CHAPTER 27 AIRWAY ASSESS/PLEURAL EFFUSION-FRICTION RUB

A client with CF who is 2 months post-operative from a bilateral lung transplant wants to begin riding his bicycle again, as his pulmonary specialist has said he can do, but his wife is concerned that this will "wear out" his new lungs faster. How will the nurse advise this couple? a. Remind the wife that activity does not damage or "wear out" the lungs and that exercise will reduce the risk for other health complications. b. Tell the wife that because the client has a reduced life expectancy, she should allow him to do whatever he wants. c. Remind the client that this is the "honeymoon phase" of recovery and that he will not feel well for very long. d. Advise the client to protect his lungs at all cost.

ANS: A Although the disease process may cause problems eventually in the new lungs, activity does not damage the lungs. All exercise in a client who has undergone a lung transplant for CF must begin slowly and progress at an appropriate rate for each client, there is no restriction on the type and eventual intensity of the exercise unless another health problem is present.

A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this client's plan of care? a. Assistance with activities of daily living b. Physical therapy activities every day c. Oxygen therapy at 2 liters per nasal cannula d. Complete bedrest with frequent repositioning

ANS: A A client with dyspnea and difficulty completing activities such as climbing a flight of stairs has class III dyspnea. The nurse should provide assistance with activities of daily living. These clients should be encouraged to participate in activities as tolerated. They should not be on complete bedrest, may not be able to tolerate daily physical therapy, and only need oxygen if hypoxia is present.

A nurse auscultates a harsh hollow sound over a client's trachea and larynx. Which action should the nurse take first? a. Document the findings. b. Administer oxygen therapy. c. Position the client in high-Fowler's position. d. Administer prescribed albuterol.

ANS: A Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse should document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the client's position because the finding is normal.

Which interventions are important for the nurse to teach a client with severe chronic obstructive pulmonary disease (COPD) to help ensure adequate nutrition? (Select all that apply.) a. Avoid eating gas-producing foods b. Cough to clear mucus right before eating c. Drink plenty of fluid with every meal d. Eat smaller meals more frequently e. Rest immediately following a meal f. Eat more raw fruits and vegetables g. Use your bronchodilator about 30 minutes before each meal

ANS: A, B, D, G Gas-producing foods contribute to early satiety (feeling full) and interfere with adequate food intake. Coughing and clearing mucus right before a meal makes the client more comfortable (not to mention those eating with him or her) and helps prevent the need to cough during a meal, interrupting the process. Eating 4 to 6 smaller meals daily instead of 3 larger ones helps improve nutrition by not tiring the client out as much. Psychologically, a smaller-appearing meal looks less daunting to someone who may not be feeling very hungry. Using the bronchodilator before a meal eases respiratory effort by reducing dyspnea. This allows the client to concentrate on eating instead of on breathing. Drinking liquids during a meal is discouraged because it contributes to early satiety and reduces the amount of food the client actually eats. Eating raw fruits and vegetables requires considerable chewing and is likely to tire the client without increasing the overall caloric intake.

A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Encourage deep breathing and coughing. b. Implement an air mattress overlay. c. Ambulate the client three times each day. d. Provide a diet high in protein and vitamins. e. Administer acetaminophen (Tylenol) twice daily.

ANS: A, C, D Regular pulmonary hygiene and activities to maintain health and fitness help to maximize functioning of the respiratory system and prevent infection. A client at high risk for a pulmonary infection may need a specialty bed to help with postural drainage or percussion; this would not include an air mattress overlay, which is used to prevent pressure ulcers. Tylenol would not decrease the risk of a pulmonary infection.

Which assessment findings are most important for the nurse to determine when assessing a client with dyspnea? (Select all that apply.) a. Onset of or when the client first noticed dyspnea b. Results of most recent pulmonary function test c. Conditions that relieve the dyspnea sensation d. Whether or not dyspnea interferes with ADLs e. Inspection of the external nose and its symmetry f. Whether stridor is present with dyspnea

ANS: A, C, D, F Rationale: Dyspnea, especially if it is new onset, is a sensitive indicator of the possible presence of life-threatening respiratory problems. Dyspnea is subjective and determining onset, relieving factors, interference with ADLs, and presence of stridor should be elicited from the client to help assess severity and determine the level of intervention needed. Pulmonary functioning and inspection of the external nose are objective data.

