Abstract
This is a case study analysis that was performed following a certain patient’s hospitalization. The purpose of this case study analysis is to encourage the reader to critically think and identify certain pathophysiological processes, medications, clinical manifestations, abnormal assessment data, and abnormal laboratory values. The purpose of identifying the abnormalities is to critically deliberate what this means to the patient in question and why it matters. What diagnostic tests should physicians use? What do abnormal results mean? Does the patient require a new medication? Does the patient require a transfer to a higher level of care? By explanation and identification of deviations, clinicians can better serve other patients in their treatment. This case study will also prove that all pieces of the care plan are as equally important as the next and that the healthcare teams, especially nurses, must use their critical thinking skills and assessments skills to make sound and safe decisions for the patients.
Keywords:
Vital signs, signs, symptoms, clinical manifestations, decline, medications
Case Study Analysis of Patient’s Evolving Health Status
The patient is a 56-year-old Hispanic female presented to the emergency department with a stated complaint of back pain exacerbating over the past three days. The patient reported a fever, chills, myalgias,
dysuria, urinary frequency, and swelling in the left foot and leg. The patient had recently discharged from the same hospital a few days prior to this admission date and diagnosed with multiple compression fractures and was status post kyphoplasty.
Medical history includes diabetes mellitus type two, atrial fibrillation, chronic obstructive pulmonary disease, hypertension, and multiple spinal compression fractures. Past surgical history includes vertebroplasty and hysterectomy. The social history of the patient is that she is married and lives at home with her husband. She has five children and is on disability for the compression fractures. The patient denies any history of alcohol abuse but reports the previous usage of cocaine and marijuana. The patient underwent admission to a medical-surgical unit and was alert and oriented times four and cognitively intact until the evening of day four of admission. The patient became confused and began to decline neurologically and respiratory wise. The patient was transferred to the intensive care unit on the afternoon of day five on BiPAP and was subsequently intubated on day six of admission.
The patient has a past medical history of diabetes mellitus type two, chronic obstructive pulmonary disease, atrial fibrillation, hypertension, and multiple spinal compression fractures. Diabetes mellitus is an endocrine disease process related to how blood glucose is absorbed and controlled in the body. In a working pancreas, beta cells secrete insulin when there is a rise in blood glucose (this is usually at the point where the body is eating). Insulin is released from the pancreatic beta cells and enables glucose to move back into the cells, decreasing the amount of free glucose in the bloodstream. In a patient with diabetes mellitus type two, beta cells release insulin. However, the tissues that absorb glucose become desensitized so that nearly as much glucose that is released into the bloodstream is not absorbed. The body gets adjusted to chronically having an increased amount of insulin, also known as hyperinsulinemia. Medications and clinical manifestations will be discussed in a later section of this case study analysis.
This patient also had a history of chronic obstructive pulmonary disease. In particular, emphysema. Chronic obstructive pulmonary disease is a respiratory disorder related to expiration. A patient that has chronic obstructive pulmonary disease is able to get air and oxygen in. However, the process of exhalation is impaired. In emphysema, there is a breakdown and thinning of the alveolar walls and therefore, impairs gas exchange. Since the walls are thin, they are not as flexible and cannot inflate or recoil properly and effectively holding the carbon dioxide in the lungs. Generally, patients with chronic obstructive pulmonary disease have both chronic bronchitis and emphysema, but the patient’s medical record stipulates emphysema. When a patient has more carbon dioxide in the lungs than there is supposed to be, it can cause the patient to have the blood’s pH become acidic and can cause problems related to arterial blood gases and effective breathing.
Atrial fibrillation is a condition of the heart that instead of the heart’s atrium contracting and relaxing, they tremble and shake. When the atrium shakes, it cannot pass blood effectively into the ventricles to disperse or become oxygenated. The blood then pools in the bottom of the atrium and when there is a contraction that empties out the atrium, it will send the blood out. Typically, the pulse will have to be a heart rate of greater than 100; that is not always the case. Since the blood is pooling, it is becoming stagnant and can form a thrombus. Atrial fibrillation causes an increased risk of cerebrovascular accident. Most likely, it is a stroke that is ischemic.
Hypertension is chronically elevated high blood pressure. It is divided into two categories: primary and secondary. For primary hypertensive patients, the blood pressure is chronically elevated for unknown reasons. Secondary hypertension is a byproduct or spinoff of a disease process that is affecting the blood pressure i.e. chronic kidney disease. For the patient in the case study, she was diagnosed with primary hypertension. Hypertension is dependent on three factors: cardiac output, stroke volume, and total peripheral resistance. Cardiac output is the quantified volume that exits the heart. Cardiac output, along with heart rate, determines the stroke volume. Stroke volume is the blood volume expelled with systole contraction, as dictated by the heart rate and cardiac output. Total peripheral resistance is how much resistance to pressure there is from ventricular pumping. If hypertension is left untreated, it will create damage not only to the vessels in which the pressure is weakening the vessel walls but to the organs the blood within the vessels is producing nutrients and oxygen to.
