrenergic blocker/ broncho dilators
Ipratoopiumlalbvt hey →to help .

open airways
Six hour after implementing the above orders, Mrs. C’s
assessment is as follows:
ABG (on BIPAP):
⑨ steroid
ftp.ratropium/A1bUter0lneb
most isp ! .
.

​pH 7.29 40W ! ! ) then oxygen via Bipap

​PaO2 58% 10W
​CO2 66 mm Hg high ! !
​HCO3 27 mEq/l high
​POX 83% 10W !
Physical Assessment:
Lethargic, oriented to self only
Lungs: Diminished breath sounds throughout with course
crackles right middle lobe and right base.
Respirations: labored, use of accessory muscles
VSS: BP 154/86, RR 34, Pulse 124 bpm
10. What further intervention do you feel is indicated for Mrs.
C?
11. Communicate your concerns to the provider utilizing
SBAR format.
Intubation via mechanical ventilation administer
⑧
+

demand
morphine to reduce oxygen
resp
about Mrs c. in ICU Come in for
④ Nurse calling
.

Caroline
.
.

She was treated with ciprofloxacin Soong

distress 6h B. ago
.

neb Currently on BIPAP

& Ipratrop talbot
methyl pred
.
.

34 & pulse 124

are BP 154186 , RR
.

60%
15.2 , fi 02 Vitals
sounds diminished with
.

oriented to self only Long

base with feverof
+
Lethargic
.

crackles in middle lob + right

right
show resp acidosis Due to ineffective
coarse
102°F Most recent ABG s recommend intubation on
. .

placing
.

decline , I
BIPAP & resp
-

ventilator
Mrs. C on mechanical
.
 Mrs. C. is intubated at the bedside and placed on mechanical
ventilation.
12. What are the complications of mechanical ventilation.
13. What nursing interventions are appropriate for Mrs. C?
④ VAP is # concern ! pulmonary edema
, pulmonary embolism
,

pneumothorax & pressure injuries .

needed
⑨ Oral care of4h , elevated HOB 350-400 suction as
,

monitor vitals , resp assessment reposition 82h

.

promote early ambulation , support patient

if
agitated or

uncomfortable
Mrs. C is agitated and restless on the mechanical ventilator. The
ventilator is alarming high pressure. Prioritize your nursing
actions to troubleshoot the alarm. Discuss the possible causes
for both high pressure and low pressure alarms on the ventilator.
needs to be , Kinks
High pressure mucus
:
high blockage ,
suctioning , pt biting
in tube , plug , excessive airway secretions
disconnected or loose connections)
Low pressure : air leak ( tubing
① Assess pt
looking for alarm
causes
ventilate pt while
② manually
Three days later, Mrs. C. is able to wean off of the ventilator.
She is now tolerating nasal cannula at 2L. Her POX is 92%.
She is ready to be discharged to home in the care of her
daughter.
14. Is her pulse oximeter reading concerning?
15. What discharge teaching should Mrs. C receive?
↳ next
page
⑧ poise ox reading concerning ?
-
we would normally prefer
pt to have pulse ox of
Mrs. C has h ✗
981 above for discharge
.

94-1001 → .

. .

baseline pulse ox lower than

OfCOPD & will have a
her
are optimistic about
expected range we .

of intubation
only days
3
.

successful wearing t

status
This indicates a stable resp
.

④ Discharge Teaching ?
safety
:
Oz
-
Supplemental at all times , wear
cotton clothes t
• upright
store tank
blankets
don't use any synthetic !
near equipment sakes
NO smoking
from flame / heat
•

least away ]
•
Keep 025ft at CNO Petroleum on skin
Water-based products only
•

rlt COPD
:

recommendations meals
Dietary
calorie , small +frequent
-

High stick to
candy ] +
carbs (sugar, breads )
limit simple pasta
&
grain
•

complex carbs Cuhole dnhkptenty

day
•

fiber each offluids

Eat 20-30 g
limit caffeine
•

in diet
• limit sodium ,

modifications r It COPD :
Behavioral exercise
right needed
&
-

cessation ! eat
smoking
•

use Oz as
of rest
plenty
•

of infection
•

+soirees
• avoid crowded spaces
to expel
mucus
learn techniques
.