This week there will be 3 Case Studies. Pick 1 and then SBAR the patient.  SBAR is situation, background, assessment, and recommendation. I do not expect you to know what exactly to recommend, but if there is an oxygen issue you might want to recommend an ABG and/or oxygen. It does not have to be the exact modality.  Or if there is an issue with the heart an ECG might be needed.  Review the Case Studies at the end of Chapter 21 for guidence. You do not need to replay to your classmates posts.  You will have to post your answer before seeing your classmates answers. Do Not Edit without notifing me first. Case Study 1 You work at a medium size community hospital and are called to the emergency department to see a patient who is complaining of SOB. An order has been written for bronchodilator treatment. On arrival, you find a 68-year-old moderately obese man sitting upright on the examination table in the examination room. You observe that his respiratory rate is about 22 breaths/minute, with pursed-lip breathing and slight cyanosis around the lips, and he is unable to say more than a few words per breath. He is complaining of left elbow pain. His heart rate is 129 beat/minute and irregular. On auscultation, you hear fine crackles in both lung bases. He reports a nonproductive cough for the last 3 days, with increasing SOB, an inability to lie flat, and increasing leg pain. You notice that he is unable to tie his shoes because his feet are swollen and that his legs are very red, shiny, and painful to the touch. His current PEF is 45% of predicted. A room air ABG was done before your arrival: pH, 7.47; PaCO2, 32 mm Hg; PaO2, 53 mm Hg; HCO3−, 23 mEq; BE, 0; SaO2, 89%. No chest radiograph has been ordered yet. You give the ordered bronchodilator treatment with O2, but the patient reports no subjective relief. No changes in vital signs are noted. His color does improve a little during the treatment (O2 at 6 L/minute via small-volume nebulizer), and his breath sounds are unchanged. His cough is nonproductive, and there is no measurable change in the peak flow after treatment. SBAR this patient. Case Study 2 You are the night shift respiratory therapis at a local hospital. The charge nurse calls you to the medical floor on the night shift because a patient has awakened with SOB. You find a 63-year-old man sitting upright in his bed, leaning forward on the nightstand. He is pursed-lipped and using accessory muscles to breathe, with a prolonged expiratory phase, at a rate of 18 to 20 breaths/minute. In the dim light of his private room, it is hard to see his color, but his skin is warm and moist over his upper torso, and his chest has an increased anteroposterior diameter. His SpO2 is 85% on room air. On auscultation, you hear fine crackles in the right base and expiratory low-pitched wheezing in the upper lung fields bilaterally. Breath sounds in the left lung base are diminished. He has expectorated at least 8 mL of thick greenish-yellow sputum; no blood is seen. By palpation, his pulse is rapid and occasionally irregular. He was admitted 8 hours earlier for a knee fracture incurred during a fall that afternoon. When interviewed, he relates that he has COPD but has not been receiving any treatment for it for the last 8 months. When he was taking medication, it was only one MDI, 2 puffs in the early morning and afternoon, but he does not remember the name of the medication. The physician has been called, and you are awaiting a return phone call. You and the nurse agree to do the following: 1. Start O2 therapy at 2 L/min via nasal cannula 2. Repeat SpO2 after O2 therapy 3. Get an ECG stat 4. Call the physician again and call the nursing and respiratory supervisors Immediately after completing these interventions and telling your supervisor what you have done, you sit down to chart your assessment and what has transpired. SBAR this patient. Case Study 3 You work at a large city hospital and you are just starting your morning shift in the adult ICU, and you have been assigned a 20-year-old woman with a history of acute asthma. The shift report to you is that she has been on q1h bronchodilator therapy with 2.5 mg albuterol in 3 mL normal saline for 16 hours; concurrently she has been receiving 50% via air-entrainment mask, with a “PRN ABG for SOB” order and with a continuous pulse oximeter and ECG. She has been alert and cooperative, and her SOB had diminished through the night shift. Her admission ABG levels on 50% FIO2 were pH, 7.46; PaCO2, 30; PaO2, 70; HCO3−, 22; BE, 1; SaO2, 94%; Hb, 12.0; COHb, 0.7%. When you arrive in the ICU, you note a slightly sleepy but easily aroused cooperative young adult. Her SpO2 is reading 92% on 50% O2, heart rate is 128 beats/minute, and respiratory rate is 18 breaths/minute without accessory muscle use. Auscultation reveals that she has bilateral inspiratory and expiratory wheezing. Her chest radiograph report states that there is hyperinflation noted bilaterally, with patchy infiltrates and atelectasis in the right lung base. Her radial pulses are strong and unaffected by her respiratory pattern. Her stat morning electrolyte levels are all within normal limits; her CBC shows eosinophilia but otherwise is within normal limits. You start her treatment at 0730 and finish at 0745; vital signs and breath sounds are unchanged throughout the treatment. You finish your charting and go to your next patient. At 0800, the nurse calls you and asks you to come see the same asthmatic patient. You immediately recognize that her ECG rate and respiratory rate have increased in the last 30 minutes, and her accessory muscle use has increased. She is becoming restless, pulling her air-entrainment mask off and complaining of increasing SOB. You cannot hear any breath sounds over her right lower lobe. With the nurse helping hold the patient’s arm steady, you draw an arterial sample. Her SpO2 is now 88% on the air-entrainment mask when she keeps it on. Before you go to analyze the ABG levels, you put her on a non-rebreather mask per physician orders. Her ABG levels are pH, 7.26, PaCO2, 52 mm Hg; PaO2, 50 mm Hg; HCO3−, 22; BE, 5; SaO2, 86%; Hb, 12.0. On your return, the patient’s physician is at the bedside, and she tells you the patient is going to be intubated and placed on a ventilator. The anesthesiologist is called to intubate as you leave to get the ventilator. The patient is successfully intubated and placed on the ventilator per physician initial orders. Before you start an in-line bronchodilator treatment, you note and report that her auto-PEEP is 10 cm H2O at a respiratory rate of 16 breaths/minute with an I/E ratio of 1:2.5. After the in-line treatment, the breath sounds, peak pressures, and auto-PEEP are all unchanged, but the SpO2 has improved to 96%. According to hospital policy, you now have to write an assessment in the medical record. SBAR this patient I only need about 300 words,

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