1.

Diaphoretic: Sweaty

2. Febrile: High temperature

3. Tachycardic: High heart rate

4. Tachypnoeic: Increased respiratory rate

5. Sats: A test of the oxygen-saturated hemoglobin

6. ABGs: A test of gases and pH in arterial blood

7. Coarse rales: A series of short low popping sounds, also called 'crackles'

8. Haemoptysis: Coughing bloody sputum

9. Cyanosis: Bluish tinge around the skin, nail beds, and mucus due to lack of oxygen in the blood

10. Consolidation: Areas of density due to fluid, mucus, and edema on a chest X-ray

1. CONSIdER ThE pATIENT SITUATION

Trent’s tachypnoea and cough are most likely due to which of the following?
a His upper respiratory tract infection
b His history of smoking
c Early pulmonary oedema
d None of the above

Pneumonia affects gas exchange in which of the following structures of the lungs?
a Pleural space
b Alveoli
c Bronchi and bronchioles
d Trachea

2. COLLECT CUES/INfORMATION
You would expect a healthy patient to have areas of lung consolidation on chest X-ray.
a True
b False
b) Gather new information
You enter Trent’s room and he appears to be more settled than he was overnight. His oxygen mask is still
in place. You do another set of observations, with the following results:

Temperature 38.8°C
Pulse rate 110 beats/min
Respiratory 33
rate breaths/min
Blood pressure 100/55
mmHg
SpO2 90%
You then repeat Trent’s ABGs.

Q1 Which of the following should be included in an assessment for someone with suspected
pneumonia? (Select the five most correct responses.)

a Urine output
b White cell count

c Past cardiac history

d ECG

e Urinalysis

f Mental status

g Full blood count and serum electrolytes

h Breath sounds

i Assessment of pursed-lip breathing and/or use of accessory muscles

Q2 A person with pneumonia is likely to display rales (crackles) on auscultation.
a True
b False

Q3 A person with pneumonia is likely to display hyper-resonance on percussion.

a True
b False

Q4 Which two of the following is an abnormal finding on chest inspection?

a Respiratory rate of 12–20 breaths/min in an adult
b Abdominal movement
c Mouth breathing
d Inspiration lasting approximately twice as long as expiration

Q5 The body’s respiratory centre is primarily stimulated by:

a An increase in heart rate
b A rise in blood carbon dioxide
c A decrease in blood oxygen
d All of the above

Q6 List four common causes of low arterial oxygen levels (hypoxaemia).

Q7 The inflammation of pneumonia is most likely to cause a change in:

a Pulmonary circulation
b Diffusion of gases
c Work of breathing
d Regulation of breathing

Q8 A person experiencing respiratory difficulties may be able to speak only one or two words
between breaths.
a True
b False

Q9 When gathering information from a person who is very breathless, it is important to ask
__Closed__ ended questions.

Select from the following, four groups of people most likely to be affected by pneumonia.
a Older people
b Sportsmen/women
c Those with alcoholism
d Immunocompromised people
e Indigenous Australians
f Those with a chronic illness
g Those with cancer

1. Build-up of fluid in the space between the lung and chest wall: Pleural effusion

2. Malaise: Generalized feeling of being unwell

3. Pockets of pus in the space between the lung and chest wall: Empyema

4. Bacteremia or septicaemia: Bacteria in the bloodstream or throughout the body

5. Sputum material coughed up from the lungs: Mucus production.

6. Pockets of pus that form in the lung itself: Lung abscess.

7. Secondary bacterial lung infection after a viral infection: Secondary infection

8. Clinical sign of hypoxia, manifested by a feeling of breathlessness: Dyspnea.

9. Subjective sensation of a patient reporting loss of endurance: Fatigue

pROCESS INfORMATION
(a) interpret
You review and interpret all the information you have about Trent’s respiratory condition.
Q1 Trent’s respiratory rate is 33 breaths/min. Is this described as tachypnoea or orthopnoea?

Tachypnoea. Orthopnoea is a condition where a person finds it easier to breathe when sitting up.

