Acute on Chronic Respiratory Failure with Hypoxia

Background Information

Demographic

The patient who I will refer to as M.J is a 55-year old single male Caucasian American living in Cleveland OH. He relocated to Cleveland 10 years ago from South Carolina where he has family. He has never been married. He has 4 siblings, a sister 20 years his junior who he claims he has never met and 3 brothers ages 22, 25 and 35 years respectively. His family according to M. J still reside in South Carolina. He has no family here in Cleveland. The assessment was done on June 10, 2019, at Metro Health Cleveland.(Acute on Chronic Respiratory Failure with Hypoxia)

History of Present Illness

M.J has been relatively healthy until a month ago when he had noticed difficulty breathing while doing yard work around his property. He has been doing this for the past 5 years without any issues but was now experiencing shortness of breath after working on a small family garden. The symptoms according to M.J did not decrease with time but has gotten worse over the past few days. M.J mentioned he has shortness of breath for simple things like taking a shower, walking his dog two blocks from his home and lying down for a nap. He said he had always slept with his windows closed and one pillow, but now must sleep with his windows open, a working fun and two to three pillows with the bed adjusted to a 30 to 45-degree angle. M.J also said he has recently suddenly gain lost about 5 to 15-pound weight without trying.(Acute on Chronic Respiratory Failure with Hypoxia)

Relevant Past Medical and Surgical History

He has no known drug-related allergies and is a full code patient. He has no past surgical history. Additional findings of M.J past medical history includes Cirrhosis of the Liver diagnosed within the past 3 years, hepatitis C, severe back and shoulder pain from a work-related injury, pressure headaches, depression, COPD, anxiety, abdominal distension, GERD and GOUT. M.J said he quit drinking and smoking 2 years ago. He reported smoking approximately 108 pack of cigarettes a year an average of 2 packs a day for the past 40 years. He also reported drinking 9 ounces of alcohol a day for 40 years(Acute on Chronic Respiratory Failure with Hypoxia). The patient was admitted to Metro Health Cleveland on June 7, 2019, for exacerbation of respiratory symptoms. The rest of M.J medical history is unremarkable. The patient upon arriving at the hospital did not use supplementary oxygen at home and at the time of his hospital assessment. He reported bowel incontinent which he stated started about 4 months ago and consistently occur once or twice a week. He gets about 4 loose liquid like stool per day.(Acute on Chronic Respiratory Failure with Hypoxia)

Admitting Diagnosis(es)

He was rescued with a bipap for shortness of breath (dyspnea). The patient was diagnosed with the following including but not limited to, acute on chronic respiratory failure with hypoxia, COPD exacerbation, Paroxysmal A-fib and pneumonia of the left upper lobe due to an infectious organism, Atrial Fibrillation (also called AFib or AF) with RVR (HCC) after an EKG was ordered. The patient initial RVR responded to diltiazem however he developed RVR again after a few hours that failed to respond to bolus. His heart rate was now at 98 with diltiazem drip and jumping up.(Acute on Chronic Respiratory Failure with Hypoxia)

Laboratory and Diagnostic Tests

A chest X-ray revealed bilateral pleural effusions. Chest x-ray showed changes consistent with COPD. An electrocardiogram showed Paroxysmal atrial (A-fib). A transthoracic echocardiogram revealed a dilated left atrium, an increase in right-sided filling pressure, and mild to moderate mitral regurgitation. The left ventricular ejection fraction (LVEF) was within normal limits. The patient’s Vital signs were as follows: temperature, 99.4 F(37.4°C); heart rate, 62 beats per minute; respiratory rate, 23 breaths per minute; blood pressure, 92/56 mmHg(Acute on Chronic Respiratory Failure with Hypoxia). The patient was well-nourished and in an acute on chronic hypoxic and hypercapnic respiratory distress (oxygen saturation of 96% on room air). His current weight was 71.5kg with a height of 5’8 inches. The patient’s physical exam was normal with clear respiratory sounds and no lower extremity edema. However, the patient failed NIV due to increased work of breathing and was intubated and sedated on mechanical ventilation. The ventilation settings were as follows FiO2 (30), Tidal Volume (400), Respiratory Rate (23), PEEP (5). Lab ordered included WBC count 17.4, RBC count 4.25, Hemoglobin 12.9,Hematocrit 38.4,Platelet count 211,APTT 20,Sodium 135 mEq/L, Potassium 4.5 mEq/L ,Chloride 118 mEq/L ,Magnesium 1.3 mEq/L,CO2 21 mEq/L, BUN 8 mg/dL ,Creatinine 0.5 mg/dL, AST 28 U/L, ALT 17 U/L, Total protein 6.8 g/dL, Albumin 4.6 g/dL,  Total bilirubin 0.9 mg/dL,  Direct bilirubin 0.2 mg/dL and BNP of 827.(Acute on Chronic Respiratory Failure with Hypoxia)

