1

A65yearoldmalepresentedtotheERcomplainingofSOB.PMHincludesaorticstenosis,arthritis,
asthma,AFIB,CHF,HTN,Gout,HLD,aBioprostethicaorticvalvereplacement1yearago.Patientwas
admittedto2Eastformonitoringandtreatment.BloodcultureswerepositiveforEnterococcal
bacteremiaandchestxrayrevealedcommunityacquiredpneumonia.
Noticing

Subjectiveandobjectivedata:
o
o
o
o
o
o

Patientstatedtheywereshortofbreath
Patientwasexperiencinganxiety
Patientappeareddiaphoretic
Patientwasveryobeseandhad+3edema.
Crackleswereheardbilaterallyinlowerlobes.
RhythmstripsshowedpatientinAFIB

Howdidyouknowtherewasaproblem?Abnormalpatientpresentationoryourgutfeeling?
o

Duringmysecondassessment,thecrackleswereauscultatedbilaterallyandthepatients
lipsandfingertipsappearedblue.HisO2satwasdownto78%.

Interpreting

WhatotherinformationdoIneedtomakeadecision?
o

Noadditionalinformationwasneededatthispoint.

IsthereanyoneelseIneedtoinvolveornotify?
o
o

Inotifiedmynurseimmediately.
Respiratorywascalledandthepatientreceivedabreathingtreatmentandnasalcannula
wastakenourandthepatientwasgiveno2throughasimplefacemask.

Whatcouldbehappeningandhowcriticalisthissituation?
o

Itwasbelievedthatthepatienthasbeenoverexertedashewastakenforachestxray
earlierthatday.Thetransporterstookhimtotheprocedureinabedinsteadofa
wheelchair.Hestatedthathedoesntuseabedashesleepsinarecliner,ashedoesnot
layflat.HehadjusthadaPICClineplacedsothathecouldbedischargedandreceivehis
IVabxthroughhomehealth.Physicaltherapyhadjustbeeninwithhimaswell.

Responding

ShouldIdosomethingnoworwaitandwatch?
o

Withsignsofimpairedoxygenandperfusion,Ineededtoactimmediately.

HowwillIknowifIammakingthebestdecision?

Draft 8-18-16_LL

2
o

Delayedresponsecanleadtoalowerchanceofasuccessfulrecoveryordeathifapatient
islackingo2andnotbeingperfused.

WhatinterventionscanIdelegatetoothermembersofthehealthcareteam?
o

IcouldhavedelegatedvitalsignstothePCTandaskthechargenurseforhelp
monitoring/administeringmedicationstomyotherpatientsuntilthesituationwas
resolved.

Rittayamai,N.,Tscheikuna,J.,Praphruetkit,N.,Kijpinyochai,S.(2015).Useofhighflownasalcannula
foracutedyspneaandhypoxemiaintheemergencydepartment.RespirCare,60(10),13771382.
Reflecting

DidImaketherightdecision?
o

Yes,Ireflectedonthesituationwithmypreceptor,andwebothagreedIhandledthe
situationcorrectly.

DidIachievethedesiredoutcome?
o

Yes,thepatientspinkcolorreturnedandhisO2satwentbackuptohisbaselineof90
92.

WhatdidIdoreallywell?WhatcouldIhavedonebetter?
o

Draft 8-18-16_LL

Inotifiedthenurseimmediatelyandwegotrespiratorydownimmediatelytoprovidea
breathingtreatmentandswitchedtheO2mask.Istayedcalmanditfeltgreattoseethe
patientbouncebackandreturntobaseline.

Draft 8-18-16_LL