Acute metabolic encephalopathy is an imbalance of chemicals in the brain. Most commonly, it is a change in a patient’s mentation. For this patient, her encephalopathy was related to an elevated ammonia level. Metabolic encephalopathy can be caused by a number of different ailments. For example, elevated ammonia, medications, other neurologic disorders, and hypoxemia. Also, in this patient’s case, the patient’s respiratory system had become compromised and later had to placed on BiPAP and then intubated.
Concept map
Chronic Obstructive Pulmonary Disease
Nursing diagnoses
-Ineffective airway clearance
-Impaired gas exchange
-Ineffective breathing pattern
What is it?
COPD is an obstructive breathing disease that makes it harder to people to exhale normally.
Clinical Manifestations and lab values
-Coughing mucus greater than three months over two years
-Arterial blood gas abnormalities
-Difficulty breathing
-Pursed lip breathing
-Chest tightness, especially when coughing
-bluish colored lips
-lower oxygen saturation percentages
Treatment and Management
-Albuterol inhalation nebulizers
-intravenous corticosteroids
-corticosteroid inhalation breathing treatments
-Ambulation
-Incentive spirometer
Clinical manifestations
For the patient in the case study, the patient had clinical manifestations that progressively started to decline in health status. For the morning assessment, the patient was alert but not oriented to person, place, time or situation (when stated in the report the patient was alert and oriented times four up until day four of admission). The patient was also confused, restless, agitated, and increasing in hostility and becoming combative with the staff. The patient had bilateral lower lobe fine crackles and expiratory wheezes and had a 91-92% oxygen saturation on four liters nasal cannula. The patient was also using accessory muscles and had sternal retractions. The patient was experiencing tachycardia in the 120s. The patient’s lower extremities were graded at 2+ pitting edema. The patient had a yellow generalized skin appearance and was warm and wet from sweating.
For a patient that was previously alert and oriented times four and cognitively intact until day four of admission to become confused, erratic, and unable to answer any questions is a steep decline in mentation. As it would later come about, the patient was in acute metabolic encephalopathy that ran parallel with acute hypercapnic respiratory failure. The confusion, combative actions were caused by an elevated ammonia level. Ammonia levels are between 11 and 32 and the patient’s levels were 85. The patient had to a drug called Lactulose in an enema form in order to get to ammonia level down. The impaired liver function also caused the yellow generalized appearance for the patient.
The patient was reading sinus tachycardia in the 120s on her telemetry monitor. This is a compensatory mechanism for increased respiratory effort. In addition, the patient’s confusion, restlessness, and agitation also played a factor in the patient’s elevated heart rate. The blood pressure was also elevated.
The patient had a previous medical history of chronic obstructive pulmonary disease and yet her respiratory system started to decline. The patient developed bilateral lower lobe crackles and expiratory wheezing. Since the patient’s gas exchange was already compromised from her history of chronic obstructive pulmonary disease; the crackles were evident by the patient’s inability to release carbon dioxide properly so more than likely (not confirmed at the time information was gathered to write the case study) the patient may have had atelectasis. The expiratory wheezing was trying to get the carbon dioxide out of the lungs. The use of accessory muscles and sternal retractions were present as the patient’s body was forcefully trying to compensate and let go of the carbon dioxide. The patient was also on four liters nasal cannula to get the patient to have a 91-92% oxygen saturation rate. Usually, in a patient that has chronic obstructive pulmonary disease, it is unwise to administer more than three or four liters of oxygen because it can cause them to become further hypercapnic.
One of the last clinical manifestations the patient had was 2+ pitting edema on the lower extremities. This is due to the blood pressure being increased. The patient remained in the 140s-150s systolic. The blood pressure is a hydrostatic pressure that will force blood outward. When the heart contracts, it sends blood for dispersion to other parts of the body. To adequately perfuse organs and digits, the blood much reaches the tissues and provide the oxygen and nutrients required to remain healthy. When the blood pressure is elevated for a long time, usually years, the pushing pressure becomes too much and will develop edema, or swelling, in the extremities. For this patient, the edema was graded at a 2+ which is substantial. This patient may have had a hypotonic osmolality and was fluid overloaded, which would further the cause of having edema. Coincidentally, the patient also had low serum albumin.