Which conditions are most likely to cause a "left shift" of the oxyhemoglobin dissociation curve? (Select all that apply.) a. Reduced blood and tissue levels of diphosphoglycerate (DPG) b. Reduced blood and tissue pH c. Increased metabolic demands d. Alkalosis e. Increased body temperature f. Reduced blood and tissue levels of oxygen

ANS: A, D Rationale: The oxyhemoglobin dissociation curve is shifted to the left when conditions are present that reduce overall oxygen needs. This left shift makes it harder for oxygen to dissociate from the hemoglobin molecule. Such conditions are those associated with slower or lower metabolism and oxygen need. These include less DPG, and alkalosis (fewer hydrogen ions). Reduced pH, increased metabolic demand, increased body temperature, and hypoxia are all associated with increased oxygen need and a right shift in the oxyhemoglobin dissociation curve.

A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation. Which manifestations should the nurse identify as adverse effects of this medication? (Select all that apply.) a. Visual hallucinations b. Tachycardia c. Decreased cravings d. Impaired judgment e. Increased thirst

ANS: A, D Varenicline (Chantix) has a black box warning stating that the drug can cause manic behavior and hallucinations. The nurse should assess for changes in behavior and thought processes, including impaired judgment and visual hallucinations. Tachycardia and increased thirst are not adverse effects of this medication. Decreased cravings is a therapeutic response to this medication.

While obtaining a client's health history, the client states, "I am allergic to avocados." Which responses by the nurse are best? (Select all that apply.) a. "What response do you have when you eat avocados?" b. "I will remove any avocados that are on your lunch tray." c. "When was the last time you ate foods containing avocados?" d. "I will document this in your record so all of your providers will know." e. "Have you ever been treated for this allergic reaction?"

ANS: A, D, E Nurses should assess clients who have allergies for the specific cause, treatment, and response to treatment. The nurse should also document the allergies in a prominent place in the client's medical record. The nurse should collaborate with food services to ensure no avocados are placed on the client's meal trays. Asking about the last time the client ate avocados does not provide any pertinent information for the client's plan of care.

A nurse teaches a client who is interested in smoking cessation. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Find an activity that you enjoy and will keep your hands busy." b. "Keep snacks like potato chips on hand to nibble on." c. "Identify a punishment for yourself in case you backslide." d. "Drink at least eight glasses of water each day." e. "Make a list of reasons you want to stop smoking."

ANS: A, D, E The nurse should teach a client who is interested in smoking cessation to find an activity that keeps the hands busy, to keep healthy snacks on hand to nibble on, to drink at least 8 glasses of water each day, and to make a list of reasons for quitting smoking. The nurse should also encourage the client not to be upset if he or she backslides and has a cigarette.

A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.) a. "I held the client's morning bronchodilator medication." b. "The client is ready to go down to radiology for this examination." c. "Physical therapy states the client can run on a treadmill." d. "I advised the client not to smoke for 6 hours prior to the test." e. "The client is alert and can follow your commands."

ANS: A, D, E To ensure the PFTs are accurate, the therapist needs to know that no bronchodilators have been administered in the past 4 to 6 hours, the client did not smoke within 6 to 8 hours prior to the test, and the client can follow basic commands, including different breathing maneuvers. The respiratory therapist can perform PFTs at the bedside. A treadmill is not used for this test.

