Respiratory - Nursing Case Study

Pathophysiology

• Primary mechanism: Gas exchange - the main function of the respiratory system is to facilitate gas exchange, specifically oxygen and carbon dioxide. Oxygen is inhaled into the lungs and diffused into the blood, while carbon dioxide, a waste product of cellular metabolism, is expelled from the body during exhalation.

• Secondary mechanism: Acid-base balance - the respiratory system helps maintain the body's pH by controlling the levels of carbon dioxide, a major component of blood acidity. When the body's pH is imbalanced, the respiratory system compensates by adjusting the rate and depth of breathing.

• Key complication: Hypoxia - inadequate oxygen supply at the tissue level is a major complication of respiratory disorders. It can result from problems in ventilation, diffusion, or perfusion. Symptoms include shortness of breath, rapid breathing, and cyanosis. Chronic hypoxia can lead to organ damage.

• Potential complication: Respiratory failure - defined as a failure in gas exchange

Patient Profile

Demographics:

55-year-old, male, construction worker

History:

• Key past medical history: Smoker for 30 years, diagnosed with chronic obstructive pulmonary disease (COPD) 5 years ago, occasional bouts of pneumonia

• Current medications: Albuterol inhaler, Tiotropium, Prednisone as needed

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increased shortness of breath, productive cough with yellow sputum

• Key symptoms: Fatigue, wheezing, chest tightness, slight fever

• Vital signs: Blood pressure 140/90 mmHg, heart rate 105 bpm, respiratory rate 22 breaths/min, oxygen saturation 88% on room air, temperature 100.6°F

Section 1

Change in Patient Status:

Over the next 24 hours, the patient's condition begins to deteriorate. His shortness of breath becomes more pronounced, and his oxygen saturation levels decrease to 82% on room air. His respiratory rate increases to 30 breaths per minute and his heart rate climbs to 120 bpm. Despite the use of his prescribed inhalers, the patient reports that his symptoms have not improved. He also complains of feeling increasingly fatigued and is unable to perform his usual daily activities.

On physical examination, the patient appears to be in respiratory distress with accessory muscle use. Auscultation of his lungs reveals bilateral crackles and wheezing. His temperature has risen to 101.2°F, indicating a possible infection. The worsening of his symptoms, coupled with his fever and the change in his sputum color, suggest a possible exacerbation of his COPD, potentially secondary to a respiratory infection. The healthcare team recognizes the need for immediate intervention to prevent further complications such as respiratory failure.

Section 2

New Diagnostic Results:

Lab results return showing elevated white blood cell count of 18,000/mm3, further suggesting an infection. A sputum culture is ordered and the preliminary results indicate the presence of Streptococcus pneumoniae, an organism commonly associated with community-acquired pneumonia. An arterial blood gas (ABG) is taken, revealing hypoxemia with a PaO2 of 60 mmHg, and hypercapnia with a PaCO2 of 55 mmHg, indicating a failure of the respiratory system to adequately exchange and transport gases. The patient's B-type Natriuretic Peptide (BNP) level is also moderately elevated at 580 pg/mL, suggesting some degree of heart failure.

A chest X-ray is ordered and reveals diffuse infiltrates and increased interstitial markings bilaterally, consistent with an infectious process. In addition, there is evidence of hyperinflation and flattened diaphragms, characteristic of COPD. The healthcare team must now infer from these findings and decide on the most appropriate course of action. The patient's worsening condition and the new diagnostic results suggest a need for escalation of care, possibly requiring hospitalization, administration of antibiotics, and close monitoring of his respiratory status.

Section 3

Change in Patient Status:

Over the next few hours, the patient's condition deteriorates further. His respiratory rate increases to 28 breaths per minute and he becomes increasingly dyspneic, even at rest. His oxygen saturation drops to 88% on room air, indicating worsening hypoxemia despite supplemental oxygen therapy. He also develops a productive cough with yellowish-green sputum. On auscultation, the lung fields reveal decreased breath sounds with widespread crackles and wheezes. His heart rate escalates to 110 beats per minute and his blood pressure drops to 100/60 mmHg.

At this point, the patient becomes increasingly anxious and reports a feeling of 'air hunger'. Further physical examination reveals an increased jugular venous pressure and pitting edema in the lower extremities, suggesting worsening heart failure. The team decides to reevaluate the plan of care in light of these new developments. The patient's deteriorating respiratory status and signs of escalating heart failure indicate a need for more aggressive interventions, including possible intubation and mechanical ventilation, as well as initiation of treatment for heart failure. These changes underscore the importance of vigilant monitoring and timely reassessment in response to changing clinical conditions.

Section 4

New Diagnostic Results:

With the patient's condition worsening, the team orders a complete blood count (CBC), B-type natriuretic peptide (BNP), arterial blood gas (ABG), and a chest X-ray. The CBC results show a high white blood cell count of 15,000 cells/mcL, indicating an ongoing infection. The BNP level is elevated at 900 pg/mL, supporting the clinical suspicion of heart failure. ABG analysis reveals a pH of 7.32, PaCO2 of 50 mmHg, and PaO2 of 60 mmHg, indicating respiratory acidosis and hypoxemia. The chest X-ray shows bilateral infiltrates, suggestive of pneumonia.

The new diagnostic results confirm the patient's progressive condition: pneumonia, exacerbated heart failure, and respiratory failure. The elevated BNP and ABG results, along with the physical findings of increased jugular venous pressure and pitting edema, strengthen the heart failure suspicion. The high white blood cell count and the chest X-ray support the diagnosis of pneumonia. These findings demonstrate the complex interplay between the patient's respiratory and cardiac conditions, emphasizing the need for a comprehensive, multi-system approach in managing his care. The team must now consider the best course of action to treat the pneumonia, manage the heart failure, and support the patient's respiratory function.

Section 5

Given the patient's worsening condition, the team decides to initiate aggressive treatment. The patient is started on broad-spectrum antibiotics to address the pneumonia, diuretics to manage the fluid overload related to heart failure, and supplemental oxygen to improve hypoxemia. Despite these measures, the patient's status continues to decline. His oxygen saturation levels fluctuate between 88% to 92% on 4 liters of supplemental oxygen, respiratory rate is persistently elevated at 24 breaths per minute, and he develops a new onset of confusion.

The nurse's reassessment reveals increased work of breathing, with use of accessory muscles and intercostal retractions. The patient's blood pressure has dropped to 100/60 mmHg from a baseline of 130/80 mmHg, and heart rate has increased to 110 beats per minute. Repeat ABGs show worsening respiratory acidosis with a pH of 7.28, PaCO2 of 55 mmHg, and PaO2 of 55 mmHg. The team is now faced with the challenge of responding to these changes and determining the next steps in the patient's care. The new findings suggest possible sepsis due to pneumonia and worsening of respiratory failure, necessitating a potential need for intubation and mechanical ventilation. The team must act swiftly and collaboratively to stabilize the patient and prevent further decline.