Medications

The patient’s medications included, Albuterol (proventil), Propofol infuse and Fentanyl just to mention a few. (a). Albuterol (Proventil) 0.083 % nebulizer solution 2.5mg/3ml. This medication belongs to a class of drugs known as bronchodilators. Therapeutic use of the medication is to relax patient muscles in the airways and increases air flow to the lungs helping him breathe easily without laboring. Major adverse effects include dysphonia, increased sweating, and dry mouth just to mention but a few. Nursing interventions- assess Bp, lung sounds, pulse before a domain and during peak, observe for wheezing, and note amount, color, and character of sputum produced. (b)(Acute on Chronic Respiratory Failure with Hypoxia). Propofol infuse 30 mcg/kg/min. Diprivan. Generic Name: propofol; Brand Name: Diprivan. This medication belongs to a class of drugs known as anesthetic, sedative-hypnotic. This medication used as part of balanced anesthesia and on conscious sedation in the mechanically ventilated patient. Major adverse effects include respiratory depress, hypotension, bacterial infection, seizures, and increased triglycerides (prepared in lipid emulsion). Nursing interventions- use strict aseptic technique when preparing and dedicated IV line due to lipid base and a chance of infection, discard after 12 hrs., respiratory support nearby, constant monitoring pump. (c). Fentanyl- the trade name for Fentanyl is Sublimize. Is a synthetic opioid analgesic that suppresses pain by agonizing opioid receptors in the central nervous system. Adverse reactions include Euphoria, Drowsiness, Pupillary constriction, Respiratory arrest, Decreases gastric motility, Nausea, and vomiting, Bradycardia, Chest wall rigidity. Nursing intervention -Initiate safety measures -Assess pain and pain relief with appropriate pain scale -Assess BP, pulse, and respiratory rate/status -Assess the level of sedation -Assess bowel function and prevent constipation -Perform good oral hygiene and intervention to decrease dry mouth.(Acute on Chronic Respiratory Failure with Hypoxia)

Nursing Diagnoses and Nursing Interventions and Rationales

Nursing Diagnoses

include possible ineffective airway clearance and breathing pattern; high risk for aspiration, infection, and/or altered respiratory function;(Acute on Chronic Respiratory Failure with Hypoxia)

Assessments

include determining baseline respiratory status (assess patient’s ability to cough and deep breathe effectively, auscultate the chest, and note the breathing pattern); monitor chest x-rays, blood gas levels, CBC, sputum cultures, and pulmonary function tests.(Acute on Chronic Respiratory Failure with Hypoxia)

Nursing Interventions

include frequent suctioning, intubation and ventilator support, as well as supplementary oxygen and consultation with pulmonologist, if necessary, and the respiratory regimen of chest percussion, and deep breathing due to the patients  ventilator; assist with cough as needed; provide tracheostomy care every 4 hours, chest physical therapy and deep breathing exercises every 2 – 4 hours, IPPB every 4 hours, and use of incentive spirometer every 4 hours. This will reveal the level of decompensation as well as if interventions are effective Complete a full respiratory assessment to detect changes or further decompensation as early as possible and notify MD as indicate.(Acute on Chronic Respiratory Failure with Hypoxia)

Nursing Diagnoses

include decreased cardiac output, altered tissue perfusion, the risk for peripheral neurovascular dysfunction, dysrhythmias, DVT, and hypovolemia.(Acute on Chronic Respiratory Failure with Hypoxia)

Assessments

include monitoring vital signs, cardiac monitoring for arrhythmias, monitoring response to head elevation, observation for signs of thrombophlebitis, DVT, and PE, and EKG, electrolyte and coagulation tests.(Acute on Chronic Respiratory Failure with Hypoxia)

Nursing Interventions

include treating life-threatening arrhythmias, heparin to prevent DVT, use of sequential compression boots, vasopressors and consultation with a cardiologist as needed. Provide supplemental oxygen as appropriate- Supplemental oxygen will ideally increase patient oxygen levels. (Use caution with COPD patients, as they cannot breathe out the CO2 adequately, so over-oxygenation is a concern, and they also may have a lower baseline SpO2 level). Ensure patient is in an optimal position to decrease work of breathing- Sitting up in bed to enable appropriate lung expansion allows for adequate inspiration and expiration, which facilitates better gas exchange (if clinically appropriate to be sitting up)(Acute on Chronic Respiratory Failure with Hypoxia) Prepare for rapid sequence intubation, if necessary-Helpful to be prepared, as this can progress quickly. Know where the necessary meds and equipment are and how to get ahold of assistive personnel. Remove any negative/distracting stimuli: turn the TV off, encourage family members to be calm When patients are anxious or cannot focus it can increase their work of breathing and exacerbate the issue. Promote a calming environment so all the patient must worry about is breathing. Provide oral care- If a patient is intubated or receiving oxygen via nasal cannula/face mask or tent, or other methods of delivery, oral care is essential to protect the mucous membrane and prevent infection. Cluster care- Decreases oxygen demands if the patient’s rest can be maximized(Acute on Chronic Respiratory Failure with Hypoxia)