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Chapter 19: Oxygenation and Perfusion

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Chapter 19: Oxygenation and Perfusion

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Case Study 19.2.1 §19.2 source ↗

Mrs. Jenson, a 72-year-old female, presents to the emergency room with worsening shortness of breath, fatigue, and swelling in her lower extremities over the last week. She reports increasing difficulty performing activities of daily living due to weakness and increased dyspnea.

Past Medical History Medical history: Hypertension, type 2 diabetes, heart failure (class III), osteoarthritis
Family history: No significant family history reported.
Social history: Widowed ten years ago, currently living in an assisted care facility. No children.
Current medications:

• Lisinopril 20 mg PO once daily

• Metformin 500 mg PO twice daily

• Metoprolol 50 mg PO once daily

• Aspirin 81 mg PO once daily

• Furosemide 40 mg PO once daily

• Losartan 25 mg PO once daily

• Ibuprofen 400 mg PO Q6 hours PRN mild arthritic pain
Nursing Notes 1100: Assessment
Neurological: Alert and oriented x4, follows commands appropriately
Respiratory: Labored and shallow breathing pattern, bilateral crackles in bases
Cardiovascular: Bilateral lower extremity edema, tachycardia
Abdominal: Bowel sounds present in all four quadrants, no pain or tenderness noted
Musculoskeletal: Limited range of motion in bilateral shoulder joints, patient reports pain in wrist joints related to osteoarthritis
Integumentary: Generalized pallor
Flow Chart 1100: Assessment
Blood pressure: 158/89 mm Hg
Heart rate: 111 beats/minute
Respiratory rate: 27 breaths/minute
Temperature: 98.9°F (37.2°C)
Oxygen saturation: 88 percent on room air
Pain: 6/10 (joint pain)
Recognize cues: Based on the assessment findings, what are the most important cues for the nurse to recognize?

Answer

The nurse should first recognize the patient is exhibiting signs of respiratory distress, including a low oxygen saturation level on room air, tachypnea, worsening shortness of breath, dyspnea, and crackles in the lungs. The nurse should also recognize the patient is experiencing tachycardia, hypertension, 6/10 pain, bilateral lower extremity edema, and fatigue.

Case Study 19.2.2 §19.2 source ↗

Mrs. Jenson, a 72-year-old female, presents to the emergency room with worsening shortness of breath, fatigue, and swelling in her lower extremities over the last week. She reports increasing difficulty performing activities of daily living due to weakness and increased dyspnea.

Past Medical History Medical history: Hypertension, type 2 diabetes, heart failure (class III), osteoarthritis
Family history: No significant family history reported.
Social history: Widowed ten years ago, currently living in an assisted care facility. No children.
Current medications:

• Lisinopril 20 mg PO once daily

• Metformin 500 mg PO twice daily

• Metoprolol 50 mg PO once daily

• Aspirin 81 mg PO once daily

• Furosemide 40 mg PO once daily

• Losartan 25 mg PO once daily

• Ibuprofen 400 mg PO Q6 hours PRN mild arthritic pain
Nursing Notes 1100: Assessment
Neurological: Alert and oriented x4, follows commands appropriately
Respiratory: Labored and shallow breathing pattern, bilateral crackles in bases
Cardiovascular: Bilateral lower extremity edema, tachycardia
Abdominal: Bowel sounds present in all four quadrants, no pain or tenderness noted
Musculoskeletal: Limited range of motion in bilateral shoulder joints, patient reports pain in wrist joints related to osteoarthritis
Integumentary: Generalized pallor
Flow Chart 1100: Assessment
Blood pressure: 158/89 mm Hg
Heart rate: 111 beats/minute
Respiratory rate: 27 breaths/minute
Temperature: 98.9°F (37.2°C)
Oxygen saturation: 88 percent on room air
Pain: 6/10 (joint pain)
Analyze cues: What is the relationship between the recognized cues and the patient’s past medical history?