Which laboratory values are most important for a nurse to monitor for a client who is receiving a heparin infusion for treatment of a pulmonary embolism when warfarin is added to the drug therapy? (Select all that apply.) a. Activated partial thromboplastin time b. Albumin levels c. Factor V levels d. Hepatic function tests e. International normalized ratio f. Platelet count g. Serum osmolarity

ANS: A, E, F Heparin dosing is monitored and adjusted with activated partial thromboplastin times (aPTT) and platelet counts. Warfarin dosing is monitored and adjusted based on the international normalized ratio (INR). Although warfarin is protein-bound and hypoalbuminemia may affect dosing, it is not routinely monitored at the initiation of warfarin therapy. Hepatic function and Factor V assessment are not part of dose monitoring for either heparin or warfarin.

The nurse assessing the respiratory status of a client discovers that tactile fremitus has increased from the assessment performed yesterday. For which possible respiratory problem should the nurse assess further? a. Pneumothorax b. Pneumonia c. Pleural effusion d. Emphysema

ANS: B Tactile (vocal) fremitus is a vibration of the chest wall produced when the patient speaks. This vibration can be felt on the chest wall. Fremitus is decreased if the transmission of sound waves from the larynx to the chest wall is slowed, such as when the pleural space is filled with air (pneumothorax) or fluid (such as with a pleural effusion) or when the bronchus is obstructed. Fremitus is increased with pneumonia and lung abscesses because the increased density of the chest enhances transmission of the vibrations.

A client with pulmonary artery hypertension on a continuous IV epoprostenol infusion is in the emergency department with symptoms of possible sepsis. The health care provider prescribes a broad-spectrum antibiotic to be administered IV immediately. What is the nurse's best action? a. Request a prescription for an oral antibiotic. b. Start a peripheral IV line and administer the antibiotic. c. Administer the IV antibiotic through the continuous infusion's side port. d. Stop the epoprostenol infusion for 15 minutes to administer the IV antibiotic.

ANS: B The epoprostenol infusion cannot be stopped for even 15 minutes without endangering the client's life. The drug also cannot be mixed with any other drug. With possible sepsis, the antibiotic must be administered intravenously.

A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action? a. Increased temperature b. Absent breath sounds c. Productive cough d. Incisional discomfort

ANS: B Absent breath sounds may indicate that the client has a pneumothorax, a serious complication after a needle biopsy or open lung biopsy. The other manifestations are not life threatening.

A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first? a. Encourage the client to increase fluid intake. b. Assess the client's level of consciousness. c. Raise the head of the bed to at least 45 degrees. d. Provide the client with humidified oxygen.

ANS: B Assessing the client's level of consciousness will be most important because it will show how the client is responding to the presence of the infection. Although it will be important for the nurse to encourage the client to turn, cough, and frequently breathe deeply; raise the head of the bed; increase oral fluid intake; and humidify the oxygen administered, none of these actions will be as important as assessing the level of consciousness. Also, the client who has a pulmonary infection may not be able to cough effectively if an area of abscess is present.

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next? a. Administer an albuterol treatment. b. Notify the Rapid Response Team. c. Assess the client's peripheral pulses. d. Obtain blood and sputum cultures.

ANS: B Cyanosis unresponsive to oxygen therapy is a manifestation of methemoglobinemia, which is an adverse effect of benzocaine spray. Death can occur if the level of methemoglobin rises and cyanosis occurs. The nurse should notify the Rapid Response Team to provide advanced nursing care. An albuterol treatment would not address the client's oxygenation problem. Assessment of pulses and cultures will not provide data necessary to treat this client.

A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding? a. "Are you taking any medications or herbal supplements?" b. "Do you have any chronic breathing problems?" c. "How often do you perform aerobic exercise?" d. "What is your occupation and what are your hobbies?"

ANS: B The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at a high altitude for many years. Therefore, an AP chest diameter that is the same as the lateral chest diameter should be rechecked but is not as indicative of underlying disease processes as an AP diameter that exceeds the lateral diameter. Medications, herbal supplements, and aerobic exercise are not associated with a barrel chest. Although occupation and hobbies may expose a client to irritants that can cause chronic lung disorders and barrel chest, asking about chronic breathing problems is more direct and should be asked first.

