Allied Health Essay

East Tennessee State University

Soap Example 3

Background Information

Patient originally arrived at the emergency department by ambulance at Bristol Regional Medical Center on April 4th, 2012 after experiencing a fall at Greystone Nursing Facility. After the fall, her saturation was 86% on five liters.

Chief complaint: Patient complained that she had hit her head and could not breathe. She also complained of back and neck pain.

Objective: The patient was given Xopenex at 0.63mg and Pulmicort at 180mcg. Due to her low oxygen saturation and respiratory failure, she was placed on BIPAP as well. However, her saturation continued to drop and her arterial blood gas showed persistent hypoxemia as well as hypercarbia, despite 100% FIO2 on BIPAP, therefore, the decision was made to intubate at that time.

She was also thought to have respiratory failure with a COPD exacerbation and congestive heart failure exacerbation.

The patient was later trached on April 13th, 2012 and moved to Select Specialty Hospital on April 19th, 2012, where she was weaned off of the ventilator and returned to Greystone Nursing Facility.

However, on May 3, 2012, she returned to the emergency department at BRMC as a full code due to cardiac arrest and respiratory failure. She was intubated, moved to the ICU, and later trached and then moved on May 11, 2012 to the IMU at BRMC.

History and Physical

-Co-morbidities:

Co-Morbidity	Definition	Treatment/Management
Hypernatremia	An electrolyte problem defined as a rise in serum sodium concentration above 145 mEq/l (Lukitsch, 2010).	Recognizing the symptoms when present, identifying the underlying cause, correcting the volume disturbance, and correcting the hypertonicity (Lukitsch, 2010).
Anemia	A condition in which the hemoglobin is below normal (Nabili, 2012).	Identify the underlying cause, iron supplements, blood transfusions, or Vitamin B12 injections (Nabili, 2012).
Thrombocytopenia	Any disorder in which there is an abnormally low amount of platelets (Thrombocytopenia, 2012).	Treatment depends on the cause of the condition. Usually a transfusion of platelets is required (Thrombocytopenia, 2012).
Congestive Heart Failure (CHF)	A condition in which the heart’s function as a pump is inadequate to meet the body’s needs (Kulick, 2012).	Lifestyle modification, addressing potentially reversible factors, medications, heart transplant and mechanical therapies (Kulick, 2012).
Obstructive Sleep Apnea (OSA)	A sleep disorder involving cessation or significant decrease in airflow in the presence of breathing effort (Downey 2012).	Weight loss, changing sleeping position, avoiding alcohol before bed, CPAP and BIPAP (Downey, 2012).
Mild Obesity	The state of being well above one’s normal weight (Definition, 2012).	Dietary changes, exercise, counseling/support, and medication (Definition, 2012).
Hypertension	When a person’s blood pressure is persistently above 140/90mmHg. The cause is often unknown, but it probably is “the result of increased systemic vascular resistance or an increased force on ventricular contraction” (Wilkins, Stoller and Kacmarek, 2009, p.328)	Making lifestyle changes (those that would affect blood pressure and reduce cardiovascular risk) as well as medications, including diuretics, alpha- and beta-adrenergic blockers, antihypertensives, calcium channel blockers, ACE inhibitors, and vasodilators (Riaz, 2012).
Gastroesophageal reflux disease (GERD)	The spontaneous return of gastric contents into the esophagus. The main symptom is frequent heartburn (Heartburn, 2007).	Medications, lifestyle changes, including eating small, frequent meals, and stop smoking, and possibly even surgery (Heartburn, 2007).
Chronic Kidney Disease (Stage III)	Occurs when someone suffers from gradual and usually permanent loss of kidney function over time (Kathuria, 2012).	Dietary changes, medications, stop smoking, lose weight (Kathuria, 2012).
Chronic Obstructive Pulmonary Disease (COPD)	A chronic, ongoing, progressive disease of the lower respiratory tract in the lungs (Treatments, 2012).	Quit smoking and control symptoms by using medications such as bronchodilators, corticosteroids, and oxygen (Treatments, 2012).
Type II Diabetes	A lifelong disease in which there are high levels of sugar in the blood, because the person’s body cannot move sugar into fat, liver, and muscle cells to be stored for energy (Eltz and Zieve, 2012).	Medication, diet, and exercise (Eltz and Zieve, 2012
Hypothyroidism	A condition characterized by abnormally low thyroid hormone production (Mathur, 2012).	Synthetic T4 replacement (Mathur, 2012).
Cardiomyopathy	A disease that weakens and enlarges the heart muscle (Cardiomyopathy, 2012).	Depending on which type may include, drugs, surgery, and pacemakers (Cardiomyopathy, 2012).

