Unit 5 SVN case studies By Elizabeth Kelley Buzbee AAS, RRT-NPS RCP.

Unit 5 SVNUnit 5 SVNcase studiescase studies

By Elizabeth Kelley Buzbee By Elizabeth Kelley Buzbee AAS, RRT-NPS RCPAAS, RRT-NPS RCP

Mrs. Mosby is a 45 year old who Mrs. Mosby is a 45 year old who presents in the ER with c/o presents in the ER with c/o [complaints of ] SOB [shortness of [complaints of ] SOB [shortness of breath]. She is wearing a pulse breath]. She is wearing a pulse oximeter on her finger that says 99% oximeter on her finger that says 99% How do you assess her?How do you assess her?

answeranswer

Collect VS [vital signs] to assess her Collect VS [vital signs] to assess her dyspneadyspnea

Interview her to discover her history Interview her to discover her history of recent exposures or underlying of recent exposures or underlying lung diseaselung disease

Observe her for retractions, and Observe her for retractions, and other signs of increased WOBother signs of increased WOB

Listen to her breath soundsListen to her breath sounds

Her HR is 120 bpm and her respiratory Her HR is 120 bpm and her respiratory rate is 31 bpm.rate is 31 bpm.

She is a waitress who came into the ER She is a waitress who came into the ER after a kitchen fire. She has no history of after a kitchen fire. She has no history of lung disease and does not smoke.lung disease and does not smoke.

She has nasal flaring and mild She has nasal flaring and mild supraclavicular retractions and mild supraclavicular retractions and mild intercostal retractions. intercostal retractions.

She has inspiratory and expiratory She has inspiratory and expiratory wheezing in all lobeswheezing in all lobes

What do you suggest?What do you suggest?

answeranswer

A bronchodilator to treat the A bronchodilator to treat the wheezingwheezing

Remove the pulse ox, it is unhelpful Remove the pulse ox, it is unhelpful at this pointat this point

Assess her HbC0 with a co-oximeter Assess her HbC0 with a co-oximeter reading and get her started on reading and get her started on supplementary 02 at 100% NRB to supplementary 02 at 100% NRB to washout the CO.washout the CO.

Her HbCO is 5% so the doctor orders Her HbCO is 5% so the doctor orders a NRM to washout to Carbon a NRM to washout to Carbon MonoxideMonoxide

The doctor also orders Atrovent The doctor also orders Atrovent [Iprotropium bromide ] You suggest?[Iprotropium bromide ] You suggest?

answeranswer

Atrovent [iprotropium bromide] is a Atrovent [iprotropium bromide] is a Cholinergic blocker. You might be Cholinergic blocker. You might be better starting with the Beta II first better starting with the Beta II first because that stimulates because that stimulates bronchodilator rather than blocks bronchodilator rather than blocks bronchospasm. bronchospasm.

You could keep the iprotropium You could keep the iprotropium bromide, but add Albuterol bromide, but add Albuterol

The doctor orders .25mL of 5% The doctor orders .25mL of 5% Alupent [ Metaproterenol ] in 3 ml of Alupent [ Metaproterenol ] in 3 ml of normal saline.normal saline.

You suggest?You suggest?

answeranswer

Agree, this is the correct dose, and Agree, this is the correct dose, and this is a Beta II agonistthis is a Beta II agonist

What other inhaled drug might be What other inhaled drug might be helpful with the inflammation one helpful with the inflammation one sees with thermal damage and sees with thermal damage and chemical irritationchemical irritation

answeranswer

Inhaled or IV steroids might be Inhaled or IV steroids might be helpful in this casehelpful in this case

Case study # 2Case study # 2

Your patient is a 4 year old LAF who Your patient is a 4 year old LAF who is admitted to the ER with respiratory is admitted to the ER with respiratory distress. You suggest:distress. You suggest:

answeranswer

Assess her VS Assess her VS Assess her 02 status by pulse Assess her 02 status by pulse

oximeteroximeter Assess her breath soundsAssess her breath sounds

Her VS shows a respiratory rate of 29 Her VS shows a respiratory rate of 29 bpm [slightly respiratory rate for bpm [slightly respiratory rate for age] Her HR is 135 again slightly age] Her HR is 135 again slightly highhigh

Her Sp02 is 98%Her Sp02 is 98% On auscultation, you hear scattered On auscultation, you hear scattered

rhonchi to both lungsrhonchi to both lungs


answeranswer

Continue to monitor her for Continue to monitor her for hypoxemia but for now no 02 is hypoxemia but for now no 02 is indicated. She has no s/s of indicated. She has no s/s of respiratory distress now—but respiratory distress now—but somethingsomething brought her to the brought her to the hospitalhospital

Continue to assessContinue to assess

The doctor orders an X-Ray that The doctor orders an X-Ray that shows areas of consolidation in the shows areas of consolidation in the Right Middle Lobe. He orders 2 cc of Right Middle Lobe. He orders 2 cc of 10 % Acetylcysteine. Why?10 % Acetylcysteine. Why?

answeranswer

He wants to mobilize the secretions He wants to mobilize the secretions by breaking up the chemical bonds of by breaking up the chemical bonds of the mucusthe mucus

You suggest what else might be You suggest what else might be necessary for this patient?necessary for this patient?