A client newly diagnosed with moderate asthma asks whether he can just take salmeterol instead of salmeterol and albuterol, because he has read that they are both beta agonists. What is the nurse's best advice? a. Yes, both of these drugs have the same action, and you only need one. b. Yes, because they both need to be used daily whether you are having symptoms or not, just take a little more of the salmeterol and don't take any of the albuterol. c. No, albuterol is used to relieve the symptoms during an actual asthma attack and salmeterol is used to prevent an attack. Both are needed. d. No, albuterol is taken through the use of an aerosol inhaler and salmeterol is an oral drug (tablet) that is activated in the stomach. Both are needed.

ANS: C Albuterol is a short-acting beta agonist (SABA) that has an immediate onset of action with a short duration. It is used as needed to relieve (rescue) and stop an actual asthma attack. Salmeterol is an inhaled only long-acting beta agonist (LABA) that has a slow onset of action with a longer duration. It is taken daily whether symptoms are present to prevent or control asthma, not to stop an attack that has already started. It has no real benefit as a rescue inhaler. Both forms of beta adrenergic agonists are needed in the management of moderate asthma.

1. Which description of respiratory physiologic features is correct? a. The elastic tissues of the tracheobronchial tree are the major structures responsible for gas exchange. b. The epiglottis closes during speech to divert air movement into and through the vocal cords to produce sound. c. Any problem with the right lung interferes with gas exchange and perfusion to a greater degree than a problem in the left lung. d. The left lung is responsible for approximately 60% of gas exchange and the right lung is responsible for 60% of pulmonary perfusion.

ANS: C Rationale: The right lung is larger and has more diffusing surface and more blood vessels than does the left lung. All lung functions (gas exchange and perfusion) are greater in the right lung, which means that problems in the right lung more severely affect (reduce) gas exchange than do similar problems in the left lung. Surfactant reduces surface tension rather than increases it. Gas exchange does not occur within the tracheobronchial tree because the tissues are too thick for adequate diffusion of gas in either direction.

A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? a. Client states he is dizzy. - Nurse applies oxygen and pulse oximetry. b. Client's heart rate is 55 beats/min. - Nurse withholds pain medication. c. Client has reduced breath sounds. - Nurse calls physician immediately. d. Client's respiratory rate is 18 breaths/min. - Nurse decreases oxygen flow rate.

ANS: C A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The physician needs to be notified immediately. Dizziness after the procedure is not an expected finding. If the client's heart rate is 55 beats/min, no reason is known to withhold pain medication. A respiratory rate of 18 breaths/min is a normal finding and would not warrant changing the oxygen flow rate.

A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement should the nurse include in this client's teaching? a. "Make a list of reasons why smoking is a bad habit." b. "Rise slowly when getting out of bed in the morning." c. "Smoking while taking this medication will increase your risk of a stroke." d. "Stopping this medication suddenly increases your risk for a heart attack."

ANS: C Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and heart attack. Nurses should teach clients not to smoke while taking this drug. The other responses are inappropriate.

A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60-pack-year smoking history. Which action is most important for the nurse to take when interviewing this client? a. Tell the client that he needs to quit smoking to stop further cancer development. b. Encourage the client to be completely honest about both tobacco and marijuana use. c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. d. Avoid giving the client false hope regarding cancer treatment and prognosis.

ANS: C Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances. Because the client may have guilt or denial about this habit, assume a nonjudgmental attitude during the interview. This will encourage the client to be honest about the exposure. Ask the client whether any of these substances are used now or were used in the past. Assess whether the client has passive exposure to smoke in the home or workplace. If the client smokes, ask for how long, how many packs per day, and whether he or she has quit smoking (and how long ago). Document the smoking history in pack-years (number of packs smoked daily multiplied by the number of years the client has smoked). Quitting smoking may not stop further cancer development. This statement would be giving the client false hope, which should be avoided, but is not as important as maintaining a nonjudgmental attitude.

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next? a. Call the physician and request a prescription for food and water. b. Provide the client with ice chips instead of a drink of water. c. Assess the client's gag reflex before giving any food or water. d. Let the client have a small sip to see whether he or she can swallow.

