oxygen therapy - Nursing Case Study

Pathophysiology

• Primary mechanism: Oxygen therapy increases the amount of oxygen in the blood. This is critical because cells in the body need oxygen to function and produce energy. When there is a lack of oxygen (hypoxia), cells may not function properly, causing damage to tissues and organs.

• Secondary mechanism: Oxygen therapy helps decrease the work of breathing in patients with respiratory distress. By providing supplemental oxygen, it reduces the effort the lungs need to extract oxygen from the air, allowing for easier breathing and reduced strain on the respiratory system.

• Key complication: Oxygen toxicity can occur if high concentrations of oxygen are given for an extended period. This can lead to lung damage and other complications like dry or bloody nose, skin irritation, and nausea. It's crucial to monitor oxygen levels and adjust the therapy as needed.

Patient Profile

Demographics:

68 years old, male, retired teacher

History:

• Key past medical history: Mild Chronic Obstructive Pulmonary Disease (COPD), hypertension

• Current medications: Amlodipine for hypertension, Spiriva for COPD

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Shortness of breath on exertion

• Key symptoms: Mild fatigue, occasional cough, reduced exercise tolerance

• Vital signs: Blood pressure 128/78 mmHg, pulse rate 72 bpm, respiratory rate 16 breaths per minute, oxygen saturation 94% at rest, body temperature 98.6°F

Section 1

Initial Assessment Findings:

During the initial assessment, the patient was found to be in mild respiratory distress after a short walk from the waiting room to the examination room. He appeared mildly cyanotic with an increased respiratory rate of 22 breaths per minute and his oxygen saturation dropped to 90% during the walk. Upon auscultation, there were decreased breath sounds and faint wheezing in the lower lobes of both lungs. The nurse also observed the use of accessory muscles during breathing. The patient's blood pressure was slightly elevated to 134/82 mmHg and pulse rate was increased to 78 bpm, likely due to the exertion. The patient verbalized feeling winded and stated, "I just can't seem to catch my breath as easily as I used to."

The patient's symptoms, along with his medical history, suggest that his COPD may be progressing. The decrease in oxygen saturation during exertion and his elevated respiratory rate indicate that his body is working harder to get the necessary oxygen. The observed use of accessory muscles also suggests increased work of breathing. The initial assessment findings point to a need to reassess his current COPD management plan, including his oxygen therapy regimen, to ensure it is effectively meeting his oxygenation needs.

Section 2

New Diagnostic Results:

The patient's arterial blood gas (ABG) results came back, showing a PaO2 of 58 mmHg and PaCO2 of 47 mmHg. The bicarbonate level was 32 mmol/L and the pH was 7.34, indicating a state of compensated respiratory acidosis commonly seen in COPD patients. His complete blood count (CBC) showed a slightly elevated white blood cell count of 12,000 /µL, which could suggest a minor infection. Pulmonary function tests (PFTs) revealed decreased forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) ratios, further indicating obstructive lung disease.

These results suggest that the patient's COPD is indeed worsening, necessitating a review and likely revision of his current management plan. The decrease in his PaO2 and increase in PaCO2 levels suggest that his lungs are not effectively exchanging gases. The elevated bicarbonate level is the body's attempt to compensate for the increased carbon dioxide. His decreased FEV1/FVC ratio further supports the diagnosis of COPD. The slight elevation in his white blood cell count could suggest the presence of an infection, which can exacerbate COPD symptoms. It's important to monitor the patient closely and perhaps consider antibiotic therapy if an infection is confirmed.

Section 3

Change in Patient Status:

Upon reevaluation, the patient's status appears to be stable with minor changes. His recent vital signs are as follows: blood pressure 130/85 mmHg, pulse rate 90 beats per minute (bpm), respiratory rate 22 breaths per minute, oxygen saturation 90% on room air, and temperature 98.6°F. These indicate slight tachycardia and tachypnea, common in COPD patients, and a slight decrease in oxygen saturation, aligning with the earlier ABG results.

The patient reports experiencing increased shortness of breath, particularly on exertion, and a mild productive cough with yellowish sputum. He denies fever, chills, or chest pain. Physical examination reveals bilateral wheezes and reduced breath sounds on auscultation, which is consistent with obstructive lung disease. The patient's increased shortness of breath and production of yellow sputum could suggest a minor infection, reinforcing the earlier suspicion based on the slightly elevated white blood cell count. The clinical team plans to conduct a sputum culture to confirm this suspicion and to help guide the potential use of antibiotics. The team will continue to closely monitor the patient's clinical status and adjust the management plan as necessary.

Section 4

Response to Interventions:

After 24 hours, the patient is reevaluated following the initiation of oxygen therapy at 2 liters per minute via nasal cannula, and the administration of a bronchodilator to aid his breathing. His vital signs are now as follows: blood pressure 120/75 mmHg, pulse rate 82 bpm, respiratory rate 18 breaths per minute, oxygen saturation increased to 94% with supplemental oxygen, and temperature 98.4°F. These data suggest an improvement in the patient's respiratory status, with the heart rate and respiratory rate returning to near-normal levels and oxygen saturation improving.

On physical examination, the patient's wheezing has slightly reduced and he reports a decrease in his shortness of breath. However, he continues to have a productive cough with yellowish sputum. The patient's response to the interventions so far suggest that the oxygen therapy and bronchodilator are helping to alleviate some of his respiratory distress. However, the ongoing production of yellowish sputum indicates that there may still be an underlying infection that needs to be addressed. Therefore, the clinical team decides to await the results of the sputum culture before making further changes to the management plan.

Section 5

New Diagnostic Results:

Two days later, the results from the sputum culture arrive. The culture reveals the presence of Streptococcus pneumoniae, confirming the clinical team's suspicion of an underlying bacterial infection. The sensitivity report shows that the bacteria is sensitive to amoxicillin, a commonly used antibiotic in the treatment of respiratory infections. Considering these results, the clinical team decides to add amoxicillin to the patient's treatment regimen.

Meanwhile, his latest blood work shows a slightly elevated white blood cell count of 12,000 cells/mm3, which is a typical response of the body to a bacterial infection. Although the patient's oxygen saturation remains at 94% with supplemental oxygen, the team aims to continue the oxygen therapy and monitor the patient closely to prevent any potential respiratory distress. The patient's temperature has also increased slightly to 99.2°F, indicating that the body is fighting off the infection. The team plans to reassess the patient's condition after 48 hours of antibiotic therapy.