SOAP

East Tennessee State University

November 17th, 2005

Soap 3

• Background Information

• Patient was brought by ambulance to the Emergency Department at Indian Path Medical Center on October 20th, 2005, with no family accompaniment. Patient was admitted to the hospital on the floor, patients condition worsened, patient was placed in Intensive Care Unit on October 24th, 2005.

• Chief complaint: Patient felt fatigued and felt that she looked very pale in appearance, and she also stated that she had felt short of breath for a couple of days.

• Subjective/Objective: The patient had a history of anorexia for 3 to 4 days and a history of emesis of possible coffee ground material and black stool for 4 days prior to admission. In the emergency department Hemoglobin was 4.1, Hematocrit 25 %. On October 24th, while patient was receiving physical therapy her heart rate increased to 200 bpm, and she became very short of breath. Patient was given Lopressor 5 mg IV; patient was thought to be in atrial fibrillation and was transferred to ICU. Patient was intubated with a # 7 endotracheal tube upon arrival in ICU for Adult Respiratory Distress Syndrome.

• History and Physical

• Patient suffers from Chronic Obstructive Pulmonary Disease (COPD) and Obstructive Sleep Apnea (OSA).

• Co-morbidities: 1. Hepatitis C, etiology unknown. Hepatitis is inflammation of the liver. Hepatitis C produces persistent chronic liver infections. Hepatitis C is usually spread through contact with blood products, examples include being stuck with a dirty (used) needle, using IV drugs and sharing needles, or getting a blood transfusion before 1992. Treatment is usually combination drug therapy with steroid prednisone and genetically engineered alpha interferon or antiviral drug ribaviron and interferon. If you have hepatitis C, you need to be watched carefully by a doctor because it can lead to cirrhosis and liver cancer. (Marieb, p. # 920). 2. Cirrhosis, which is progressive chronic inflammation of the liver which results from alcoholism or severe chronic hepatitis. (Marieb, p. # 922). 3. Hypertension is a condition in which patients blood pressure is persistently higher than 140/90 mmhg, caused by high systemic vascular resistance. Hypertension can cause headaches, blurred vision, confusion, and renal insufficiency, congestive heart failure, and stroke. (Egan, p. # 319). 4. Hyperlipidemia is associated with elevated lipids in bloodstream, this condition speeds up arthrosclerosis, caused mainly by life-style habits; treatment: lower LDL cholesterol, change life-style habits, and control with prescription medications. (http://www.vascular web.org/). 5. Diabetes Type II or non-insulin-dependent in this case the patient produces insulin, but insulin receptors are unable to respond. Type II must inject insulin and watch their weight. (Marieb, p.# 641). 6. Chronic Renal Insufficiency is a gradual and progressive loss of the ability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes. The two most common causes are Diabetes and hypertenison. Blood transfusions or medications such as iron and erythropoietin supplements may be needed to control anemia. Dialysis or kidney transplant may be required eventually. (Marieb, p.# 1023). 7. Chronic Anemia develops as a result of extended infection or inflammation. Must treat the primary disease causing the problem. (Marieb, p.# 659). 8. Gastroesophageal Reflux Disease (GERD) is when the acidic gastric juice regurgitates into esophagus, causing pH to drop below 4; symptoms: burning, radiating substernal pain; treatment: antacids, prescription medicines, and avoid eating-late at night, and watch diet. (Marieb p. # 901). 9. Depression. 10. Fibromyalgia is a common condition characterized by widespread pain in joints, muscles, tendons, and other soft tissues. (Marieb, p.# 318). 11. Bipolar Disease is a mood disorder characterized by mood swings from mania (exaggerated feeling of well-being, energy, and confidence in which a person can lose touch with reality) to depression with the current or most recent episode of illness characterized by depression. (Marieb, p.# 258). 12. Right Lower Extermity Deep Venous Thrombosis it involves the formation of a clot in the large veins. This clot may interfere with circulation, and it may break off and travel through the blood stream). A resulting embolus can lodge in the brain, lungs, heart, or other area, causing severe damage to that organ. (Marieb, p.# 669).

• Smoking History: 38 pack years = 1 pack per day x 38 years

• Home Medications : 1. Buspirone (Buspar) 30mg, used for anxiety. (PDR, p.# 250). 2. Temazepam (Restoril) 30mg, used for insomnia. (PDR, p.# 249). 3. Flovent Inhaler bid. 4. Interferon , used for treatment of Hepatitis. (PDR, p.# 29). 5. Spirivia. 6. Levothyroxine Sodium (Synthroid) 112mcg, used as a thyroid agent. (PDR, p.# 196). 7. Lactulose (Constulose) 30cc, used as a colonic acidifer. (PDR, p.# 210). 8. Citalopram (Celexa) 40mg, used as an antidepressant agent. (PDR, p.# 258). 9. Atenolol (Tenormin) 50mg, is a beta blocker. (PDR, p.# 99). 10. Esomeprazole Magnesium (Nexium) 40mg, used in the treatment for GERD. (PDR, .p# 208).