ANS: C The topical anesthetic used during the procedure will have affected the client's gag reflex. Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex.

A nurse is providing care after auscultating clients' breath sounds. Which assessment finding is correctly matched to the nurse's primary intervention? a. Hollow sounds are heard over the trachea. - The nurse increases the oxygen flow rate. b. Crackles are heard in bases. - The nurse encourages the client to cough forcefully. c. Wheezes are heard in central areas. - The nurse administers an inhaled bronchodilator. d. Vesicular sounds are heard over the periphery. - The nurse has the client breathe deeply.

ANS: C Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages. Hollow sounds are typically heard over the trachea, and no intervention is necessary. If crackles are heard, the client may need a diuretic. Crackles represent a deep interstitial process, and coughing forcefully will not help the client expectorate secretions. Vesicular sounds heard in the periphery are normal and require no intervention.

The client from Clinical Judgement Challenge 32-2 (p. xxx) continues to deteriorate clinically and is to be intubated. What are the most important actions for the nurse to implement? (Select all that apply.) a. Obtain a cervical X-ray. b. Discontinue the IV fluids. c. Immediately page anesthesia or the Rapid Response Team (depending on institution policy). d. Confirm that suction is at the bedside and functioning properly. e. Have the crash cart available. f. Place client on nasal cannula oxygen. g. Have manual resuscitation bag with face mask at bedside. h. Verify bilateral breath sounds post-intubation.

ANS: C, D, E, G, H Arrange for intubation per institution protocols. Suction, resuscitation bag with mask, and crash cart should be readily available for procedure (in an ICU, the crash cart may be optional). Post-intubation the nurse should confirm the presence of bilateral breath sounds. A cervical X-ray is not indicated, but a CXR is needed to confirm ET placement. The IV fluids should not be discontinued for intubation. They are required to administer medications and for fluid boluses if the patient becomes hypotensive. The rate may be decreased or they may be discontinued after the procedure if there is a concern for edema.

The nurse is trouble-shooting multiple ventilator alarms sounding for a client who is intubated and being mechanically ventilated. The alarms persist despite suctioning, repositioning the client, and ensuring the ventilator tubing is unobstructed. Which actions will the nurse perform next? (Select all that apply.) a. Turn off all ventilator alarms until a cause is found to prevent scaring the client. b. Page the healthcare provider to request additional sedation. c. Ensure the endotracheal tube marking is at the client's incisor. d. Increase the PEEP to improve oxygenation. e. Disconnect the client from the ventilator and use the manual resuscitation bag. f. Change all ventilator tubing. g. Start paging the respiratory therapist. h. Determine when the client received the last dose of the paralytic agent.

ANS: C, E, G Multiple alarms sounding indicate a serious problem with ventilating the client and the client is in danger of hypoventilation and death. When multiple alarms are sounding and the problem cannot be identified and corrected quickly, the priority is to assess whether the problem is with the client or with the ventilator. Ensuring gas exchange is critical. Care for the client first and the ventilator last. Paging the respiratory therapist immediately is critical because this interprofessional team member is the ventilator expert. Turning off the alarms is not consistent with National Patient Safety Goals or safe care. Additional sedation does not solve the problems with the ventilator or the client's gas exchange. Checking the timing of the paralytic dose wastes valuable time and does not improve the client's ventilation or gas exchange. Changing the tubing might be helpful eventually but does not help the client right now. It is possible that the endotracheal tube has advanced to the point that it is no longer reaching the client's trachea, and its position should be checked quickly and immediately. To ensure adequate gas exchange, disconnect the client from this ventilator and provide ventilation with the manual resuscitation bag until someone else fixes or changes the ventilator. Manual resuscitation allows assessment of the client and determining lung compliance by the amount of effort needed to compress the bag, observing for chest rise with compressions, and determining whether this action results in improvement in the client's oxygen saturation. If manual ventilation improves the client's saturation, the issue is with the ventilator. If the client's saturation does not improve, the issue is with the client, which would require immediate intervention by the healthcare provider or Rapid Response Team.

