NetCE - Continuing Education Online
Home About NetCE Staff & Faculty  Contact  Us 
Course Case Studies

Course Case Studies

  
Read course content

Course # 38820 • Pathophysiology: The Respiratory System

ASTHMA

Patient A is a woman, 42 years of age, admitted to the critical care unit (CCU) for an acute asthmatic attack. For three weeks prior to admission, the patient had increasing difficulty with cough with thick, white sputum, shortness of breath, syncope episodes associated with wheezing, and intermittent fevers up to 101 degrees F (37.8 degrees C).

Patient A is married and has two children in college. Although she has no smoking history, she was forced to retire from her job four years ago because of her chronic obstructive lung disease.

Past Medical History

Patient A reports allergies to erythromycin and penicillin. She has a history of asthma precipitated by dust, pollens, fumes, and air pollution requiring multiple emergency department visits and hospital admissions over the past 10 years. She also reports thrombophlebitis and hypertensive syncope accompanied by seizure activity for one year.

Past surgical procedures include left brachial artery embolectomy done 4 years previously, right knee repair completed 10 years previously, remote hemorrhoidectomy, and remote tonsillectomy and adenoidectomy in childhood. She is currently taking sustained-release theophylline, prednisone, phenytoin, warfarin, terbutaline sulfate, and metaproterenol sulfate inhaler.

Assessment and Diagnosis

Upon admittance to the CCU, a full physical exam is conducted (Table 1). An ECG is done and shows sinus tachycardia with incomplete right bundle branch block. Several laboratory tests are ordered, with the following results:

  • White blood cell count: 9.5 x 109/L

  • Hemoglobin: 18.2 g/dL

  • Hematocrit: 53.2%

PATIENT A'S PHYSICAL EXAM RESULTS

ParameterFindings
General appearance
Heavy-set, agitated, diaphoretic woman breathing with pursed lips
Height: 5 feet 2 inches (157.5 cm)
Weight: 187 pounds (85 kg)
Head and eyes
Normocephalic
Pupils equal, round, reactive to light, accommodation
EarsTympanic membranes intact and clear
Neck
Supple, without masses or thyromegaly
Jugular-vein distention to 7 cm while sitting up 45 degrees
Chest
Dyspnea with rib retractions
Unable to complete a sentence without taking a breath
Fair inspiratory effort
A few diffuse inspiratory wheezes, marked expiratory wheezing
Abdomen
Rounded with active bowel sounds
Soft and nontender to palpation
ExtremitiesPeripheral pulses full, equal, and without bruits
Genitourinary systemWithin normal limits
Neurologic status
Oriented to person, place, and time
Cranial nerves II–XII grossly intact
Sensory and motor function intact
Cardiovascular system
Point of maximal impulse not palpable
Heart sounds very difficult to hear
Peripheral pulses present and thready
Left radial pulse barely palpable
Vital Signs
Blood pressure100/60 mm Hg
Temperature101° F
Heart rate55 beats per minute
Respiratory rate18 breaths per minute

Based on the results of the assessment, Patient A is diagnosed with acute asthma attack.

Management

Patient A's ventilation and oxygenation are managed and monitored by arterial blood gas results. Pulmonary spirometry is also used to evaluate her progress, and there is marked improvement with a bronchodilator. Patient A is transferred out of the CCU on the fourth day and discharged on the seventh day.

Study Questions

  1. Why is asthma considered an obstructive pulmonary disease?

  2. What nursing interventions will help calm a hypoxic, agitated patient?

  3. How do you recognize and treat asthma?

  4. What should you think if a patient with acute asthma stops hyperventilating or has a normal CO2 level?

  5. The arterial blood gas level of a patient with asthma has changed from alkalotic to normal, and the patient seems to be sleeping. Is the patient ready to go home from the hospital?

COPD

Patient B, 69 years of age with advanced COPD, is admitted to the CCU for progressive respiratory distress. His respiratory status began deteriorating three months prior to admission following an upper respiratory tract infection. Since then, he has used oxygen at home, intermittently produced large amounts of purulent, non-bloody sputum, and lost 10 pounds. Patient B works as the owner of a movie theater and is involved in his Greek Orthodox church. He had been a heavy cigarette smoker and exposed to toxic chemicals during his working life.

