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Respiratory Case Study

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Dan Elliot

on 30 March 2014

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Transcript of Respiratory Case Study

Respiratory Case

Dan Elliot, Jenny Mackay,
Lisa Mcluskie, Rohinee Mohla


DO NOT USE THE MED; violates 5 rights of med admin. (RIGHT PATIENT)
Contact the pharmacist for stat refill (if not already done)
Emergency med kit per facility protocol
Contact the doctor
If necessary, contact the charge nurse/supervisor
Go up the chain of command if further interventions needed
Make sure meds are ordered in a timely fashion in the future for patient safety & quality care.

Case Study

While you administer the furosemide and hang the intravenous medication, G.S. tells you, “This is so strange, a couple of times this morning, I felt like my heart flipped upside down in my chest, but now I feel like there’s a bird flopping around in there.”

What two priority actions should you take? Provide your rationale.

Look at cardiac monitor & implement cardiac protocols if necessary (code) to detect arrhythmia and correct it.
Vital signs to detect current patient status and recent lab values.

Case Study
G.S.’s pulse is irregular. Her BP is 92/70 and her respirations are 28. She admits to being “a little lightheaded” but denies having pain or nausea. Your co-worker connects G.S. to the code cart monitor for a “quick look”. You are able to distinguish normal P-QRS-T complexes but you also note approximately 22 very wide complexes per minute. The wide complexes come early and are not preceded by a P wave.

What is your impression of these findings?

What is your next priority action?
Electrical defibrillation or cardioversion (electric shock)
Anti-arrhythmic medications (such as lidocaine, procainamide, sotalol, or amiodarone) given through a vein
Call a code.

What factors have contributed to these clinical findings?
Case Study
You notice that G.S. looks frightened and is lying stiff as a board.

How would you respond to this situation?
Support the patient.
Explain to the patient what is happening to ease the anxiety.
Non-pharmacological relaxation techniques.
Social worker.
Recheck EKG and VS to prevent possible V-tach

What treatment is indicated for G.S.’s arrhythmias?
Based on the recent turn of events the team of physicians recommend that a family meeting should be conducted to determine G.S.’s wishes should her condition worsen and her heart and lungs stop functioning.

Case Study
Discuss what type of ICU care is appropriate for G.S. and her family?
Coronary Care Unit (Cardiac); Cardiac Intensive Care Unit.
Need to discuss advance directives and health care proxy


What do you think this means?
ABGs 20 min later

pH 7.32, pCO2 49,
pO2 56,
HCO3 22, SaO2 86.
Chest X-ray showed diffuse bilateral infiltrates
in all lung fields.

Mode: Bilevel with conventional rate
PEEPH: 25 cm H2O
PEEPL: 10 cm H20
(3 cm H2O above L.I.P.)
Targeting Vt 4-6 ml/kg
According to IBW, 200- 300ml
TH: 1 s
RR: 20
** PSV for spont. breathing

“Prone positioning can
improve oxygenation in up to
70% of patients with acute
respiratory distress
syndrome (ARDS)
or acute lung injury (ALI).”

CXR w/diffuse bilateral infiltrates

Female, weight = 70 kg,
Height = 158cm
Intubated nasally
Current Vent Management:
Vt 650 mL FiO2 = 0.6
ABG = uncompensated respiratory acidosis with moderate hypoxemia
P/F ratio = 93 (Severe ARDS)

Proposed Vent
Management Strategy
What additional assessment findings may be found in ARDS?