-Home Medications:

Drug Name	Dosage	Indications
Acetaminophen (Tylenol)	650 mg	Used for mild pain.
Carvedilol (Coreg)	6.25mg	Treatment of cardiomyopthy.
Fluticasone (Advair)	50mcg	Used to manage COPD.
Gabapentin (Gralise)	100mg	Used to manage postherpetic neuralgia.
Levothyroxine (Levothroid)	75mcg	Used to manage hypothyroidism.
Metolazone (Zaroxolyn)	1mg	Used to treat hypertension and water retention in CHF.
Theophylline	350mg	Used to manage COPD.
Torsemide (Demadex)	10-20mg	Used to treat edema associated with CHF.
Levemir (Insulin Detemir)	35 units	Used to manage diabetes.
Coumadin (Warfarin)	5mg	Used to treat thromboembolic complications.

(PDR, 2012)

-Past Surgical History: 1. Automatic implantable Cardioverter-defibrillator placement 2. Tubal Ligation 3. Tonsillectomy 4. Adenoidectomy 5. Cesarean Section 6. Pacemaker placement

-Age: 52

-Gender: Female

-Height: 160.02cm (63in)

-Actual Weight: 102kg (224.4lbs)

-Ideal Body Weight: 45.5 + (2.3 x 63) -60 = 130.4lbs

-Smoking History: 1 pack per day x 25 years= 25 pack years

-Physical Assessment:

-Vitals: (5/11/12): Blood Pressure: 118/90

Pulse: 108

Total Respiratory Rate: 14

Temperature: 37C (98.6F)

Saturation: 92% on 100% FIO2

-General: Patient is awake but does not respond to questions. Pupils are equal, round and reactive to light.

- Neck: No jugular venous distention noted. Has a tracheostomy intact with ventilatory support.

-Lungs: Bruising on left chest area.

-Cardiac: Tachycardiac at 108bpm.

-Abdomen: Has an umbilical hernia. Her bowel sounds are decreased. Abdomen is distended. Percutaneous endoscopic gastrostomy is intact.

-Extremities: She has a left hand small hematoma area. Has a trace of edema in lower extremities and in thigh areas (+2-+3 pitting edema).

-Neurology: Awake but did not mouth any words, just smiled.

-Breath Sounds: Rhonchi and wheezes bilaterally.

-Home Oxygen: Patient uses 3LPM via nasal canula at Greystone Nursing Facility.

-Social History: No history of alcohol or illicit drug use. Stays at Greystone Nursing Facility.

-Previous Pulmonary History: Patient has significant history of COPD.

-Allergies: Patient is allergic to latex. It causes dryness, itching, and burning).

-Chest Radiograph: Taken on 5/11/12. Showed a cardiac pacer, right picc line and tracheostomy. There was improvement in aeration in the right lower lung zone, but there was also development of patchy pulmonary opacities in the right perihilar area and extending into the right apex. Opacities in the left lower lung zone appeared more confluent than previously. Cardiomegaly demonstrated. Pleural effusion may have developed. Co-existing CHF not excluded.

Equipment

The patient needs a ventilator for the time being. Along with the vent, she needs a tracheostomy tube, a tie to secure the tube, a continuous pulse-ox, an HME, a ventilator circuit, a ballard suction catheter and suction canister, materials to perform her trach care, and arterial blood gas kits.