When you administer this aerosol, When you administer this aerosol, you will use what kind of device?you will use what kind of device?

answeranswer

She needs a Beta II bronchodilator She needs a Beta II bronchodilator with the mucolytic which irritates the with the mucolytic which irritates the lungslungs

Both of these drugs can be given Both of these drugs can be given with a pneumatic aerosol generator with a pneumatic aerosol generator SVNSVN

When you add this drug to the SVN When you add this drug to the SVN you notice that is smells like rotten you notice that is smells like rotten eggs and that it seems to have an eggs and that it seems to have an oily sheen.oily sheen.

What is going on?What is going on?

answeranswer

Nothing, Acetylcysteine smells like Nothing, Acetylcysteine smells like rotten eggs and it has a sheenrotten eggs and it has a sheen

When you administer this drug, the When you administer this drug, the child starts to breath faster and her child starts to breath faster and her heart rate increases. heart rate increases.

What do you do?What do you do?

answeranswer

Listen to her breath sounds.Listen to her breath sounds. Assess her pulse ox for increased Assess her pulse ox for increased

hypoxemiahypoxemia

Her breath sounds have scattered Her breath sounds have scattered inspiratory and expiratory wheezesinspiratory and expiratory wheezes

Her Sp02 has dropped from 95% to Her Sp02 has dropped from 95% to 89%89%


answeranswer

Stop the treatment and give her a Stop the treatment and give her a Beta II drug aloneBeta II drug alone

Give the TX with 02 and the Sp02 Give the TX with 02 and the Sp02 should go back up.should go back up.

Continue to monitorContinue to monitor Consider another mucolyticConsider another mucolytic


Your patient is a 35 year old WM with Your patient is a 35 year old WM with a history of AIDS. He is admitted to a history of AIDS. He is admitted to the ER with increased respiratory the ER with increased respiratory distressdistress


answeranswer

Get VSGet VS Assess 02 status with Sp02Assess 02 status with Sp02 Listen to breath soundsListen to breath sounds Get sputum culture to send to lab Get sputum culture to send to lab

because AIDS patients get infectionsbecause AIDS patients get infections

His Sp02 is 89% on R.AHis Sp02 is 89% on R.A His respiratory rate is 31 bpmHis respiratory rate is 31 bpm He is retracting and flaringHe is retracting and flaring You hear diffuse crackles You hear diffuse crackles The doctor asks you to help collect The doctor asks you to help collect

the sputum using whatever tools you the sputum using whatever tools you have.have.

You suggest:You suggest:

answeranswer

We could give him a combination of We could give him a combination of Albuterol and Acetylcysteine to Albuterol and Acetylcysteine to mobilize secretions without mobilize secretions without stimulation of bronchospasmstimulation of bronchospasm

We could also give him hypotonic or We could also give him hypotonic or hypertonic saline to cause him to hypertonic saline to cause him to cough, but we need to monitor him cough, but we need to monitor him for wheezing triggered by the for wheezing triggered by the hypertonichypertonic

The doctor performs a bronchoscopy The doctor performs a bronchoscopy and obtains sputum that is sent to and obtains sputum that is sent to the lab. the lab.

The lab diagnosis is a PCP infection The lab diagnosis is a PCP infection of the lung. of the lung.


answeranswer

Pentamidine to control the parasitic Pentamidine to control the parasitic infectioninfection

If the pentamidine causes If the pentamidine causes bronchospasm you would like some bronchospasm you would like some Beta II drug ordered PRNBeta II drug ordered PRN

What SVN do you select to deliver What SVN do you select to deliver this drug? And why?this drug? And why?

answeranswer

The Respirgard II, because it has The Respirgard II, because it has bacteria filters in the exhalation line bacteria filters in the exhalation line to protect the RCPto protect the RCP

It has baffles to reduce the particle It has baffles to reduce the particle sizes to less than 1 micron to enter sizes to less than 1 micron to enter the alveoli where it is neededthe alveoli where it is needed


