Pulmonary Case Study: Diagnosis and Treatment

Course Announcements ► Next three modules: There is an OPTIONAL ungraded Synthesis Assignment for these modules (a copy of this assignment is posted in all 3 modules for your convenience). Use the skills from this synthesis assignment to explain/compare/contrast other cond...

Course Announcements ► Next three modules: There is an OPTIONAL ungraded Synthesis Assignment for these modules (a copy of this assignment is posted in all 3 modules for your convenience). Use the skills from this synthesis assignment to explain/compare/contrast other conditions in the lecture content that are not covered on this assignment. ► Upcoming due dates (see syllabus for more information): Pulmonary Post-Module Worksheet: due Friday, Sept 20th Synthesis Assignment 1: due Sunday, Sept 22nd Cardiovascular Pre-Module worksheet: due Tuesday Sept 24th To Have On Your Radar: ► Enrichment programs applications will be coming soon! ► Fuld Fellows: Join a quality improvement/patient safety team and be mentored by a nurse leader in a clinical setting ► Research Honors: Join a nursing research team and be mentored by a Nurse Researcher in an academic setting ► Policy Honors: Work with a mentor who influences health policy in varied settings ► Birth Companions: Become certified as a doula and provide support to birthing people in our community  Pulmonary Sarah. J. Allgood, PhD, RN With Many Thanks to Elizabeth Mounir, BSN, RN Rapid Review Exercise ► Number off 1-16 ► Find others with your number ► In your group, provide the following information: General definition, typical risks and/or causes, underlying pathophysiology, signs and symptoms, what is the hallmark S/S?, pertinent tests/labs/procedures you might expect ► Organize the information in a chart, on flashcards, on a power point slide, etc. ► Use this strategy to helps study the other pulmonary conditions/diseases Case Study #1 Welcome to the Emergency Department! ► You are working as a triage nurse in the emergency department when John is brought in by EMT’s after suffering an injury after falling from a roof trying to clean his gutters ► John (he/him/his), is an 76 year old, widowed with one daughter. ► He is only opening his eyes to sound. BP is 86/50, SpO2 is 86% and pulse is 125 ► You notice that the chest wall is exhibiting paradoxical breathing and What is Paradoxical Breathing? ► Video ► What condition does this make you suspect? Flail chest Define this condition ► Isthis a life-threatening emergency? Yes ► What other symptoms might you see? The Patient is Admitted.. ► John is stabilized and brought in for emergent surgery and chest stabilization ► He is admitted to the ICU for further management where he is currently intubated and sedated ► The next day it is noticed that John is tachycardic and short of breath with absent breath sounds to auscultation on the right side. What is Going On? ► What condition are you concerned John has developed? Pneumothorax Define this condition ► Whatare some reasons this can occur? Trauma, infection, spontaneous ► Why do you think it occurred in John? Trauma from broken rib segments The Patient is Stabilized… ►A chest tube was inserted at bedside and the next two days are uneventful. John remains intubated and sedated in bed ► On day three the ICU nurse notes he has more green secretions than previously and a productive cough. ► Temperature is 102.2 F (39 C). Lung sounds are coarse, especially at the bases of the lungs and there is expiratory wheezing. John is requiring more oxygen support from the ventilator and his heart rate is 136. What is Going On? ► Whatcondition are you concerned that John may have developed? Pneumonia – Define this condition – What clinical signs specifically point to this vs. another pulmonary condition? Fever, productive cough, green sputum, coarse lung sounds, oxygen needs Pneumonia ► Infection of the lungs (viral, bacterial, fungal) ► Causes purulent fluid in the alveoli ► Increased risk in those: >65, existing lung disease, smoker, unvaccinated BUT… anyone can get an infection in their lungs ► What symptoms will occur? Productive cough, fever, sweating, chills, tachypnea, dyspnea, tachycardia, cyanosis ► Why cyanosis? Interference in gas exchange due to alveoli