ARF Case Study

Linda Winn, RN, MSN Ed.

Acu

te R

esp

irat

ory

Fai

lure

: C

ase

Stu

dy

Acu

te R

esp

irat

ory

Fai

lure

: C

ase

Stu

dy

• You are receiving a patient from ICU• Report is called to you:– DS is 56 y.o. male

– PMH: chronic bronchitis

– Saw MD with c/o increasing exertional dyspnea

– mass found --- adneocarcenoma

– 3 days post-op: RML and RLL lobectomy

ARF: Case StudyARF: Case Study

Report ContinuesReport Continues• Current VS

– 120/70, 110, 30, 100.2

• IV D5 ½ NS at 50/hr, Right FA

• Chest tube (right chest)– Small amt serosanguineous drainage– Site D&I

• O2 at 5L N/C

• Refuses pain meds

• All pulses +

• Heart tones clear

What additional information What additional information would you ask the nurse to would you ask the nurse to

provide at this time?provide at this time?

Case Study ProgressesCase Study Progresses

• DS is transported via W/C past nurses’ station to a room at far end of the hall.

• Upon entering his room you find him sitting

on edge of bed with his left leg in bed and right foot on the floor.

• You introduce yourself to him.

• You note he keeps rubbing his left hand over the right side of his chest.

What issues or problems can you What issues or problems can you already identify?already identify?

List 4 things you would do for DS List 4 things you would do for DS right now.right now.

Case Study ProgressesCase Study Progresses

• DS states, “I have a nephew who rolled his Jeep and busted himself up real bad. He got hooked on those drugs. I don’t want any part of them.”

How would you respond?

Why is DS experiencing difficulty using his right arm? Is this expected after the

type of surgery he had?

Case Study ProgressesCase Study Progresses

• You administer Morphine 8mg IV.

• 15 minutes later you notice his call light is on.

• When you enter his room, DS says, “I think I’m going to throw up.”

What 3 things would you do?

Case Study ProgressesCase Study Progresses

• After controlling DS’s pain and nausea, you assess his chest tube insertion site.– Slightly inflammed– Incisional area is white and moist– Scant brown drainage

What action will you take now?

Case Study ProgressesCase Study Progresses

• The following day during report, the nurse tells you DS has been paranoid and demanding, but is fine.

• Upon entering his room he states, “I just can’t [breath] seem to [breath] get enough [breath] air.”

Identify 6 possible problems that Identify 6 possible problems that DS could be having that would DS could be having that would

account for his behavior.account for his behavior.

What actions should you take first?What actions should you take first?

Assessment FindingsAssessment Findings• RR 46

• Auscultation– Slight air movement over upper airways– Absent breath sounds below 3rd ICS

• Sitting on side of bed, leaning over bedside table

• Intercostal retractions with inspiration

• Diaphoretic

What would you do first?What would you do first?

Case Study ProgressesCase Study Progresses

• DS is transferred to ICU after successful resuscitation

From: Winningham and Preusser, (2009), Critical Thinking Cases in Nursing, 4th Ed., Mosby, Inc., St. Louis.