Labs
Ammonia is the result of protein breakdown. In patients with a working liver, the broken-down proteins (the ammonia) is sent to the liver to breakdown even further. When the liver function is impaired, the ammonia cannot reach the liver and therefore, ammonia levels remain in the blood and rise. Ammonia levels are known to affect the brain and cause hepatic encephalopathy. The patient reported no previous history of hepatic insufficiency or problems and the ammonia level went unchecked until just before the patient was transferred to the intensive care unit where the level was 85 on a range of 11-32. This would explain why the patient was alert and oriented times four and cognitively complete until the evening of day four when the patient started to become confused. The patient’s ammonia levels increased to a critical range.
The arterial blood gases demonstrate the body’s management of oxygen, carbon dioxide, and sodium bicarbonate. They are drawn by a respiratory therapist and analyze the patient’s pH, partial pressure carbon dioxide (PaCO
2
), and the sodium bicarbonate (HCO
3
)
.
In this case, the patient’s pH was 7.30, PaCO
2
86,
HCO
3
41.8. The pH reveals how much hydrogen ion is in the bloodstream. If the hydrogen ion is increased, the pH is low and the blood is acidic. If the hydrogen ions are not as present, the pH is elevated and the blood is basic. Any levels outside of 7.35-7.45 can be detrimental to health, depending on severity. PaCO
2
is a respiratory management compensatory mechanism to help balance out sodium bicarbonate and can retain carbon dioxide or expel it, depending on the patient’s condition. For this particular patient, the patient’s breathing was altered and the respiratory system could not compensate for the holding of carbon dioxide in the lungs. HCO
3
is a compensatory mechanism for the renal system (kidneys). For the renal system to become involved in a compensating manner, the patient’s pH and PaCO
2
failed to achieve compensation. It takes days to weeks for the HCO
3
to increase. When analyzing the patient’s arterial blood gases, they are all out of range. However, though some values are critical, it is not bad for a patient with chronic obstructive pulmonary disease. Patients with this disease typically have altered blood gases due to alveoli damage and/or chronic mucus production. The body is trying to keep up its stamina for its difficulty in expelling air.
Glucose is the energy that human cells use for fuel (other than oxygen). Glucose is simply sugar and when a person eats, the blood glucose increases from the glucose in the food. Glucose is then distributed to other parts of connective tissue for absorption. Insulin helps to sensitive receptors in the connective tissue to absorption glucose. Though a patient that has diabetes mellitus type two, their receptors become desensitized to the glucose, despite the insulin and therefore, blood glucose will stay elevated. For this patient, up until day five, her blood glucose had remained between 200-240. A normal blood glucose is between 70 and 110. When a patient has elevated blood glucose, it can increase cardiac, respiratory, and infection treatment difficult because the blood is viscous from the glucose, it moves slower than characteristic.
Albumin is a plasma protein that is responsible for sustaining the osmotic vascular pressure. Osmotic pressure is a towing pressure to maintain a working intravascular fluid balance. Therefore, if the albumin is low, the patient will experience edema. Edema is swelling. For this patient, the patient was experiencing lower extremity edema with an albumin level of 2.5. Albumin levels are affected by hepatic function and if the liver function tests are altered, that will reflect in the albumin levels.
Liver function tests such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are enzymes that are mostly found in the liver and detect hepatic impairment and injury. These enzymes appear if there has been found to have an injury to the hepatocytes. Injury can occur from a genetic standpoint or an external effect (i.e. alcohol). The patient’s ALTs were 111 on a range of 13-56 and the ASTs were 112 on a 15-37 range. Chronic alcoholism will cause injury to the liver cells and will increase liver function tests. These tests are diagnostic and should be paired with a typical basic metabolic panel. The husband later admitted to the physician that he did not think she was alcoholic because she only drinks two beers a night, every night, for the past twenty years.
Medications
Ipratropium is an inhalation bronchodilator used to expand the bronchioles to allow air passage in and out easier. Surprisingly, only 2% of this drug is absorbed by the body if used via inhalation. There is greater absorption if used via aerosol. This patient had Ipratropium nebulizers scheduled every four hours at 500mg per treatment total. However, do not use Ipratropium more than 12 times in a 24-hour period due to this establishing a pattern that this medication does not work. Nurses must teach their patients to provide good oral hygiene after a treatment followed by notifying the nurse if the patient is experiencing any rapid heart rate increase and nervousness.
