Video Case Study - Oxygenation and Perfusion

Nurse Emily works in an emergency department and is caring for Carolyn, a 77-year-old female with a history of congestive heart failure, or CHF, who came to the emergency department after shortness of breath woke her up during the night. After settling Carolyn in her room, Nurse Emily goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Carolyn's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

Nurse Emily begins by recognizing important cues. During report, Nurse Emily learns Carolyn has gained 7 pounds in the last week and has been using extra pillows to prop her up at night since she's short of breath when lying flat. Then, Nurse Emily assesses Carolyn's vital signs, which are blood pressure 110/70 mmHg, heart rate 100 beats per minute, temperature 98.8 F or 37.1 C, respirations 24 breaths per minute and pain score of 0 out of 10. Pulse oximetry is 86 percent on room air. Nurse Emily notes Carolyn has bilateral lower extremitiy edema and upon auscultation she hears crackles bilaterally She also notices Carolyn's increased work in breathing through cues like nasal flaring and intercostal retractions.

Then, Nurse Emily analyzes these cues. She reviews Carolyn's diagnostic test results and sees her CBC, basic metabolic panel, or BMP, and ECG are within normal limits; however, her arterial blood gas, or ABG, reveals a decreased partial pressure of oxygen, or PaO2. Nurse Emily remembers that since Carolyn has CHF, her heart is not pumping effectively, impairing oxygenation, which is the ability of the lungs to exchange oxygen and carbon dioxide. This also impairs perfusion, which is the ability of oxygen-rich blood to travel throughout the body. Nurse Emily also realizes Carolyn's CHF is causing blood to pool in Carolyn's pulmonary and systemic circulation, leading to her symptoms.

So, using the information she's gathered, Nurse Emily chooses a priority hypothesis of impaired gas exchange.

Then, she generates solutions to address Carolyn's impaired gas exchange. She establishes the expected outcome that Carolyn will maintain an oxygen saturation above 92% by the end of the shift.

Next, Nurse Emily takes action to implement these solutions. As prescribed, Nurse Emily applies supplemental oxygen via nasal cannula.

Nurse Emily: You'll start to feel air flow through the tubing I placed in your nose. It's important to inhale slowly through your nose and exhale through your mouth.

Carolyn: Okay.

Nurse Emily: I'm also going to administer a diuretic through your IV, which your health care provider prescribed. It works like the water pill you take at home. This will help your body get rid of some of its extra fluid, making it easier for you to breathe. Now, this medication might make you feel dizzy, so please use your call light to ask for help before getting out of bed.

Carolyn: Alright, thank you, I will.

Nurse Emily then proceeds to administer Carolyn's medication using the six steps of medication administration and three checks.

Nurse Emily also ensures emergency equipment, including a bag valve mask and oral airway, are at Carolyn's bedside in case her breathing starts to deteriorate. Then, she inserts an indwelling urinary catheter, as prescribed, and collaborates with assistive personnel on closely monitoring Carolyn's intake and output. Nurse Emily routinely monitors Carolyn's vital signs throughout her shift and titrates Carolyn's oxygen based on pulse oximetry readings.

Near the end of her shift, Nurse Emily evaluates the outcome of her actions. She takes Carolyn's vital signs, which are blood pressure 106/72 mmHg, heart rate 90 beats per minute, temperature 98.4 F or 36.9 C, respirations 18 breaths per minute, pain score of 0 out of 10, and pulse oximetry 96 percent on 4 liters nasal cannula. Nurse Emily notes Carolyn's breathing is eased, and she's draining light yellow urine through her catheter. Nurse Emily recognizes the expected outcome has been met, so she documents assessment findings and prepares to transfer Carolyn to the cardiac unit for further monitoring.

Nurse Emily: Well, I'm happy to report your oxygen levels are staying where they need to. I'm going to transfer you to the cardiac unit where your health care team will continue to monitor you.

Carolyn: Thank you. It's such a relief to breathe easier.

Alright, as a quick recap... Nurse Emily recognized and analyzed cues related to Carolyn's acute CHF exacerbation and prioritized hypotheses and generated solutions to address this problem. Nurse Emily took action by administering oxygen and a diuretic, as well as by monitoring Carolyn closely. At the end of her shift, she evaluated Carolyn and determined that she met the expected outcomes.