Q2 You review Trent’s current ABGs. His PaO2 is 50 mmHg. The normal PaO2 for a healthy man of
Trent’s age would be between 75 mmhg and 100 mmhg.

Q3 Trent’s PaCO2 is 37. A normal PaCO2 for Trent would be between 35mmhg and 45mmhg,
while a normal pH would be between 7.35 and 7.45.

Q4 Trent’s PaCO2 is low and his pH of 7.45 indicates alkalosis. The most likely reason for this would be:
a Trent’s respiratory rate is raised due to hypoxaemia and a low PaO2 and he is retaining CO2 which has raised his
pH.
b Trent’s respiratory rate is raised as he is hypoxic, he has a low PaO2, and his rapid respiratory
rate has caused him to ‘blow off’ CO2 and raise his pH.
c Trent’s respiratory rate is decreased, so he is retaining CO2 and his pH is consequently raised.
d Trent’s respiratory rate is faster and the low PaO2 is causing a raised pH.
Select four cues that you believe are most relevant to the assessment of Trent’s hypoxia.
a Blood pressure: 100/55 mmHg
b Respiratory rate: 33 breaths/min
c Temperature: 38.8°C
d Pulse rate: 110 beats/min
e Headache
f SpO2: 90% on room air
g Appetite: decreased
h ABGs: PaO2 50 mmHg, PaCO2 37 mmHg, pH 7.45
i Urine output: 40 mL/hr

Q2 When Trent complained of some pain in the chest during his initial assessment in the ED, the
nurse asked him to describe the pain and whether it was travelling to his jaw or to his left arm.
The nurse’s question was asked to determine whether the chest pain could be due to:
a Myocardial infarction
b Congestive heart failure
c Bronchitis
d Pneumonia

(c) relate
It is important to cluster the cues together and to identify relationships between them (based on the
information you have collected so far).

Q1 Which of the following statements are true?

a Trent is tachypnoeic due to a high fever.
b Trent is hypoxic as mucus is partially blocking his airways and impeding gas exchange.
c Trent’s pulse is faster as a compensatory mechanism to increase gas exchange.

Q2 Select the most important cue cluster for a patient with pneumonia.
a Purulent sputum, clubbing of the fingers, cyanosis, cough, hyper-resonance, excessive thirst
b Cough, low oxygen saturations, a high BGL, retention of fluid as evidenced by weight gain,
hypo-resonance, tactile fremitus
c Tachypnea, fever, purulent sputum, a cough, coarse rales, oxygen saturation lower than
normal
d Weight loss over a few weeks, fatigue, low oxygen saturations, frothy blood-tinged sputum

(d) infer
It is time to think about all the cues you have collected about Trent’s condition, and make inferences
based on your analysis and interpretation of those cues.
Q1 In your opinion, and from what you know of Trent’s history, signs and symptoms, Trent is (select
two from the list below):
a Afebrile and tachypnoeic
b Hypertensive and tachycardic
c Tachypnoeic and tachycardic
d Hypertensive and afebrile
e Hypoxic and febrile
f Hypotensive and afebrile

Select five early signs of hypoxia from the list below.

a Tachypnoea or bradypnoea
b Dyspnoea
c Tachycardia or bradycardia
d Hypotension
e Fatigue
f Cyanosis
g Cardiac arrhythmias
h PaO
2 50–60 mmHg
i PaCO
2 50–60 mmHg
j Confusion

From the list below, select the seven late signs of hypoxia.

a Dyspnoea

b Tachypnoea or bradypnoea

c Cyanosis

d Unresponsiveness to verbal command

e Tachycardia or bradycardia

f Hypertension

g Cardiac arrhythmias

h Fatigue

i Hypotension

j PaO2 < 50 mmHg

k PaCO2 > 60 mmHg

l SpO2 < 90%

Trent’s SpO2 and PaO2 are both abnormal, indicating hypoxia. What factors do you think have
contributed to his hypoxia? (Select two.)
a Age
b Partial obstruction of his airways by mucus
c History of smoking
d Poor gas exchange due to mucus and fluid in the alveoli
e History of asthma

e) Predict
Q1 If you do not take the appropriate actions at this time, what could happen to Trent if his hypoxia
is not corrected? (Select two.)
a He will gradually improve over the next few days.
b He may become even more febrile and develop delirium.
c His chest pain could worsen leading to a cardiac arrest.
d His hypoxia will worsen and may lead to a respiratory arrest.