Ventilator Settings

On 5/11/12, her ventilator settings were:

Mode: Assist Control FIO2: 100% Tidal Volume: 550ml

Set Rate: 14 Total Rate: 14 PEEP: 5 cmH2O

On 5/17/12, her ventilator settings were:

Mode: SIMV + PS FIO2: 40% Tidal Volume: 500ml

Set Rate: 10 Total Rate: 22 PEEP: 5 PS: 10 cmH2O

Diagnostic Testing

Lab Values	Actual Values	Normal Range	Interpretation
White Blood Cells	21,000	5,000-10,000	High
Red Blood Cells	3.05 million/cumm	4-6 million/cumm	Low
Hemoglobin	9.1gm	12-16gm	Low
Hematocrit	29.8%	40-50%	Low
Sodium	147mEq/l	135-145mEq/l	High
Potassium	3.6mEq/l	3.0-5.0mEq/l	Normal
Chloride	105mEq/l	85-100mEq/l	High
Blood Urea Nitrogen	44gm/dl	8-25gm/dl	High
Creatinine	1.56mEq/l	0.7-1.3mEq/l	High

Interpretation of Diagnostic Testing: The patient’s white blood cell count it extremely high, in return making her red blood cell count, hemoglobin, and hematocrit low. All of these values were checked again on 5/17/12 and most of them were improved. Her white blood cell count was back in normal range, and her red blood cell count, hemoglobin and hematocrit were still slightly under normal range, but improved from 5/11/12.

Arterial Blood Gas (Taken on 5/11/12)

At the time, the patient was on a ventilator at 100% FIO2.

Lab Values	Actual Values	Normal Range	Interpretation
pH	7.36	7.35-7.45	Normal
PaCO2	50mmHg	35-45mmHg	Acidic
HCO3	28mEq/l	22-26mEq/l	Alkaline
PaO2	60mmHg	80-100mmHg	Moderate Hypoxemia

Interpretation of arterial blood gas: The blood gas is a fully compensated respiratory acidosis with moderate hypoxemia. Another blood gas was done on 5/17/12 and it looked similar to this one so due to her COPD, this probably is not too far from normal for her and should not be worried about too much.

Physician’s Plan

Patient was started on diuretics for her CHF. Lasix was chosen. A bronchoscopy was performed which showed methicillin resistant staphyloccus aureus pneumonia. She was found to be in acute renal failure so nephrology was consulted, her medications were adjusted, and she then had a gradual improvement in renal function. The patient was tried to be weaned off the ventilator but failed so a tracheostomy was placed by Dr. Hoskere on 4/13/12. She also had a percutaneous endoscopic gastrostomy tube placed by Dr. Ampudia. He said she had been having persistent diarrhea with negative clostridium difficle stools a few weeks ago, and decided to start her of Questran. The patient was then transferred to Select Specialty Hospital for continuous pulmonary management as well as medical management. Pulmonary was consulted to decide what her ventilator needs were. She was supposed to have ventilator checks every two hours. She was also ordered to be weaned and adjusted as tolerated. As well as trach care every shift, suction as needed, and to have her ventilator circuit changed once a month. Repeat labs and further workups were also ordered.

-Hospital Medications:

Coumadin (Warfarin)	5mg	Used to treat thromboembolic complications.
Humalog	3-15 units	Used to manage diabetes.
Lantus	26 units	Used to manage diabetes.
Prilosec (Omeprazole)	20mg	Used for treatment of heartburn and other symptoms associated with GERD.
Furosemide (Lasix)	60mg	Used as a diuretic due to CHF.
Levothyroxine (Levothroid)	150mcg	Used to manage hypothyroidism.
Lisinopril (Prinivil)	5mg	Used to manage hypertension
Lorazepam (Ativan)	1mg	Used to manage anxiety.
Metoprolol Tartrate (Lopressor)	25mg	Used to manage hypertension
Amiodarone (Cordarone)	200mg	Used to treat life threatening ventricular fibrillation.
Digoxin (Lanoxin)	125mg	Used to treat mild-moderate heart failure.
Fragmin (Dalteparin sodium)	120 IU/kg	Prophylaxis of ischemic complications in unstable angina.
Aldactone (Spironolactone)	25mg	Used for heart failure.
Nexium (esomeprazole magnesium)	40mg	Used for treatment and maintenance of erosive esophagitis due to GERD.
Synthroid (Levothyroxine)	150mcg	Used to manage hypothyroidism.
Carafate (Sucralfate)	1g	Short term treatment of active duodenal ulcer.
ProAir (Albuterol Sulfate)	4 puffs	Used to treat bronchospasms.
Flovent (Fluticazone)	2 puffs	Used as a corticosteroid.
Prilosec (Omeprazole)	40mg	Used for treatment of heartburn and other symptoms associated with GERD.
Zosyn (tazobactam sodium)	4.5g	Used for moderate community acquired pneumonia.