Answer

Many of the patient’s symptoms recognized in the previous question (e.g., crackles, tachypnea) are consistent with the patient’s past medical history of heart failure. Additionally, the patient’s blood pressure is elevated, which is consistent with her history of hypertension. The patient is also reporting 6/10 joint pain, which is likely related to her history of osteoarthritis.

Case Study 19.2.3 §19.2 source ↗

Mrs. Jenson, a 72-year-old female, presents to the emergency room with worsening shortness of breath, fatigue, and swelling in her lower extremities over the last week. She reports increasing difficulty performing activities of daily living due to weakness and increased dyspnea.

Past Medical History Medical history: Hypertension, type 2 diabetes, heart failure (class III), osteoarthritis
Family history: No significant family history reported.
Social history: Widowed ten years ago, currently living in an assisted care facility. No children.
Current medications:

• Lisinopril 20 mg PO once daily

• Metformin 500 mg PO twice daily

• Metoprolol 50 mg PO once daily

• Aspirin 81 mg PO once daily

• Furosemide 40 mg PO once daily

• Losartan 25 mg PO once daily

• Ibuprofen 400 mg PO Q6 hours PRN mild arthritic pain
Nursing Notes 1100: Assessment
Neurological: Alert and oriented x4, follows commands appropriately
Respiratory: Labored and shallow breathing pattern, bilateral crackles in bases
Cardiovascular: Bilateral lower extremity edema, tachycardia
Abdominal: Bowel sounds present in all four quadrants, no pain or tenderness noted
Musculoskeletal: Limited range of motion in bilateral shoulder joints, patient reports pain in wrist joints related to osteoarthritis
Integumentary: Generalized pallor
Flow Chart 1100: Assessment
Blood pressure: 158/89 mm Hg
Heart rate: 111 beats/minute
Respiratory rate: 27 breaths/minute
Temperature: 98.9°F (37.2°C)
Oxygen saturation: 88 percent on room air
Pain: 6/10 (joint pain)
Prioritize hypotheses: Based on the patient’s symptoms, which type of heart failure (left or right) is the patient most likely experiencing?

Answer

The patient is likely experiencing a mix of both types. The patient is exhibiting crackles in the lungs, dyspnea, and tachypnea, which are consistent with left-sided heart failure. The patient is also experiencing bilateral lower extremity edema, which is more prevalent in cases of right-sided heart failure. Because this patient has a history of heart failure, it is possible that it originally started on the left but then began to affect the right side of the heart over time.

Case Study 19.3.4 §19.3 source ↗

Refer back to Unfolding Case Study #4: Part 1 for a review on the patient data.

Provider’s Orders 1145: New orders

• Admit to telemetry unit.

• Perform 12-lead ECG.

• Administer oxygen therapy to maintain oxygen saturation > 92 percent.

• 20 mg furosemide IV STAT.
Nursing Notes 1200:
12-lead ECG completed; results show sinus tachycardia. 2 L oxygen via nasal cannula applied, patient reports slight improvement in dyspnea. IV placed in right AC, 20 mg furosemide IV administered. Patient instructed to call before getting up to use bathroom. Patient has not voided since admission. Patient admitted to room on cardiac unit and handoff given to telemetry nurse.
Flow Chart 1230: Assessment
Blood pressure: 150/82 mm Hg
Heart rate: 108 beats/minute
Respiratory rate: 22 breaths/minute
Temperature: 98.9°F (37.2°C)
Oxygen saturation: 93 percent on 2 L nasal cannula
Pain: 6/10 (joint pain)
Generate solutions: What is the rationale for each of the provider’s orders?