The chest tube of a client who is 12 hours postoperative from a lobectomy separates from the drainage system. What is the nurse's best first action? a. Immediately call the surgeon or rapid response team. b. Notify respiratory therapy to set up a new drainage system. c. Cover the insertion site with a sterile occlusive dressing and tape down on three sides. d. Place the end of the disconnected tube into a container of sterile water positioned below the chest.

ANS: D This soon after surgery an open chest drainage tube can have air suck through it back into the client's chest and collapse the lung. This is an emergency. Although the surgeon or rapid response team should be called, the nurse first prevents the situation from becoming worse by sealing the tube with water. Because the chest tube is still in place in the client, using an occlusive dressing will not help prevent a lung collapse. Setting up a new drainage system can wait until after the tube is secured.

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? a. The client rates pain as a 5/10 at the site of the procedure. b. A small amount of drainage from the site is noted. c. Pulse oximetry is 93% on 2 liters of oxygen. d. The trachea is deviated toward the opposite side of the neck.

ANS: D A deviated trachea is a manifestation of a tension pneumothorax, which is a medical emergency. The other findings are normal or near normal.

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure? a. Measure oxygen saturation before and after a 12-minute walk. b. Verify that the client understands all possible complications. c. Explain the procedure in detail to the client and the family. d. Validate that informed consent has been given by the client.

ANS: D A thoracentesis is an invasive procedure with many potentially serious complications. Verifying that the client understands complications and explaining the procedure to be performed will be done by the physician or nurse practitioner, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis.

A nurse assesses a client's respiratory status. Which information is of highest priority for the nurse to obtain? a. Average daily fluid intake b. Neck circumference c. Height and weight d. Occupation and hobbies

ANS: D Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client's occupation and hobbies. Although it will be important for the nurse to assess the client's fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. Determining the client's neck circumference will not be an important part of a respiratory assessment.

The patient is a 26-year-old who was admitted to the surgical floor 2 days ago after a motor vehicle crash. His injuries include a thoracic fracture, for which he must remain flat, and some chest bruising. He was started on enteral feeding yesterday. His IV fluid rate is 150 cc/hr, and he is receiving IV morphine every 2 hours for pain. At change of shift, your assessment findings include that the patient is dyspneic and slightly confused. Lung sounds are diminished in the right base and he is febrile to 101.5 (38.6). Pulse is 120 bpm; respirations are 36 per minute and shallow. Blood pressure is 88/56 mm Hg, pulse oximetry shows an SpO2 of 88%, and an end-tidal CO2 (ETCO2) shows 48. 1. Is this patient experiencing ventilatory failure, oxygen failure, or combination of ventilatory and oxygenation failure? Explain your answer. 2. What are some possible causes of the patient's distress? 3. Which interprofessional team members should you contact now and why? 4. What diagnostic tests should you anticipate the healthcare provide to order?

Suggested Responses: 1. Is this patient experiencing ventilatory failure, oxygen failure, or combination of ventilatory and oxygenation failure? Explain your answer. ANS: The patient is likely experiencing a combination of ventilatory and oxygenation failure. His respirations are rapid and shallow with poor tidal volumes and an ETCO2 of 48. An ABG which shows hypercarbia (PCO2 >45) with acidosis (pH <7.35) indicates ventilatory failure. His SpO2 of 88% suggests hypoxia, which can also be confirmed with an ABG. 2. What are some possible causes of the patient's distress? ANS: Potential causes of ventilatory failure are poor inspiratory effort due to chest injury, over-sedation due to pain medication, PE, pneumothorax, ARDS. Potential causes of oxygenation failure are pneumonia (potentially an aspiration pneumonia or community acquired as it is less likely a hospital-acquired pneumonia on hospital day 2), PE, hypotension/hypovolemic shock. 3. Which interprofessional team members should you contact now and why? ANS: The healthcare providers are responsible for the patient. They need to be informed about the change in the patient's condition and may order additional diagnostic tests. The respiratory therapist should be contacted to assist with providing supplemental oxygen, additional respiratory treatments as indicated including aerosols, and hyperinflation therapy. 4. What diagnostic tests should you anticipate the healthcare provide to order? ANS: Titrate oxygen to maintain an SpO2 >92%, ABGs, chest X-ray (to evaluate for potential disease, i.e., pneumonia, collapse, pneumothorax), blood cultures with initiation of antibiotics (febrile patient, concern for infection), decrease IV fluid rate (concern for edema), CT chest to evaluate for pulmonary embolus. Some providers may discontinue enteral feedings until aspiration and/or decreased gastric motility is ruled out.

