Sara case

Sarah is a 69-year old female that presented to the emergency department with
shortness of breath. Her past medical history includes heart failure and COPD. Her
pulse oximetry on room air is 82%. You notify the provider, and he orders oxygen at 2 L
via nasal cannula NC. Sarah’s chest x-ray reveals bilateral pneumonia. Her arterial
blood gas result are below:
pH: 7.30
PaCO2: 58 mm Hg
PaO2: 78 mm Hg
HCO3: 26 mEq/L
Sarah is admitted to a general medical floor. You are the nurse assigned to Sarah.
1. What potential problems can occur based on the above findings?
2. How would you provide multidimensional care for Sarah?
3. Describe the roles of other departments in Sarah’s treatment plan.

After your initial post comment on these 2 students’ post.
Student #1

What potential problems can occur based on the above findings?
From above findings this patient may have developed respiratory acidosis due to the
pneumonia. “Mechanisms of respiratory acidosis include increased carbon dioxide production,
alveolar hypoventilation, abnormal respiratory drive, abnormalities of the chest wall and
respiratory muscles, and increased dead space.” (Epstein & Singh, n.d).
Here the blood PH is low, there’s an excess co2 in the blood, patient is having hypoxia. This
brings great effects on the central nervous system because the poor blood flow and lack of
Oxygen is killing neurons that cannot undergo mitosis, and in the cardiovascular system will
interfere with normal heart function. "If hypoxia is not corrected, hypotension will develop.
As hypoxia worsens, the patient’s vital signs, activity tolerance, and level of consciousness will
decrease, and patient could die. "(Doyle & McCutcheon, 2015).
How would you provide multidimensional care for Sarah?

I would provide multidimensional care for Sarah by remaining alert for critical changes in
patient’s respiratory, CNS and cardiovascular functions. Report such changes as well as any
variations in ABG values or electrolyte status immediately. I would position Sarah with head of
the bed elevated, in a semi-Fowler’s position as tolerated since this position allows increased
thoracic capacity, total descent of the diaphragm, and increased lung expansion preventing the
abdominal contents from crowding. She must maintain adequate hydration as well as patent
airway and providing humidification if acidosis requires mechanical ventilation. Perform
tracheal suctioning frequently and vigorous chest physiotherapy, if ordered. Continuously
monitoring arterial blood gases.
Describethe roles of other departments in Sarah’s treatment plan.
When a patient has this kind of emergency, a group of care is important in managing the
disease process or condition. The first is to identify or diagnose the disease ant it's progress.
Chest radiography is one of the most important, so the radiology department will play a crucial
role. The help of a respiratory therapist will also be needed to manage this patient's breathing
problems while maintaining ease of breathing. Nutrition also plays an important role, because
much of the protein deficiency is present in pneumonia, adequate nutrition will be needed for
an easy recovery, so nutritionists have an important role in the team.

References

Epstein, S. K., & Singh, N. (n.d.). Respiratory acidosis. Respiratory care. Retrieved April 24, 2022,
from https://pubmed.ncbi.nlm.nih.gov/11262556/
Doyle, G. R., & McCutcheon, J. A. (2015, November 23). Signs and symptoms of hypoxia. Clinical
Procedures for Safer Patient Care. Retrieved May 5, 2022, from

5.4 Signs and Symptoms of Hypoxia

Student#2

Sarah was admitted to the general medical floor after coming into the ER with a complaint of
shortness of breath. Her lab work came in shortly after showing abnormalities in her ABG. Her
pH was below level showing acidosis. Her PaCO2 was elevated showing that she had an
accumulation of carbon dioxide inside her body. Her PaO2 was decreased showing she was
becoming hypoxic. Her bicarbonate is elevated from trying to compensate for the excess
carbon dioxide in the body. With these ABG results, Sarah has Respiratory acidosis which has
likely been caused by the pneumonia due to ventilation/ perfusion mismatch from the
decreased gas exchange. She is also a high risk for Respiratory acidosis since she has COPD
(Story, 2020).
Since Sarah is considered a geriatric patient, we must place her on a falls risk due to her
impaired breathing levels, since she is hypoxic, she is at risk for injury. Since she has

pneumonia, oxygen needs to be kept administered via nasal cannula 2L to raise her pulse ox to
her baseline; repositioning every 2 hours and incentive spirometer needs to be implemented to
increase pulmonary hygiene and oxygen therapy. Sarah’s breathings status needs to be
monitored hourly and listening to breath sounds and assessing whether patient is using
accessory muscles to breath. Drug therapy will be implemented as well by using
bronchodilators, anti-inflammatories, and mucolytics. For the pneumonia antibiotics will need
to be administered. A mechanical ventilator may need to be used if the patient has respiratory
muscle fatigue (Workman, 2021).
There are many providers that will be working on Sarah’s case; PCP, Pulmonologist,
Respiratory therapist, Dietician/ Nutritionist, Radiology techs, Physical therapy, and Nurses.
Each has a specific role in her care. The PCP or internal medicine doctor and Pulmonologist
would be the one managing her COPD since she has a history of it and now has Pneumonia as
well as Respiratory acidosis. The respiratory therapist will work on her oxygenation needs and
educate her on breathing exercises. The radiology techs will perform all her imaging needs. The
Dietician/ Nutritionist will create a meal plan specifically for her needs that will aid in recovery.
Physical therapy will stop by every day and encourage mobility. The nurses are there to
advocate for their patient and provide therapeutic communication to help the patient get better
not only physically but by providing emotional support. They will all get together and create a
treatment plan. All of these things combined will aid in the patient making a full recovery (Patel,
2021).

References:
Patel, S., & Sharma, S. (2021, June 24). Respiratory acidosis . Statpearls – NCBI bookshelf.
Retrieved May 4, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK482430/

Story, L. (2020). Pathophysiology: A Practical Approach (4th Edition). Jones & Bartlett
Learning. https://ambassadored.vitalsource.com/books/9781284229967

Workman, D.I.M. L. (2021). Medical-Surgical Nursing (10th Edition). Elsevier Health Sciences
(US). https://ambassadored.vitalsource.com/books/9780323654050