Past Medical History

Patient B has a history of spring "hay fever" and rare asthma since puberty. For the past 18 years, he has had progressive emphysema with a reversible component. Two years previously, he was diagnosed with adenocarcinoma of the lung. He also reports an allergy to penicillin.

At 12 years of age, Patient B underwent right inguinal herniorrhaphy. Sixteen years ago, he underwent gastrojejunal anastomosis, followed by right upper lobotomy requiring tracheotomy, and right upper lobotomy for benign organized pneumonitic process. Nine years previously, an appendectomy and repair of perforated sigmoid disarticulates with peritonitis were performed.

Assessment and Diagnosis

Upon admittance to the CCU, a full physical exam is conducted (Table 2). Complete blood count, electrolytes, and urinalysis are all within normal limits.

PATIENT B'S PHYSICAL EXAM RESULTS

ParameterFindings
General appearance
Thin, wasted, tired-looking man in acute respiratory distress
Height: 5 feet 9 inches (175 cm)
Weight: 152 pounds (69 kg)
Head and eyes
Normocephalic
Pupils equal, round, reactive to light, accommodation
Foul odor to breath
EarsTympanic membranes intact and clear
Neck
Supple, without masses or thyromegaly
Jugular venous pulse not visualized
Chest
Increased anteroposterior diameter
Decreased breath sounds in the right lower lobe posteriorly and anteriorly with scattered loud wheezes, rhonchi, and rales
Prolonged expiratory time and rib retractions with dyspnea and tachypnea
Abdomen
Scaphoid, with several mature scars
Bowel sounds active in all quadrants
Soft, nontender without masses
Lower liver edge palpable 2 cm below right costal margin
Extremities
Peripheral pulses full, equal, and without bruits
Pitting edema (2+) noted on lower extremities and sacrum
Genitourinary systemWithin normal limits
Neurologic status
Oriented to person, place, and time
Cranial nerves II–XII grossly intact
Sensory and motor function intact
Patient fatigues quickly
Cardiovascular system
Sinus tachycardia
Faint heart sounds
Normal S1 and S2 with summation gallop
Skin warm and moist
Vital Signs
Blood pressure140/100 mm Hg
Temperature97.8° F
Heart rate134 beats per minute
Respiratory rate40 breaths per minute

Based on the results of the assessment, Patient B is diagnosed with:

  • Acute respiratory failure

  • COPD

  • Adenocarcinoma of the lung

Management

Patient B is given aerosolized bronchodilators every one to two hours initially. An aminophylline infusion is administered as well. The frequency of the aerosol treatments is gradually reduced to every four hours, with supplemental oxygen administered by nasal cannula. Patient B's ventilation and oxygenation are managed and monitored by arterial blood gas results (Table 3).

PATIENT B'S ARTERIAL BLOOD GAS RESULTS

Time O2 pH PCO2 PaO2 CaO2
0 hours (admission)2 L/minute7.0692.8308.8
2 hours4 L/minute7.1866.26220.0
4 hours6 L/minute7.2172.36921.4
6 hours4 L/minute7.2860.85519.9
9 hours4 L/minute7.3552.84819.6
24 hours4 L/minute7.3752.26221.7
Discharge2 L/minute7.457.86621.3

The nurses work with a dietitian to provide small, frequent, high-calorie and high-protein meals. This approach, adapted to his anorexia, dyspnea, and previous gastric surgery, improves Patient B's nutritional status. Patient B is transferred out of the CCU on the second hospital day and discharged five days after admission.

One month after discharge, Patient B is readmitted in acute respiratory failure. He and his family decide no resuscitation should be performed, and he dies two days after readmission.

Study Questions

  1. Discuss the etiology of COPD. What lifestyle restrictions does the patient face?

  2. Describe the pathophysiology of Patient B's chronic respiratory failure. What changes occur when acute respiratory failure is superimposed?

  3. According to the arterial blood gas results, was Patient B improved at discharge?

  4. If it is not possible to achieve normal arterial blood gas levels in a patient with respiratory failure, what levels are considered acceptable?

  5. Identify Patient B's nursing problems. What outcomes are appropriate for him in view of his end-stage respiratory failure?

back to top