Respiratory Case Study

CONCEPT: OXYGENATION and INFECTION

The story….

C.C is a 82 year old female with a longstanding history of COPD and DM. She presents to the ED with a 5 day history of worsening dyspnea, productive cough with moderate amounts of yellow-greenish sputum, fever, chills and malaise. Inaddition, she reports increasing nausea and vomiting over the past 3 days. She is unable to keep food, fluids or her medications down. Due to her limited po intake, she has discontinued her AM regular insulin.

Questions to ponder/answer…(please try to think about/answer these prior to moving on in the case study…cover up additional information with a sheet of paper if your eyes are drawn to the “rest of the story”)

  • What do you think is going on with this woman?
  • What information above caused you to sit up and take ‘notice’?
  • What information/data would you want to gather from her via assessment in order to safely and effectively care for her?

The story continues….

Vital signs reveal the following:

  • T: 38.6,
  • P: 120,
  • RR: 30,
  • BP: 90/58,
  • O2 sat: 78 on RA,
  • Weight: 100 pounds (decreased 2 pounds from her last visit in the pulmonary clinic one week ago).

Significant findings on her physical exam include the following:

  • General: ill appearing female in acute respiratory distress.
  • HEENT: unremarkable.
  • CV: Tachycardia, rhythm regular. S1 S2 noted no murmur, no gallop, and no rub.
  • Resp: Crackles 1/3 way up lower lobes, inspiratory and expiratory wheezes noted throughout lung fields. Dull to percussion in LLL.
  • GI: bowel sounds hyperactive, non tender, no hepatosplenomegaly noted.
  • Neuro: grossly intact.
  • Ext: cool to touch, cap refill > 3 sec, pedal pulses weak, no edema.
  • Integumentary: unremarkable.

Labs/diagnostics reveal the following:

  • WBC15.8
  • Hgb 15.5
  • HCT 45
  • PLTS 250
  • Na:146
  • Cl: 100
  • K: 3.2
  • CO2: 30
  • BUN: 30
  • Cr: 1.7
  • Glucose: 162
  • ABG’s: pH: 7.32 Pa CO2: 58 HCO3: 24
  • CXR: pending
  • Blood cultures: pending
  • U/A remarkable for specific gravity 1.040

Questions to ponder/answer…(please try to think about/answer these prior to moving on in the case study…cover up additional information with a sheet of paper if your eyes are drawn to the “rest of the story”)

  • What type of fluid balance/imbalance do you suspect and why? (No Imbalance, FVD, FVE)
  • What data from the case study supports this balance/imbalance?
  • What labs are you most concerned about? Why?
  • Is the hypokalemia actual or relative? And why?
  • What signs and symptoms might you see with hypokalemia?
  • How do you expect the provider will treat the hypokalemia?

More information is added as the story evolves….

The plan is to admit her to the hospital for treatment and admission orders are as follows:

  • Diagnosis: pneumonia with exacerbation of COPD
  • Code: FULL
    Diet: 1800 ADA
  • I/O: strict
  • Vital signs: Q 4 hours
  • O2: titrate to keep greater than 96%
  • Labs: daily CBC C diff, BMP
  • Vanco peak & trough with third dose
  • Blood cultures x 2 Q 24 hours for temp > 38.2
  • MIVF: to be determined by nursing students rate: 125 ml/hr
  • Meds:
  • Vancomycin 1 gram IVPB Q 12 hours
  • Ceftazidime 2 grams IVPB Q 12 hours
  • Prednisone 20 mg po QD
  • Albuteral inhaler 2 puffs q 4 hours prn
  • Phenergan 25 mg iv/po prn q 4 hours n/v
  • Tylenol 650 mg po Q 4 hours fever
  • Sliding scale Insulin
  • CBG 60-120 no coverage
  • 121-1402 units regular insulin
  • 141-1804 units regular insulin
  • 181-2008 units regular insulin
  • 201-22010 units regular insulin
  • 221-24012 units regular insulin
  • 240-30014 units regular insulin
  • > 300 call HO

Questions to ponder/answer…(please try to think about/answer these prior to moving on in the case study…cover up additional information with a sheet of paper if your eyes are drawn to the “rest of the story”)

  • What type of MIVF would you order and why?
  • What one lab would tell you that your fluid imbalance is improving?
  • What type of acid-base imbalance do you have? Associated signs and symptoms?
  • What might CXR reveal?
  • Are there any orders that cause you concern? Is so, what are they, how would you change them if necessary or what would you monitor to ensure potential patient complications are at a minimum?

And the story continues…

36 hours later you return for a 12 hour shift. You note the following:

  • T: 37.6,
  • HR: 90,
  • RR: 32,
  • BP: 156/90,
  • O2 sat: 88 on 3 L O2 via nasal canula,
  • Weight: 106 pounds.

Labs/diagnostics reveal the following:

  • WBC 9.8
  • Hgb 10.3
  • HCT 36.2
  • PLTS 248
  • Na:135
  • Cl: 97
  • K: 3.7
  • CO2: 30
  • BUN: 45
  • Cr: 3.3
  • Glucose: 108
  • CXR: pending

Questions to ponder/answer…(please try to think about/answer these prior to moving on in the case study…cover up additional information with a sheet of paper if your eyes are drawn to the “rest of the story”)

  • What type of fluid balance/imbalance do you suspect and why? (No Imbalance, FVD, FVE)
  • What do you suspect the cause of the imbalance to be?
  • What other lab values are of concern to you? What other data (assessment, etc.) would you want to obtain to validate or allay your concerns?
  • What would you expect the medical and nursing management to be?

Developed by Carol Thorn, RN, MS

May use with permission for the purposes of nursing education

If questions/comments, please contact Carol Thorn at