being filled with fluid What other lung condition might he have that is increasing his risk for pneumonia? Atelectasis Define this condition: Collapsed lung tissue at the level of the alveoli How does this condition put someone at risk for pneumonia? Poor/inadequate alveolar ventilation doesn’t allow for proper airway clearance of secretions which can lead to infection and pneumonia How does this condition differ from a pneumothorax? Atelectasis = poor alveolar ventilation and/or air trapping and absorption Pneumothorax = separation of the Good Nursing Assessments Saves Lives!! ► The nurse’s excellent assessment and advocating skills alerted the care team that John may have a possible lung infection like pneumonia. ► By treating this you know that the progression into acute respiratory distress syndrome (ARDS) secondary to the acute lung problem of pneumonia may have been prevented ARDS – Acute Respiratory Distress Syndrome What is a defining feature of ARDS? Refractory Hypoxia What Lab Test Might be Drawn? ► Arterial blood gas Acid/base balance Oxygen status ► What blood gas results might you see as a consequence of ARDS? Might be any of them depending on RR, lung damage, infection  Let’s take a time out for ABG Interpretation ► 46 year old with a history COVID-19 infection. Respiration rate is labored and fast at 26 breaths per minute. Oxygen Hemoglobin has an increased saturation is 95%. An ABG is drawn: affinity for O2: hemoglobin is pH: 7.48 (7.35-7.45) saturated but is less likely to pO2: 53 mmHg (80-100 mmHg) leave and go to the tissues due to pCO2: 25 mmHg (35-45 mmHg) the left shift in ox-heme diss. curve HCO3: 22 mEq/L (18-26 mEq/L) ► How will you interpret this blood Respiratory gas? Alkalosis ► What is causing the low CO2?Rapid respirations are “blowing off” CO2 ► Why do you think the oxygen saturation is not terribly low? Left shift ABG Interpretation ► Same person with history of COVID-19 infection. Temperature is 103.2F (39.6C), BP: 102/54 (low), HR: 147, RR: 20, oxygen saturation 86%. An ABG is drawn: Metabolic Acidosis pH: 7.27 (7.35-7.45) Need an anion gap to pO2: 83 mmHg (80-100 mmHg) make sure, but in this case is probably CO2: 36 mmHg (35-45 mmHg) getting used up by HCO3: 15 mEq/L (18-26 mEq/L) excess acid production ► How will you interpret this blood gas? ► What is the most likely cause of the low HCO3?  ABG Interpretation ► Same person with history of COVID-19 infection. Respiration rate is 16 breaths per minute. Oxygen saturation is 87% - they are now ventilated. Mucous membranes are a bright pink and auscultation Respiratoryreveals Acidosis bilateral wheezing. An ABG is drawn: CO2 retention in the pH: 7.30 (7.35-7.45) lungs Hemoglobin has a reduced affinity pO2: 88 mmHg (80-100mmHg) for O2: hemoglobin is less likely to CO2: 57 mmHg (35-45 mmHg) pick up oxygen in the first place – HCO3: 22 mEq/L (18-26 mEq/L) we need more oxygen in the blood to saturate hemoglobin ► How will you interpret this blood gas? ► What do you think migh be the cause of the high CO2? Back to Our Case Study…Confirming their lung condition… ► Chest x ray and blood cultures drawn ► The chest x ray shows bilateral lower lobe infiltrates and the blood cultures come back positive which is indicative of a system-wide infection stemming from the lungs ► John is started on IV More Lung Complications… ► The x ray also also showed some excess fluid in the pleural space on the right lung. What is this called? Pleural effusion ► What are some symptoms associated with this condition? Pain on inspiration, dyspnea, cough, fever, difficulty taking deep breaths ► What put John at risk for the development of this lung condition? Infection ► What other procedure might be performed? What The Fluid Tells Us… Getting Better?? ► John has been receiving antibiotic therapy for the past 3 days and it seems like he is improving! ► The chest tube is removed and we are getting ready to extubate him. ► Given the trauma he experienced, the care team had decided to not administer heparin (which is often standard practice in those who are post-op). ► What is heparin? What blood test would you expect to be drawn to test heparin’s effectiveness? Medication that inhibits intrinsic clotting factors, PTT Uh Oh…What Now? ► John seems to be struggling