Analysis of Blood Gas Report

Part 1

Mr John Brown is an 84yr gentlemen on a 2 week holiday on the Gold Coast from South Australia with his wife, Ethel Brown.  They have been married for 62 years and 2 children.  Over the last week John has been getting increasingly short of breath and for the last 2 days has been confined to the holiday apartment. He has a non-productive cough.  Last night (Thursday) John was unable catch his breath after a coughing episode and his wife rung QAS. He was then admitted to hospital with a chest infection and diagnosed with a chest infection and transferred to the respiratory ward.

His medical and surgical history includes:

• Ex Smoker 40years pack a day (quit in 2000)
• Spontaneous Pneumothorax – ICC
• Bronchoscopy
• Hypertension;
• Hypercholesterolaema
• Myocardial Infarct treated with Angioplasty and Stent (2007)
• Coronary Artery Bypass Graft 1995
• Persistent Angina
• Atrial Fibrillation
• Chronic abdominal pain-undiagnosed cause
• Colonoscopy – NAD

Medications:

• Isosorbidemononitrate
• Avapro
• Plavix
• Acetylcysteine
• GenRxMetroprolol
• Diaformin
• GenRx Simvastatin

Allergies: Penicillin, iodine

Admission

It is Saturday morning and you have started your early shift.  You perform your assessment and find out the following information:

• 84yr man presents complaining of shortness of breath
• Vomited x 2 overnight – 10mg Maxalon given
• Fell out of bed and ? banged head, no loss of consciousness
• Respiratory Rate 18, Oxygen saturation 70% on room air increased to 96% on 4 L Oxygen via nasal prongs, unable to complete sentences
• ECG – 70, BP 95/45, Temp 38.1, 1 x cannula,
• Cool extremities, pitting oedema noted
• GCS 14 – Eyes – open to voice, Motor – Obeys Commands, Verbal – knows name and date of birth
• Incontinent of urine x 1 overnight

Questions

1. If you are the nurse receiving this patient what are the initial priorities of care you would provide?
2. Explain the reason why Johns GCS is 14

Identify the pathophysiology behind why Mr M would be hypotensive.

Part 2

Dr Kildare has seen the patient and diagnosed a lower lobe respiratory tract infection; Mr Brown also appears to have developed sepsis. As Mr Brown's condition is critical, Dr Kildare transfers him to the High Dependency Unit (HDU).

The following observations are made:

Questions

9. Interpret these observations and identify their implications for you as a nurse and for the management of Mr M.
10. Consider the SIRS criteria, which of these criteria does Mr Brown present with?
11. Discuss the signs and symptoms of septic shock and outline the management of a patient with sepsis

A severe complication of a chest infection such as pneumonia may include hypotension and shock and respiratory failure, especially if the infection is caused by gram – negative bacteria in older adults.  These complications are also more likely to occur if the patient has underlying comorbidities which this 84 year old male does.

In this case, Mr M has a decreased oxygen saturation of 70% on room air, is hypotensive with a blood pressure of 95/45 and is presenting with pitting oedema, a sign of congestion of the peripheral tissues and the viscera, due torespiratory failure and therefore failure of the right side of the heart to pump effectively.  Pitting oedema is obvious only after retention of at least 4.5 litres of fluid.  Congestive heart failure and cardiac arrhythmias are also complications of pneumonia.

Initial therapy may include haemodynamic and ventilator support to combat peripheral collapse, maintain arterial blood pressure and provide adequate oxygenation.  The main indications for emergency oxygen therapy are O2 sats less than 90%, systolic BP less than 100 mmHg.  The aim would be to have the oxygen saturation above 90% and this has been achieved with 4 L of O2 via nasal prongs.  I would have a Hudson mask present and also a non – rebreather mask should the patient deteriorate even further.  I would initiate a MET call for urgent medical intervention.  Mr M's heart may be beginning to fail as a pump and there may not be enough fluid returning to the heart to fill it sufficiently and therefore dropping the blood pressure or there may be loss of vascular tone seen in examples of sepsis.  I would determine what the patient's urine output has been over the last few hours to rule out the presence of oliguria, test for capillary refill time, and assess GCS so that the patient can be treated with an urgent fluid challenge of 500 – 1000ml of IV saline.  I would take a full set of observations frequently and document on MET form.  Patient may be in the early stages of sepsis, presenting with a temperature of above 38 degrees C, hypoperfusion and hypotension.  Mean arterial pressure should be greater than 65 and urine output should remain greater than 0.5 ml/kg/hr.    Patient may need antibiotics and corticosteroids.