CNA772: Interpreting Patient Deterioration - Case Study

Assignment Task

Assessment task 2 Case study

Example of an essay – Not for replication
This essay relates to Mrs. Smith who presented with type 2 respiratory failure secondary to acute exacerbation of chronic obstructive pulmonary disease (COPD). Assessment findings related to Mrs. Smith deterioration episode and health history will be briefly described at the beginning of the essay. The paper will address two management strategies that were used to assist Mrs Smith with her acute respiratory distress. With the support of recent research, the provision of oxygen therapy as one management strategy used in the context of COPD pathophysiology and evolving respiratory failure, and the use of patient positioning as a nursing management strategy will be explored in the essay.

Mrs. Smith was a 68-year-old lady who was admitted to the ward for acute exacerbation of chronic obstructive pulmonary disease (COPD) in the context of recent upper respiratory tract infection. Mrs. Smith presented to the hospital with increased dyspnoea after a recent episode of upper respiratory tract infection treated with antibiotics. The relevant medical history included COPD which was managed with bronchodilators. She has a history of hypertension and hyperlipidaemia, both of which requiring therapy which is outside the scope of the paper. Mrs. Smith was an exsmoker of over 30 years, and she had stopped smoking about a year ago. Mrs Smith had been on the ward for two days for review of her respiratory tract infection on a background of COPD. During my first shift with Mrs. Smith, she appeared anxious with a respiratory rate of 28. She was on 2L of oxygen supplied via nasal cannula and initially maintained her oxygen saturation at 88%. Other vital signs were within normal range.

Mrs. Smith rang the call bell shortly after nursing handover. She was sitting in a chair in a forward leaning position stating that she could not breathe. Mrs. Smith appeared extremely anxious and had difficulty talking in full sentences. Accessory muscle use, such as purse-lipped breathing, nasal flaring and upper rib retraction was also observed. After reassurance and a call for medical assistance, vital signs were attended, with a tachypnoea of 36 per min, tachycardia at 124 beats per minute and slightly elevated blood pressure at 155/84 mmHg. Mrs. Smith was afebrile but appeared diaphoretic with cold clammy skin. Oxygen saturation dropped to 79% on 2L oxygen via nasal cannula. Oxygen administration was increased to 4L/pm to aim for the patient’s target range of greater than 88mmHg. COPD patients generally have a target oxygen saturation range of 88-92% (Rolfe and Paul, 2018b). Mrs. Smith’s oxygen saturation increased to 84?ter 5 minutes. However, Mrs. Smith still complained of difficulty breathing and pain on inspiration. She also continued to have increased in work of breathing, characterized by tachypnoea, severe wheezing, sweating, and the use of accessory muscles. A medical emergency call was initiated. Arterial blood gas attended, showing Mrs. Smith was in a respiratory acidosis status with a pH 7.28, partial pressure of oxygen in arterial blood (PaO2) 53mmHg and partial carbon dioxide in arterial blood (PaCO2) 63mmHg. A mobile chest x-ray was attended which excluded pulmonary oedema and pleural effusion but showed enlarged lungs and flattened diaphragm. Mrs. Smith was diagnosed with type 2 respiratory failure secondary to exacerbation of COPD. She was shifted to the high acuity unit for non-invasive ventilation therapy. This paper will now discuss two management strategies that were used. The first was the use of patient positioning to improve diaphragmatic and respiratory muscle effort and the second strategy discussed is the role of oxygen in the patient with COPD and how the delivery of oxygen links to the physiology behind COPD.
The remainder of the paper has been omitted, but includes in the body of paper

• Explanation of COPD and why patient positioning and oxygen is needed
• Work of breathing and respiratory muscle fatigue
• Links to alveolar function and dysfunction in the setting of COPD
• Gas transfer principles
• Cellular use of oxygen
• How oxygen can displace other gases and how this affects alveolar function
• Oxygen as a drug and its associated complications

In conclusion, Mrs Smith developed type 2 respiratory failure secondary to exacerbation of COPD. COPD is a chronic disease normally consisting of chronic bronchitis and emphysema. In acute exacerbation, the altered physiology includes excessive mucus production, narrowing of small airways with increased airway resistance resulting in hyperinflated lungs, all of which made the patient vulnerable to develop respiratory failure. This leads to impaired gas exchanges, causing hypoxaemia and hypercapnia and altered work of breathing which reflected in Mrs Smith’s arterial blood gas results. Central chemoreceptors and peripheral chemoreceptors will detect the chemical changes in the blood and send impulses to the respiratory centre in the brain stem to regulate the breathing. Mrs Smith was showing signs and symptoms of respiratory compromise due to hypoxaemia and hypercapnia, including tachypnoea, tachycardia, and the use of accessory muscles, and diaphoresis. Oxygen consumption for Mrs Smith during breathing was excessive, accompanied with increased work of breath necessitating the provision of oxygen therapy. The oxygen did not address the underlying respiratory changes, however, could assist in supporting gas exchange and the fatigued respiratory muscles. Along with the provision of other therapies such as non-invasive ventilation resulted in improvement in respiratory rate, oxygen saturation, and arterial blood gas result from baseline.

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