Question

A patient has been admitted with an obvious problem with GAS EXCHANGE. The patient's room air ABGs are: pH 7.12, PO2 62 mm Hg, PCO2 66 mm Hg, HCO3 22 mm Hg. The patient's oxygen saturation is 84%, and you assess coarse lung sounds with some wheezing in all fields. The patient is anxious and reports feeling very short of breath. The patient is febrile at 102.3° F (39° C); pulse is 148 beats/min, respirations 38 breaths/min, and blood pressure is 98/52 mm Hg.

1. Which immediate care actions do you anticipate?

2. After addressing the patient's GAS EXCHANGE needs, which care priorities should you focus on next?

3. The primary health care provider leaves the following prescriptions for the patient. In what order should you accomplish them?

a. Start gentamycin (Garamycin) 500 mg IVPB now

b. Obtain sputum and blood cultures

c. Insert indwelling urinary catheter

d. Administer acetaminophen 1000 mg orally once for rib pain e. Increase rate of IV infusion to 150 mL/hr

4. Which member(s) of the interprofessional team would be most helpful in this situation and why?

5. Which other assessments should you perform?

Answer 1

The ABGs of this patient suggest -

1. Low PH that means he has ACIDOSIS.

2. Low levels of partial pressure of oxygen and high levels partial pressure of carbon dioxide in blood that means he has HYPOVENTILATION.

3. Normal HCO3 level.

So, ABGs report is suggestive of RESPIRATORY ACIDOSIS in this patient.

• The signs/symptoms and vitals of this patient are as follows:-

1. Coarse lung sound with some wheezing

2. Anxious

3. Shortness of breath

4. O2 saturation is 84%

5. Febrile at 102.3° F (39° C)

6. Pulse is 148 beats/min ( Fast heart rate also called Tachycardia in medical terminology)

7. Respirations 38 breaths/min

8. Blood pressure is 98/52 mm Hg (Low blood pressure also called as Hypotension)

All these signs/symptoms and vitals are suggestive of SEVERE PNEUMONIA.

Thus, the diagnosis in this patient becomes SEVERE PNEUMONIA   with RESPIRATORY ACIDOSIS.

Now , answering all the questions according to our diagnosis that we made.

ANSWER 1:- The immediate action that we will anticipate is stabilizing the O2 saturation by giving Oxygen supplementation to get oxygen saturation upto around 94% from 84%, so that patient doesn't feel shortness of breathness. And ventilation is improved.

ANSWER 2:- After addressing patient's gas exchange issue, our next priority will be to act on Stabilizing :-

• LOW BLOOD PRESSURE of patient by giving intravenous FLUIDS to increase blood pressure of patient which will also help in decreasing the HEART RATE as this patient is having tachycardia due to low blood pressure.

• Administering intravenous antipyretic drug for example Provas infusion to lower the high temperature (102.3° F).

ANSWER 3:- The prescription left by primary health care provider will be accomplished by me in following order:-

1. Start Gentamycin (Garamycin) 500mg IVPB now.

2. Administer acetaminophen 1000 mg orally once.

3. Insert indwelling urinary catheter.

4. Obtain sputum and blood cultures.

5. Increase rate of IV infusion to 150 mL/hr.

ANSWER 4:- The interprofessional member that will be helpful in this case is a CONSULTANT PULMONOLOGIST.

Why?

• Because this patient is a case of severe pneumonia and specialist in chest disease will better help in accessing the situation and prescribing the further drugs that might be needed which a primary health care might have missed due to lack of sufficient knowledge about pulmonology. And also pulmonologist will advise more tests like X-ray chest or CT-Scan chest other than baseline and sputum culture to assess the situation more deeply as to how much lungs have been dismantled by disease.

ANSWER 5:- Other assessment/s that I will perform will be:-

1. Chest X-Ray PA view.

2. Ct- Scan Chest ( if X-ray chest doesn't give proper finding).

3. Acid fast bacilli testing of sputum to rule out Tuberculosis.