Lactulose is an osmotic laxative used to stimulate people to have a bowel movement followed by a significant period of constipation. Lactulose also binds to ammonia and excretes it through the stool, effectively lowering the ammonia levels. Lactulose can be given orally and rectally. Rectal lactulose is usually administered in an intensive care unit because if the patient requires rectal lactulose, they are too sick to be on a medical-surgical unit. For the patient in this case study, lactulose was administered through a 300mL enema to get the ammonia level to decrease. As for nursing implications, pay attention to how many bowel movements the patient is having and if the bowel movements are becoming more and more diarrhea-like. This could lead to possible electrolyte depletion and abnormal values.
Metformin is a biguanide that controls blood glucose production from the liver. Metformin also decreases glucose reuptake in the intestines and does not cause hypoglycemia. It does not cause hypoglycemia because its mechanism of action is not in the pancreas, it is in the liver. Patients taking Metformin should be cautious that this medication can cause diarrhea and nausea within the first two weeks of starting the drug. Patients should also be taught to check blood glucose before meals and at bedtime to see how effective metformin is and report this to their doctor. Patients should notify their physicians and healthcare team that they are currently taking Metformin prior to having a scan performed with intravenous contrast, as it can lead to nephrotoxicity and lactic acidosis. The case study patient was on Metformin, oral 500mg twice a day.
Propofol is a lipid emulsified sedative drug used in the intensive care unit and the operating room. Propofol’s purpose is to sedate the patient and often times can make them forget. Propofol is only administered through an intravenous line and the patient has to be on a cardiac monitor. Nurses should be careful when drawing labs on the same extremity the Propofol is infusing on, as it can affect the complete blood count and basic metabolic panel labs. Nurses should also be careful in their administration of Propofol, as too much of the drug can cause hypotension. Nurses are not to intravenous push Propofol but can titrate as directed by the ordering physician. For initiating Propofol, 2-2.5mg/kg initiation rate. After the patient is proven to be sedated, the drip can be titrated. The patient here was intubated on day six of admission and Propofol was used for sedation.
Methylprednisolone is an intermediate-acting corticosteroid used to strengthen lung capabilities for patients with asthma and/or chronic obstructive pulmonary disease. It can be administered oral, intravenous, and intramuscular. Patients and nurses should be aware to not stop any type of corticosteroids abruptly, as this can cause an adrenal crisis. Patients should be tapered off of steroids for the prevention of adrenal crisis. Corticosteroids also increase bone demineralization. For this patient, the corticosteroids she was taking at home contributed to the spinal compression fractures she complained of. The patient’s dosage started off at 125mg oral of this medication and would start to taper off the steroids on day seven.
Diagnostic tools
The patient ended up receiving a computed tomography (CT) scan of the brain that showed no acute intracranial process. This was done early in the morning of day five of admission to rule out a cerebrovascular accident. A CT scan is a relatively cheaper option (as compared to a magnetic resonance imager) that can note vascular and structural changes in the brain. As for this patient, the CT scan could not determine the cause of the patient’s confusion. Later on, a basic metabolic profile came back with ammonia level elevated.
The patient, later on, received a chest x-ray. An x-ray can be a portable machine used to view the body on a flat plane rather than 3D. The patient’s chest x-ray demonstrated that the patient’s heart was slightly enlarged and fluid overloaded.
Medical and nursing care plans
The medical care plan included medications, diagnostic tests, insertion of invasive lines and airways, and laboratory workups. For medications, the physicians ordered Precedex for agitation, scheduled Solumedrol 60mg every eight hours, Propofol for sedation, and ipratropium nebulizing treatments. Diagnostics are a daily chest x-ray and an echocardiogram. An arterial line was inserted into the left radial artery and the patient was intubated with an endotracheal tube after failing to wean off of BiPAP and became the respiratory effort doubled worse than before the patient was in the intensive care unit. Laboratories include daily arterial blood gases, complete blood counts, basic metabolic panels with ammonia. Venous thromboembolism prophylaxis includes sequential compression devices and heparin subcutaneous injections.
For nursing diagnoses: ineffective airway clearance related to damaged vessel walls as evidenced by desaturation of oxygen levels and increased respiratory effort. Ineffective breathing pattern related to the inability to properly exchange blood gases as evidenced by a desaturation in oxygen and partially compensating arterial blood gases.
Conclusion
Ultimately, this patient survived her decline in health status and was able to recover well after being downgraded from the intensive care unit four days after admission to a higher level of care. This case study was intended to introduce all aspects of the patient care plan and all the variables that contribute to the patient and the outcome. All parts of the care plan are equally important and it is the job of the healthcare team to become as knowledgeable as possible, in order to treat patients timely and accurately.
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