Q2 From the following list, choose the clinical indicator most indicative of impending respiratory arrest.
a Blood pressure: 100/55 mmHg
b Respiratory rate: 33 breaths/min

c Urine output: 40 mL/hr

d ABGs: PaO2 50 mmHg, PaCO2 37 mmHg, pH 7.45

4. IdENTIfy ThE pRObLEM/ISSUE

Now bring together (synthesise) all of the facts you’ve collected and inferences you’ve made to
identify the most correct nursing diagnosis for Trent.

a Risk of hypoxia due to confusion, low SpO2 level, tachypnoea and abnormal ABGs
b Hypoxia related to ineffective breathing pattern as evidenced by confusion, low SpO 2,
tachypnoea and abnormal ABGs
c Impaired gas exchange related to airway obstruction due to excessive secretions,
bronchospasm and alveoli destruction
d Risk of oxygen toxicity related to the provision of high concentrations of oxygen over a
prolonged period of time.

ESTAbLISh GOALS
Before implementing any actions to improve Trent’s condition, it is important to clearly specify what
you want to happen and when.
From the list below, choose the most important short-term goal for Trent’s management at this time.
a For Trent to be afebrile and to have no pain within 20 minutes
b For Trent’s infection to be resolved within 3–5 days
c For Trent to have a normal respiratory rate and an oxygen saturation level of >94%
d For Trent to be normotensive and euvolaemic
--------- 6. Take action

Monitor oxygen saturations and ABGs regularly:

To increase partial pressure of oxygen in alveoli and increase diffusion into capillaries.

Check cognitive status regularly:

To maintain psychosocial wellbeing.

Position in semi- or high Fowler’s:

To reduce oxygen demand.

Reassure patient and reduce anxiety:

To reduce oxygen demand.

Teach patient deep breathing and coughing:

To aid in removal of secretions.

Keep patient well hydrated:

To reduce pain and increase comfort.

Maintain oxygen therapy via nasal prongs or Hudson mask:

To increase partial pressure of oxygen in alveoli and increase diffusion into capillaries.

Give patient paracetamol:

To reduce viscosity of secretions.

Identify three priority nursing actions from the list below:

a- Reassure patient.

b-Run to find another nurse to help you.

c- Initiate a rapid response or medical emergency team (MET) call.

d- Reconnect the oxygen.

e- Get ready to start CPR (cardiopulmonary resuscitation).

f- Check that Trent’s fluids are running.

g- Monitor Trent’s pain score.

h- Monitor Trent’s vital signs and oxygen saturation level.

Q3 Identify three factors that may have caused deterioration in Trent’s respiratory status, leading to

severe hypoxia and acute respiratory failure.

a -Trent was given too much to drink as well as IV fluids, leading to fluid overload and

pulmonary oedema.

b- The increase in Trent’s mucus secretions led to decreased gas exchange.

c- Increasing confusion and continual removal of the oxygen mask led to increasing hypoxia.

d- Ventilation was reduced due to reduced chest wall expansion from increasing, untreated pain.

e- Decreased neurological status due to administering the central nervous system (CNS)

depressant morphine, which affected the brain stem and reduced breathing rate.

