Question

A 63-year-old man who is complaining of severe shortness of breath is brought by ambulance to the ED. He is 5 ft, 11 in (71 in) and weighs 175 lb (79.5 kg). His vital signs are blood pressure = 175/115 mm Hg; heart rate = 140 beats/min and the rhythm is irregular; f = 22 to 24 breaths/min; and he has a normal temperature. His lips are cyanotic, his neck veins are distended, and both of his ankles show evidence of pitting edema. Breath sounds reveal bilateral basilar crackles and wheezes. He has a productive cough with small amounts of pink, frothy secretions. He is very anxious and refuses to lie down on the gurney, saying, “I get too short of breath when I lie down.” The electrocardiogram reveals atrial fibrillation with a ventricular rate of 138 to 140 beats/min and occasional premature ventricular contractions. The respiratory therapist places a pulse oximeter sensor on the patient’s left index finger and notices that the patient’s hand is cold. The respiratory therapist is unable to obtain an accurate pulse oximeter reading. After placing the sensor on the right index finger and rubbing the hand to warm it, an SpO2 reading of 87% is obtained.The patient is started on a nasal cannula at 2 L/min and given intravenous furosemide, dobutamine, and digitalis. ABGs obtained 1 hour later are pH = 7.16; PaCO2 = 79 mm Hg; PaO2 = 33 mm Hg; HCO3 − = 28 mEq/L on 2 L/min by nasal cannula. The patient’s urine output was 580 mL in the past hour, and he remained cyanotic.

1. What was the problem with the POX on the left index finger?

2. How would you interpret the ABG?

3. What is the action of furosemide, dobutamne and digitalis?

4. Why are these meds being used to treat this patient?

5. Why is the 580 ml significant? The 2 L/min nasal cannula was not adequate. He is slow to respond to verbal commands

. 6. How would you treat this patient?. Explain why you choose this treatment.

7. What are the indications for your choice?

Answer 1

1. The patient finger was cold , so vasoconstrition of blood vessles occure due to cold low blood flow to the fingers due to vasoconstriction of blood vessels resulting in inaccurate reading.

2. According to the ABG ressult, the PH of blood is acidic, the partial pressure of carbondiaoxide is high , partial pressure of oxygen is low, bicarbonate is normal or slightly elevated.

3.

• furosemide also know as lasix   is a type of loop diuretic and acts in the loop of henle, it blocks the reabsorption of sodium, potassium and causes diuresis.
• dobutamine causes vasodilation. increase the stroke volume and cardiac output by stimulating the beta 1 adrenoceptors.
• digoxin increase the contractility of the heart by inhibiting Sodium and potassium ATP. Also. reduce the heart rate by increasing the vagal efferent activity reduce the conductiting velocity of electrical impulses throught the AV node.

4. Patient is having edema. and increase in blood pressure so diuretic is used to remove the excess fluid and to maintain the blood pressure.Dobutamine is administered to improves the blood supply to the body organs by increaseing the cardiac output. Digoxin is given to increase the contractility of the heart and also to treat atrial fibrillation.

5. urine output of 580 ml in 24 hours is less . normal urine level per 24 hour should be 800 - 2000ml.

6. ACE inhibitors, beta blocker,diuertic,digoxin, oxygen administration. ACE inhibitors dilates the blood vessels, resulting in decrease bp and improves blood flow, beta blockers lowers heart rate and also decrease bp, diuretic removes excess fluid, digoxin imporve contractility and increase the cardiac out also reduce dysrhythmias, oxygen supply is needed as the patient oxygen level in arterial blood is low.

7. indication

• hight blood pressure, edema, atrial fibrilltion, low oxygen, increase heart rate