• Patient wears home oxygen at 2 liters per minute.

• Patient wears CPAP at home when sleeping.

• Age: 56

• Gender: Female

• Height: 66 inches

• Actual weight: 243 pounds

• Ideal Body Weight: 45.5 + (2.3 x 66) – 60 = 137.3

• Physical Assessment: (10/20/05) Temperature 99.2 ° Fahrenheit

Pulse 89

Respiratory Rate 20

Saturation on 2 liters 92%

• Breath Sounds: Anteior Wheezes

• Mental Status: Alert and Oriented x 3

• Echo: Pericardial Effusion when excess fluid collects in the sac (pericardium) surrounding the heart. Causes include: infection, inflammatory diseases, cancer, kidney failure with excessive BUN levels, and heart surgery. (Marieb, p. # 683).

• Equipment -Patient needs a ventilator. The ventilator chosen for this patient was a Puritan Bennett 7200. The patient also needs a ventilator circuit, HME, ballard suction catheter, suction canister, pulse-ox, end-tidal CO2 monitor, and a tie to secure the patients’ ET tube. If the patient was to be weaned he would need a GIN or some form of humidity, air and oxygen would be needed, tubing, water trap bag, a mask. Patient would need ABG kits for samples that need to be analyzed.

• Ventilator Settings – Mode = CMV

Ventilator = Puritan Bennett 7200 Set Rate = 20 Set Volume = 500 ml

PEEP 10 cmH2O FIO2 = 55%

• Diagnostic Testing -

Lab Values Actual Values Normal Range Interpretation

WBC	24,000	5,000-10,000	H
Hemoglobin	8.8gm	12-16gm	L
Hematocrit	26%	40-50 %	L
Sodium Na	132 mEq/l	135-145 mEq/l	L
Potassium K+	3.4 mEq/l	3-5 mEq/l	N
Chloride Cl	95 mEq/l	85-100 mEq/l	N
Blood Urea Nitrogen	76 mg/dl	8-25 mg/dl	H
Creatinine	0.7 mEq/l	0.7-1.3 mEq/l	N

ABG - (10/30/05) Patients’ FIO2 was 70% at this time with a saturation of 91%.

Lab Values Actual Values Normal Range Interpretation

pH	7.44	7.35-7.45	N
PCO2	35 torr	35-45 torr	N
PO2	56.7 torr	80-100 torr	Moderate Hypoxia
HCO3	22.4 mEq/l	22-26 mEq/l	N

Results of ABG: Normal with moderate hypoxia

• Physician’s Plan

• Treat patients’ low hemoglobin levels by giving blood transfusions. Keep patients’ oxygenation within normal range. Keep patient on the ventilator.

• Medication: 1. Azithromycin (Zithromax), used for mycobacterium complex. (PDR, p.# 52). 2. Diltiazem (Cardizem) 60mg, used as a calcium channel blocker. (PDR, p. # 101). 3. Pantoprazole sodium (Protonix) 40mg, used as a proton inhibitor pump for GERD. (PDR, p. # 209).4. Albumin Human 25%. 5. Furosemide (Lasix) 80mg, used as a diuretic. (PDR, p.# 118). 6. Methylprednisone Sodium Succinate (Solu- Medrol) 60mg, used as a systemic corticosteroid. (PDR, p.# 188). 7. KCL 40mcg. 8. Epoetin Alpha (Epogen, Procrit) 2000 U, used as a hematopoietic agent. (PDR, p.# 231). 9. Nystatin (Mycolog II) 100,000 U, used as an antibiotic and anti-inflammatory agent. (PDR, .p# 146). 10. Digoxin (Lanoxin) 125mcg, used as a antiarrhythmics agent. (PDR, p.# 107). 11. Heparin/NaCl 1500ml. 12. Spironolactone (Aldactone) 100mg, used as a diuretic that is potassium sparing. (PDR, p.# 119). 13. Insulin 14U. 14. Albuterol Sulfate (Proventil) 3ml. 15. Budesonide (Pulmicort) 0.25mg. 16. Acetaminophen 650mg. 17. Ipratropium Bromide (Atrovent) 2.5ml. 18. Methylprednisone 60mg. 19. Lorazepam (Ativan) 0.5mg, used as a anticonvulsant. (PDR, p.# 252). 20. Morphine Sulfate 5mg. 21. Citalopram Hydrobromide (Celexa) 40mg, used as an antidepressant agent. (PDR, p.# 258). 22. Warfarin Sodium (Coumadin) 3mg, used as a coagulation modifier. (PDR, p.# 116).