f- Failure of the ward nurses to recognise Trent’s increasing respiratory distress as evidenced by

his increasing confusion and low SpO2

Q4 Match the oxygen delivery devices to the appropriate flow rate and FiO2

Oxygen delivery device Flow rate FiO2

Nasal prongs 6–15 L/min 0.24–0.36

Hudson mask 10–15 L/min 0.4–0.6

Non-rebreather mask 2–4 L/min 0.6–0.9

Nasal prongs: 2–4 L/min; 0.24–0.36 FiO2

Hudson mask: 10–15 L/min; 0.4–0.6 FiO2

Non-rebreather mask: 10–15 L/min; 0.6–0.9 FiO2

7. Evaluate

Q1 With the correct treatment, you would expect Trent’s SpO2 to increase to ~97% and his respiratory
rate decrease to between 12 and 18 if his condition resolves.

a True b False
 Action
Monitor oxygen saturations and ABGs regularly
Check cognitive status regularly
Position in semi- or high Fowler’s
Teach patient deep breathing and coughing
Keep patient well hydrated
Maintain oxygen therapy via nasal prongs or
Hudson mask
Reassure patient and reduce anxiety
Give patient paracetamol
Rational
Changes may indicate worsening hypoxia
Anxiety and restlessness may indicate
worsening hypoxia
To reduce oxygen demand
To aid in removal of secretions
To reduce viscosity of secretions
To increase partial pressure of oxygen in alveoli
and increase diffusion into capillaries
To maintain psychosocial wellbeing
To reduce pain and increase comfort

Q3 What nursing actions may have prevented Trent’s deterioration? (Choose three from the list below.)

a- A sedative should have been administered to help Trent settle.

b- More frequent observations of pulse oximetry and vital signs should have been conducted.

c- The significance of his ABGs should have been recognised.

d- A medical review should have been requested earlier.

e- Trent’s fluids should have been increased.

f- Trent should have received more antibiotics to treat his infection.

Power point

The _____ has the thickest walls as it pumps blood to ______. Choose

the correct responses below.

a. Right atrium, systemic circulation

b. Right ventricle, pulmonary circulation

c. Left atrium, pulmonary circulation

d. Left ventricle, systemic circulation

Freshly oxygenated blood enters the heart through the ______, and is

pumped out into the _______. Choose the correct response sfrom the

options below.

a. Right atrium, aorta

b. Left atrium, aorta

c. Right ventricle, pulmonary arteries

d. Left ventricle, pulmonary arteries.

--- What does ACS mean? Acute Coronary Syndrome

• What does GTN mean? Glyceryl Trinitrate

• What are the two signs of a myocardial infarction that may be seen on

an ECG?

• ST depression

• ST elevation

• T wave inversion

• Abnormal P-wave development

From the list below, identify the cue that is not relevant to your assessment of David at this time.

• 12-lead ECG

• Potassium level

• Blood pressure

• Sodium level

• Pain score

• Temperature
The normal ST segment on an ECG is usually iso-electric

• True • False

The monitor was showing ventricular fibrillation • True • False

The rapid response team arrives and takes over CPR that you have started. Place the following actions
in the correct order

1. Attach defibrillator pads

2. Check monitor and assess rhythm as shockable or non-shockable
3. Deliver shock
4. Continue CPR

• What is the ratio of breaths to compressions in BLS? 2:30

• Which of the following rhythms is a ‘shockable’ rhythm?

• Aystole

• Ventricular tachycardia

• Pulseless electrical activity

Which of the following are correct nursing diagnoses for David at this time?

• Chronic pain related to tissue ischaemia, evidenced by facial grimacing,

restlessness, changes in LOC, changes in pulse rate and blood pressure

• Risk of fluid volume deficit related to decreased sodium/water retention

• Risk of fluid volume excess related to increased sodium/water retention

• Risk of decreased cardiac output related to changes in rate, rhythm and electrical conduction

From the following list of goals, which would be 2 most appropriate short-term goals

• For David to have no chest pain within 20 minutes

• For David’s fluid restriction to be maintained during his admission

• For David to have no evidence of impaired gas exchange within one hour

• For David to be free from anxiety by using stress reduction techniques within five days

• What would be nursing actions for your selected short-term goals?

• Pain relief/analgesia (morphine), pain assessment and cardiac monitoring

• Administer oxygen if decreased SpO2