more with breathing while on the ventilator and he starts to cough up some blood ► He seems sweaty, he is tachycardic, his heart rate is irregular, and his oxygen levels are decreasing. ► What condition are you concerned might have developed? Pulmonary embolism ► What is the definition of this condition? Blood clot that is lodged in a blood vessel in the lungs ► What risk factors does this patient have that are associated with this condition? Trauma, surgery, in-dwelling catheters, inactivity, inflammation Risk Factors… Good Catch! ► The nurse’s expert assessment skills helped the team diagnosis John with a pulmonary embolism! ► John undergoes a procedure to assess the extent of the PE and is given a medication to break up the clot ► He is also started on heparin therapy to prevent further clot formation ► John is extubated on the next day Almost Out of Here!! ► John has been doing well after all of the events that happened to him when he was critically ill. ► He is about ready to transfer out of the ICU when he starts having dyspnea while walking to the bathroom, orthopnea, wheezing, anxiety and a wet cough that produced frothy sputum. Oh No! What Now? ► What lung condition is most associated with these symptoms? Pulmonary edema ► What is the definition of this condition? ► What has John experienced that could contribute to the development of this? Inflammation from trauma and infection increased capillary permeability  loss of albumin out of vasculature of the lungs  decreased capillary oncotic pressure  fluid leaving capillaries and entering the alveoli Embolism blocked blood flow in capillaries of the lungs  increased What is Causing Pulmonary Edema? No More Climbing on Roofs, John!! ► Itwas determined that John had severe pulmonary edema due to the overall damage done to the lungs after being critically ill. ► He is started on diuretics to remove some of the fluid from accumulating in the lungs. ► John is transferred to the med surg floor and discharges back to his home later in the week. He is advised to find someone else to clean his gutters  Case Study #2 Back In the ED ► The next patient that arrives at your triage desk in the emergency room is a 14 year old named Andi (they/them/theirs) with severe wheezing when breathing both in and out, coughing, chest tightness, anxiety and difficulty talking ► Their vital signs are as follows: HR 140, BP 122/67, O2 90% on room air. They are only able to talk in short sentences and you can audibly hear wheezing when they are next to you. ► What lung condition do you suspect? Obstructive vs. Restrictive ► You are right! Andi has a history of asthma. ► Is this an obstructive or restrictive lung disease? Obstructive ► What test can be performed to determine obstructive vs. restrictive? Pulmonary function test (PFT’s) aka spirometry What Characterizes a Restrictive-Type Lung Disease? ► Not enough space in the chest cavity to fully expand rib cage Pregnancy, anatomical conditions such as severe scoliosis ► Scaringor inflammation at the level of the interstitial space between the alveoli and the capillaries in the lungs preventing diffusion of You Take a Comprehensive History ► What are some triggers for an asthma exacerbation? Environmental triggers such as smoke, poor air quality, exercise, etc. ► Andi’s parent says they are staying at a hotel nearby and they noticed that there was mold in the corners of the window in the room. ► This makes sense as it is very cold outside and there is an abundance of moisture trapped in the windowsill. ► Unfortunately, even though the hotel is non smoking, What Happens in the Lungs During an Asthma Attack? Asthma  Yay for Albuterol!! ► Andi is immediately given a respiratory treatment with bronchodilators and IV steroids and their symptoms begin to improve. ► If Andi underwent spirometry testing after treatment, what would the results most likely be? Probably close to normal with no obstructive patterns since they have no symptoms Obstructive lung patterns in asthma are reversible with treatment ► Andi is discharged to the care of their parents with a recommendation to change their hotel room and to follow-up Case Study #3 Back in the ED ► The third patient that arrives to the triage desk in the emergency department is Susie (she/her/hers), a homeless 56 year old self-identified female with an unknown past medical history ► Upon assessment it was noted that Susie has exertional dyspnea, a RR of 32, dusky colored skin, and a cough with increased sputum production. ► She states this has been occurring for the last 3-4 months and happens at least once a year for the past 3 years Gaining a Social History is so Important! ► Susie says that she has been homeless for the past 5- 6 years and spends most of her time sleeping next to the meat packing plant downtown in the largest homeless encampment in the city ► She spends most of her time busking for change which she explains enables her to buy cigarettes and IV drugs. Susie started smoking cigarettes at age 16 ► She has no known past medical history but also has not had access to a doctor for the past 30 years What’s Going On? ► What are some lung-related conditions for which this patient should be assessed? COPD – specifically chronic bronchitis, possibly TB, lung cancer ► What risk factors for COPD does this patient have? Smoking, possible chemical exposure from meat packing plant, living conditions, age ► What risk factors for TB does this patient have? Housing insecurity, possible exposure from encampment, IV drug use, possible nutritional deficiencies What About The TB? ► What are some signs and symptoms associated with TB? ► How is it transmitted? Airborne disease What Is COPD? ► Umbrella term for progressive obstructive lung disease caused by chronic inflammation and damage to cilia in the airways ► Two main types to start but can develop both over time: Chronic bronchitis Emphysema ► Mostrisk factors are related to environmental and psycho-social factors such as smoking, chronic exposure to chemicals, age, etc.  Emphysema Chronic Bronchitis They are very similar! With Key distinguishing features… Study Exercise ► Doing the synthesis assignments is active studying ► You use specific critical thinking skills to integrate content and answer the questions ► You can use these skills to study other conditions not covered in the synthesis assignments ► Let’s try it with the different types of COPD!  Chronic Bronchitis Emphysema ► The damage is in the The damage ► Where is in the is the damage? Where is the damage? BRONCHI ALVEOLI Ventilation ► is IMPAIRED ► Ventilation What happensisto IMPAIRED ventilation? What happens to ventilation? ► ► What happens to gas What happens to is Gas exchange gas IMPAIRED Gas exchange is IMPAIRED exchange? exchange? ► Distinguishing signs and Distinguishing signs ► Distinguishing and Signs/symptoms? Distinguishing Signs/symptoms? symptoms: Productive Why? symptoms: Why? “Pink” cough, cyanosis, appearance (minimal extremity edema, cor cyanosis), barrel chest,  Chronic Bronchitis Emphysema ► Damage is in the Bronchi ► Damage is in the Alveoli Impaired ventilation due to Impaired ventilation because of narrowed airways from bronchial alveolar destruction and poor lung edema recoil (”spring back” to breathe air Impaired gas exchange because out) of poor ventilation and excess mucus Impaired gas exchange because production of decreased surface area from Distinguishing Signs and alveolar septal wall destruction symptoms: Distinguishing Signs and –Cyanosis – mucus plugging and symptoms: alveolar collapse lead to poor gas –”Pink” appearance (minimal exchange and reduced uptake of cyanosis) – poor lung recoil leads to oxygen causing hypoxia hyperinflation of lungs (barrel (cyanotic/blue appearance) chest) causing CO2 retention and –Wet productive cough – mucus hypercapnia (pink rather than production and poor airway cyanotic appearance) clearance –Pursed lip breathing – holds air Testing What testing would we use to determine if Susie has COPD (chronic bronchitis/emphysema)? Pulmonary function tests (PFT’s; spirometry) chest x-ray sputum culture medical history (looking for risk factors/exposures) Back to the Case Study ► Susie’s tests come back negative for TB! But she does have COPD. ► You educate Susie on signs and symptoms of TB so she is aware in case she develops them later. ► You also connect her with a social worker who is helping to coordinate her care with a local primary care provider and other resources to help manage her newly-diagnosed COPD Questions?