(PDR, 2012)

My Plan

The patient has improved quite a bit from the time she was moved to the IMU on 5/11/12 as far as her ventilator settings go. She is down to 40% FIO2 from 100% FIO2, she is now breathing around twelve times per minute on her own as opposed to not at all before, and she has been able to be switched from assist control mode to SIMV with pressure support. Therefore I would suggest continuing to wean her off of the ventilator. I would first check all of the weaning parameters including her maximum inspiratory pressure, maximum expiratory pressure, vital capacity, and tidal volumes to make sure she fell into the acceptable category. As long as she did, I would start by decreasing her pressure support and PEEP as tolerated. If she continued to do well weaning, I would then start with two hours per day aerosol trach collar weaning trials at around 40% FIO2 to 45% FIO2 and increase it by a couple of hours each day until she could come off of the ventilator completely. Eventually I would suggest she be weaned off of the trach collar as well.

I would also suggest a follow up chest radiograph to find out if there was a pleural effusion that had developed, and if so continue with the necessary treatment of tapping it at the fourth or fifth intercostals space mid axillary.

I think all home medications as well as hospital medications for her co-morbidities should be continued during her stay, especially the Lasix for her congestive heart failure to try and improve the +2 to +3 pitting edema, and the bronchodilators for her COPD.

Regarding the patient’s arterial blood gas, I would not change much because her values are probably very normal for her. Her PaCO2 is elevated but not to an extreme amount and her PaO2 shows moderate hypoxia which is not uncommon for a patient with an obstructive lung disease. I would continue to monitor this, but would not put a lot of emphasis on it unless the values start to change.

Home Care

The patient will not return home but instead to Greystone Nursing Facility, where she was originally brought from before her fall. After she returns, as long as she was weaned and the trach was removed before leaving BRMC, she will need to have stoma care and possibly suctioning through her stoma performed. She will most likely need a small amount of supplemental oxygen as well.

Since the reason she was brought to BRMC in the first place was due to a fall, I would suggest she be placed as a fall risk patient at Greystone and be monitored carefully. I think she would benefit from a walker and working with physical therapy in order to hopefully prevent another fall, and possible intubation.

Her medications for her co-morbidities that she was previously taking before her stay in the hospital should be resumed or continued.

References

Cardiomyopathy. (2012, May 24). Retrieved from http://www.mayoclinic.com/health

/cardiomyopathy/DS00519/DSECTION=treatments-and-drugs

Downey, R., III. (2012, June 27). Obstructive Sleep Apnea. Retrieved from http://emedicine.

medscape.com/article/295807-overview

Definition of Obesity. (2012, June 14). Retrieved from http://www.medterms.com/script/main/

art.asp?articlekey=4607

Eltz, D. R., & Zieve, D. (2012). Diabetes. Retrieved from http://www.ncbi.nlm.nih.gov/

Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease (GERD). (2007, May). Retrieved from http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/

Kathuria, P. (2012). Chronic Kidney Disease. Retrieved from http://www.emedicinehealth.com

/chronic_kidney_disease/article_em.htm

Kulick, D. L. (2012). Congestive Heart Failure. Retrieved from http://www.medicinenet.com/

congestive_heart_failure/article.htm

Lukitsch, I. (2010, April 19). Hypernatremia Treatment and Management. Retrieved from http://emedicine.medscape.com/article/241094-treatment

Mathur, R. (2012). Hypothyroidism. Retrieved from http://www.medicinenet.com/

hypothyroidism/page4htm.

Nabili, S. T. (2012). Anemia. Retrieved from http://www.medicinenet.com/anemia/article.htm

PDR. (2012). Retrieved from http://www.pdr.net

Riaz, K. (2012, January 27). Hypertension Medication. Retrieved from http://emedicine.

medscape.com/article/241381-medication

Thrombocytopenia. (2012, June 28). Retrieved from http://www.nlm.nih.gov/medlineplus/ency/

article/000586.htm

Treatments for COPD. (2012, February 1). Retrieved from http://www.rightdiagnosis.com/c/

copd/treatments.htm

Wilkins, R. L., Stoller, J. K., & Kacmarek, R. M. (2009). Fundamentals of Respiratory Care. Missouri: Mosby.