Your patient is a newborn who Your patient is a newborn who presents with increased respiratory presents with increased respiratory distress. He is tachypnic and distress. He is tachypnic and tachycardia. tachycardia.


answeranswer

Assess hypoxia with pulse oximeterAssess hypoxia with pulse oximeter Assess breath soundsAssess breath sounds

The Sp02 is 89% and the doctor The Sp02 is 89% and the doctor orders a heated hood at 30% for the orders a heated hood at 30% for the baby whose respiratory rate baby whose respiratory rate decreases. The Sp02 rises to 93%decreases. The Sp02 rises to 93%

You listen to breath sounds and hear You listen to breath sounds and hear diffuse wheezing and inspiratory diffuse wheezing and inspiratory stridorstridor


answeranswer

Give Beta II bronchodilator for Give Beta II bronchodilator for wheezing wheezing

Give racemic epinephrine for stridorGive racemic epinephrine for stridor

How do you administer the Beta II How do you administer the Beta II bronchodilator?bronchodilator?

answeranswer

Via the pneumatic SVNVia the pneumatic SVN

How do you administer the racemic How do you administer the racemic epinephrine?epinephrine?

Via the pneumatic SVNVia the pneumatic SVN

The doctor orders a nasal wash on The doctor orders a nasal wash on this child because she suspects he this child because she suspects he has RSV pneumonia.has RSV pneumonia.


answeranswer

Administer 6 grams of Ribavirin in Administer 6 grams of Ribavirin in 300 ml sterile water to run over 18 300 ml sterile water to run over 18 hours for three days. If the nasal hours for three days. If the nasal wash is negative for RSV, we can just wash is negative for RSV, we can just stop the TX, but we have to start stop the TX, but we have to start within 24 hours of symptoms, within 24 hours of symptoms, otherwise Ribavirin is uselessotherwise Ribavirin is useless

How do you administer this drug?How do you administer this drug?

answeranswer

Via the SPAG unit into the baby’s Via the SPAG unit into the baby’s heated hood.heated hood.


Your patient comes into the ER in Your patient comes into the ER in great respiratory distress. This 22 great respiratory distress. This 22 year old has a long history of severe year old has a long history of severe asthma.asthma.


answeranswer

Assess VSAssess VS Assess Sp02Assess Sp02 Assess breath soundsAssess breath sounds If she is wheezing, and if she can If she is wheezing, and if she can

handle it offer a PERFhandle it offer a PERF

Her respiratory rate is 34 bpm, her Her respiratory rate is 34 bpm, her heart rate is 130 bpmheart rate is 130 bpm

Her Sp02 is 88% on 2 lpm nasal Her Sp02 is 88% on 2 lpm nasal cannula started by the EMTcannula started by the EMT

Her breath sounds show diminished Her breath sounds show diminished breath sounds in the Right middle breath sounds in the Right middle lobe and scattered expiratory and lobe and scattered expiratory and inspiratory wheezes to all other lobes.inspiratory wheezes to all other lobes.

Her exhalation is prolongedHer exhalation is prolonged She refuses to even try the PERFShe refuses to even try the PERF You suggest?You suggest?

answeranswer

She needs more 02, increase her She needs more 02, increase her from 2 lpm to 5 or 6lpmfrom 2 lpm to 5 or 6lpm

Start her on 2.5 mg Albuterol now Start her on 2.5 mg Albuterol now Disregard the PEFR, it will only Disregard the PEFR, it will only

confirm what we already know—she confirm what we already know—she is in bronchospasmis in bronchospasm

After the 2.5 mg of Albuterol, and After the 2.5 mg of Albuterol, and getting a steroid IV started, the getting a steroid IV started, the doctor orders another TX in 30 doctor orders another TX in 30 minutes. It does no good. minutes. It does no good.

He decides to start continuous He decides to start continuous treatments. treatments. You set up what?You set up what?

answeranswer

A “Heart” SVN with a deeper medication A “Heart” SVN with a deeper medication cup will hold enough bronchodilator for a cup will hold enough bronchodilator for a continuous TX.continuous TX.

She needs an arterial blood gas [ABG] to She needs an arterial blood gas [ABG] to assess her C02 for her ventilatory statusassess her C02 for her ventilatory status

Continue to monitor Sp02, VS and breath Continue to monitor Sp02, VS and breath sounds. Get serial ABGs because if her sounds. Get serial ABGs because if her C02 rise in 15 minutes she needs to be C02 rise in 15 minutes she needs to be intubatedintubated

Unit 5 SVN case studies By Elizabeth Kelley Buzbee AAS, RRT-NPS RCP.

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Transcript of Unit 5 SVN case studies By Elizabeth Kelley Buzbee AAS, RRT-NPS RCP.