The patient is a 53-year-old woman who had major abdominal surgery for a bowel resection 2 days ago. She is a current smoker with a 40 pack-year smoking history. She also has chronic obstructive pulmonary disease and had a right upper lobe lung removal in the past. The nursing assistant calls you to the patient's room because her pulse oximeter is alarming and indicates an SpO2 of 50%. The patient reports mild shortness of breath and her blood pressure is 76/42. 1. What should be your first actions? Provide a rationale for your choice(s). 2. The health care provider asks you to send a D-dimer laboratory test. Is this test diagnostic for a PE? Why or why not? 3. The health care provider believes that patient has a PE and wants to start anticoagulation before the patient has a CT scan for confirmation. Is this an appropriate action? Why or why not? 4. Your patient does have a PE and has completed her inpatient therapy. She is to be discharged to home on warfarin therapy. What are the important issues to include in the discharge plan? 5. What other interprofessional team members would be helpful to involve in this patient's care and why?

Suggested Responses: 1. What should be your first actions? Provide a rationale for your choice(s). ANS: Provide supplemental oxygen or increase the delivered FiO2. This patient is very hypoxic. Call the rapid response team. The low blood pressure along with the hypoxemia indicates hemodynamic instability. She needs immediate assistance to prevent further clinical deterioration. The FiO2 should be increased to provide an oxygen saturation of at least 92%. She will most likely need IV fluids and vasopressors to manage the hypotension. 2. The health care provider asks you to send a D-dimer laboratory test. Is this test diagnostic for a PE? Why or why not? ANS: The D-dimer is the degradation product of fibrinogen. High levels can indicate the presence of a clot; low levels can rule out a clot. However, it is not specific for a pulmonary embolism and many factors can cause elevated levels, including surgery. Because this patient had major surgery only 2 days ago, this test would not be helpful to diagnose a PE. 3. The health care provider believes that patient has a PE and wants to start anticoagulation before the patient has a CT scan for confirmation. Is this an appropriate intervention order? Why or why not? ANS: If the health care provider has a high suspicion that the patient has a PE, it is appropriate to start parenteral anticoagulation even though she had surgery 2 days ago. Delaying anticoagulation therapy could result in extension of an existing clot and development of new clots. 4. What other interprofessional team members would be now helpful to involve in this patient's care and why? ANS: It is appropriate to involve the respiratory therapist and the pharmacist in addition to the Rapid Response Team and the healthcare provider. They can assist with providing optimal oxygen therapies and determining appropriate pharmacological interventions. It is also reasonable to involve pastoral care for spiritual support, and social work to start long-term planning, depending on the patient's needs. 5. Your patient does have a PE and has completed her inpatient therapy. She is to be discharged to home on warfarin therapy. What are some important issues to include in the discharge plan? ANS: Because the patient is being discharged on warfarin, she will need routine blood monitoring. This can be a barrier for many patients. Determine whether the patient will follow with her own health care provider, be referred to an anticoagulation clinic, or need to establish care with anew provider. Work with the discharge planner to arrange appointments before discharge. Ensure that the patient understands when and where she will need any blood work prior to her appointment. There are dietary interactions with warfarin and the patient may benefit from a nutrition consultation with a registered dietitian before or after discharge. The patient is a current smoker with significant pulmonary-related problems. Now her risk for PE is ongoing and is not helped by her continuing smoking. Although this topic can be difficult, she should be counseled about the benefits of smoking cessation and how to go about it.