Pulmonary HTN
Multiple organ system failure
Cyanosis of skin, lips, nail beds
Delayed capillary refill
Adventitious lung sounds
Prolonged hypoxemia
despite 02 delivery

-heart flip-flop sensations
pulse irregular
-b/p 92/70
-RR 28
-"a little lightheaded"
-denies pain
-denies nausea
-22 very wide complexes/minute
-early complexes
-not preceded by P wave

-A premature ectopic impulse originating in the ventricles
-Usually caused by increased automaticity and electrical irritability in the ventricular conduction system or muscle tissue
-Can lead to more serious arrhythmias (V tach: 3 PVCS in a row with a fast rhythm,150-250 HR) and decreased cardiac output
-Characterized by an early, abnormal QRS complex
-No P wave; P wave can be within underlying rhythm
-Some causes are Hypoxia, acidosis, electrolyte imbalance, anxiety which are related to G.S.
-Typically dx after patient describes "skipping, racing, flipping, flopping sensations"
-Those sensations are due to a pause after the premature
contraction and then a powerful contraction after the pause.
Signs and symptoms include:

Abnormal EKG

Irregular heart beat
• Shortness of breath

• Feeling your heart beat (palpitations)
• Feeling of occasional, forceful beats
• Increased awareness of your heart beat

Premature Ventricular Contractions
-Correct underlying problem
-Could require no treatment
-If frequent or poorly tolerated, IV lidocaine or procainamide may be used
-In non-acute setting, oral antiarrhythmics may be given

-heart flip-flop sensations
-pulse irregular
-b/p 92/70
-RR 28
-"a little lightheaded"
-denies pain
-denies nausea
-electrolyte imbalances; WHAT ELECTROLYTE IS MOST IMPORTANT?
-respiratory acidosis

-22 very wide complexes/minute
-early complexes
-not preceded by P wave

Ventricular Tachycardia Treatments
-correcting the underlying causes
-correct electrolyte levels; oxygen
-continue current meds
-continue cardiac monitoring and VS
-support the patient and family
-prevent further complications
50-year female,
70 kg, 158 cm presented
with respiratory distress, and confusion developing after
seven days of fever, dysentery
and weakness. Oxygen by
venti-mask at 50 % and
prophylactic antibiotic
therapy initially helped.

Second day:

The patient became extremely
restless, violent and confused.
She started showing signs of
cyanosis and tachypnea
(RR>50/min). It was decided to
nasally intubate this patient
and initiate mechanical ventilation.
IPPV was started at FiO2 60 %
(tidal volume 650ml; RR 12/min).

Key Points:
Advantages of Bi Level
The ARDS Foundation

Nursing 2009 Critical Care May edition
Prone Ventilation in Trauma or Surgical Patients With Acute Lung Injury and Adult Respiratory Distress Syndrome:

ALI/ARDS patients who received prone kinetic therapy had greater improvement in PaO2/FiO2 ratio, lower mortality, and less pulmonary related mortality than did supine positioned patients.
James W. Davis, MD, FACS

Patients with ARDS and severe hypoxemia (as confirmed by a PaO2/FiO2 ratio of
< 150 mmHg, with an FiO2 of ≥ 0.6 and a PEEP of ≥ 5 cm of H2O) can benefit from prone treatment when it is used early and in relatively long sessions.

Improved oxygenation
with ARDS

Efficient drainage of secretions

Lung fits into the prone thorax with less distortion

Proning Benefits

Sustained response to recruiting maneuver

Protects against Ventilator-Induced lung injury

Shown to decrease mortality

***Supine position predisposes airway closure in the dorsal regions that receive the
majority of blood

Proning Benefits
An easy and effective way to deliver the proven benefits of prone therapy, the RotoProne Therapy System has been designed to help aggressively treat patients with severe pulmonary complications such as Acute Respiratory Distress Syndrome.

RotoProne Bed

New Technology
466 patients were recruited from 27 “experienced” ICUs (where prone positioning had been used in daily practice for more than 5 years) and randomized to undergo daily prone-positioning sessions of at least 16 hours or to be left in the supine position.

Rocks. He is awesome!
Parameter / Setting

Peep H 30 cmH20
Peep L 5 cm H20
Time H 1 sec.
RR 10
PSV 15 cmH20

Thank you
and Goodnight!
Full transcript