Answer

The provider has ordered that the patient be admitted to the telemetry unit. This is likely because the patient is exhibiting symptoms that are indicative of heart failure exacerbation, which will require close cardiac monitoring. The rationale for the 12-lead ECG is to monitor the electrical activity of the heart to make sure the patient is not experiencing any abnormal underlying cardiac dysrhythmias. The oxygen has been ordered because the patient’s oxygen saturation is low (88 percent on room air). This indicates that the patient is not receiving an adequate amount of oxygen to perfuse the lungs and other tissues of the body, which can be improved with application of supplemental oxygen. The IV furosemide is ordered because it appears the patient is in a fluid overload state, related to her heart failure, as evidenced by the crackles in the lungs and bilateral lower extremity edema.

Case Study 19.3.5 §19.3 source ↗

Refer back to Unfolding Case Study #4: Part 1 for a review on the patient data.

Provider’s Orders 1145: New orders

• Admit to telemetry unit.

• Perform 12-lead ECG.

• Administer oxygen therapy to maintain oxygen saturation > 92 percent.

• 20 mg furosemide IV STAT.
Nursing Notes 1200:
12-lead ECG completed; results show sinus tachycardia. 2 L oxygen via nasal cannula applied, patient reports slight improvement in dyspnea. IV placed in right AC, 20 mg furosemide IV administered. Patient instructed to call before getting up to use bathroom. Patient has not voided since admission. Patient admitted to room on cardiac unit and handoff given to telemetry nurse.
Flow Chart 1230: Assessment
Blood pressure: 150/82 mm Hg
Heart rate: 108 beats/minute
Respiratory rate: 22 breaths/minute
Temperature: 98.9°F (37.2°C)
Oxygen saturation: 93 percent on 2 L nasal cannula
Pain: 6/10 (joint pain)
Take action: What additional actions should the nurse take at this time?

Answer

The nurse needs to keep a close watch on the patient's electrolyte levels due to the administration of an IV diuretic. Diuretics, especially when administered intravenously, can deplete electrolytes in the circulatory system, which can quickly become life-threatening if not replaced. The nurse should also closely monitor the patient’s output, as the IV diuretic will cause the patient to urinate more frequently. She has not yet used the bathroom, so that will be something to monitor closely.

Case Study 19.3.6 §19.3 source ↗

Refer back to Unfolding Case Study #4: Part 1 for a review on the patient data.

Provider’s Orders 1145: New orders

• Admit to telemetry unit.

• Perform 12-lead ECG.

• Administer oxygen therapy to maintain oxygen saturation > 92 percent.

• 20 mg furosemide IV STAT.
Nursing Notes 1200:
12-lead ECG completed; results show sinus tachycardia. 2 L oxygen via nasal cannula applied, patient reports slight improvement in dyspnea. IV placed in right AC, 20 mg furosemide IV administered. Patient instructed to call before getting up to use bathroom. Patient has not voided since admission. Patient admitted to room on cardiac unit and handoff given to telemetry nurse.
Flow Chart 1230: Assessment
Blood pressure: 150/82 mm Hg
Heart rate: 108 beats/minute
Respiratory rate: 22 breaths/minute
Temperature: 98.9°F (37.2°C)
Oxygen saturation: 93 percent on 2 L nasal cannula
Pain: 6/10 (joint pain)
Evaluate outcomes: What signs indicate that the patient’s condition is improving? Does anything indicate that the patient’s condition is not improving?

Answer

The patient’s blood pressure, respiratory rate, oxygen saturation, and heart rate have all slightly improved, indicating that the interventions were effective. The patient is still reporting 6/10 joint pain, so this aspect of her condition is not showing signs of improvement. Now that the patient’s vital signs are stabilizing, it is important for the nurse to address and treat the pain.

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Problems and answers are adapted from Fundamentals of Nursing by Christy Bowen, Lindsay Draper and Heather Moore, OpenStax, and are used under the CC BY-NC-SA 4.0 licence. Access for free at https://openstax.org/books/fundamentals-nursing/pages/1-introduction. Illustrations: Copyright Rice University, OpenStax, under CC BY-NC-SA 4.0 license. This adaptation is released under the same licence, is non-commercial, and is neither affiliated with nor endorsed by OpenStax or Rice University.