• My Plan

• This patient is in very serious condition. I would like to be aggressive with her care, and try new options in the care plans that are available to the medical team.

• Concerning her labs: White Blood Cell count is elevated, 24,000. In this patients’ case I believe infection, anemia, and malnutrition are causing these elevated levels. To treat the high levels keep providing antibiotics, anticonvulsants, antithyroid agents, barbiturates. I would also try an antihistamine on top of these other drugs to treat her high WBC. Hemoglobin is still low 8.8, however it is not as low as when she presented to the ER, give blood transfusions as needed. Hematocrit is still low, 26% probably due to her anemia. BUN is excessively high, 76%, which I believe would be from renal problems, and possibly shock.

• As far as treating this patients’ ARDS, the three things to remember are 1. Treat the precipitating problem, 2. Ensure adequate tissue oxygenation and cardiovascular support, 3. Provide adequate nutritional support.

• I would like to place a Swan-Ganz catheter in place to measure cardiac output, PCWP, CVP, and PvO2. The PvO2 measurement would help with tissue oxygenation. A PvO2 less than 35mmHg suggests that oxygenation of the tissues is inadequate. PvO2 can also help to monitor optimal PEEP levels for this patient, so there is not a great reduction in cardiac output levels due to high levels of PEEP.

• I would also like to place the patient in prone position to help with oxygenation. Keep patient sedated and paralyzed. Initiate muscle relaxers to prevent movement and reduce body’s oxygen demands.

• Mechanical Ventilation: Continue with CMV mode. Use smaller tidal volumes 5 to 8mL/kg and a respiratory rate of 15-25 per minute. Maintain peak airway pressures of less than 35-45 cmH2O. Keep PEEP levels adjusted to where they are keeping the SaO2 greater than 90%, with an FIO2 of less than 60% (hopefully). However, if the PEEP and oxygen levels are not being adequately maintained I would initiate inverse I : E ratio ventilation. Make sure patient is paralyzed and try setting the ventilator in time-cycled mode. Lower the respiratory rate by adding an inspiratory hold.

• I would also like to see what the patients’ nutritional status and oxygen demands are so I would order a metabolic cart study to be done on this patient. So, in turn this might provide us with some useful information.

• Weaning: Make sure this patients’ underlying problem has been corrected or in her case stabilized, the issues that this patient suffers from are issues that are not going to be cured, but may be stabilized. In weaning this patient I would begin each shift observing what the patients’: vital capacity, NIF, PaO2/FIO2 ratio, maximum voluntary ventilation (MVV). Due to this patients’ poor oxygenation status I would consider weaning her when the FIO2 requirement was less than 40%, with PEEP requirement of 5cmH2O or less. Initially try switching the patient to SIMV mode first, so she can gradually assume the work of breathing required for spontaneous ventilation. Continue to monitor patients’ vitals, respiratory rate, tidal volume, minute ventilation, oxygen status, acid-base status, renal function, electrolytes, blood pressure, and nutritional status. If the patient did seem that she may be able to come off of the vent I would try a, T-piece. Initially try small periods and increase. Continue to suction as you would during your vent checks, may use a sterile suction catheter kit or hook patient back to ventilator. Also may want to try CPAP which would help to maintain patients’ lung volumes which would ultimately improve oxygenation status. After extubation I would start this patient on IPPB treatments with her bronchodilators.

• Home Care

• I would suggest supplemental oxygen when she goes home. The patient would need to be recertified for home O2. In recertifying the patient they would need to have this performed the day of discharge. The patients PaO2 must be less the 55, stat less than 88 on room air; or PaO2 less than 55, stat less than 88 during sleep; or PaO2 less than 55, stat less than 88 during exercise on room air; or PaO2 less than 59 with documented polcythemia or Hematocrit greater than 55%.

• I would suggest a visit to pulmonary rehab, because with ARDS the lung function may never completely recover. I would schedule an appointment for a pulmonary function test to be performed to see how her lungs are doing post-hospital.

• This patient may also need physical and occupational services since she was bedridden for so long and she is probably very weak from the sedation and muscle weakness. She also may need a walker, and may even need a hospital bed for a short period of time. Ultimately she needs adequate rest, with prevention of DVT.

• I would insist that she continue to wear her CPAP at home, and may even switch her to a BiPAP for more assurance. Continue with breathing treatments.