Running head: CASE STUDY BH 1 Case Study: BH Nursing Care of Adults-NURS 30030 Constance Contreras Kent State University at Stark CASE STUDY: BH 2 Data Collection Client Profile B.H. is a 58 year old male with the admitting diagnosis of acute exacerbation of chronic obstructive pulmonary disease (COPD) and hypoxia. He came to the emergency room due to increasing dyspnea. COPD is a combination of chronic obstructive bronchitis, emphysema, and asthma. He has a history of scoliosis, schizophrenia, schizoaffective disorder with paranoia and depression. The pathophysiology for chronic obstructive bronchitis is the result of bronchial inflammation that leads to increased mucous production, chronic cough, and scarring of the bronchial lining. In chronic obstructive bronchitis, there is an increase in the size and number of submucous glands in the large bronchi, increasing mucus production. There is also increased number of goblet cells, which produce, mucous also. There is also a resulting impairment of ciliary function reducing excess mucous clearance. The mucous primarily affects the larger airways but eventually affects all areas. The thickened, uncleared mucous along with the inflammation of the bronchi affect expiration of CO; thus causing collapse of the airways and air trapping in the lower portions of the lung. The patient with chronic obstructive bronchitis typically presents as stocky build, pursed lip breathing, a productive cough, decreased tolerance of exercise, shortness of breath, wheezing, and prolonged expiration. As the disease progresses, more profuse amounts of sputum are produced and lung infections become increasingly common. The client will also present with chronic hypoxemia and hypercapnia. Orthopneic breathing in the tripod position is characteristic of COB sufferers. The pace they ambulate and their gait is determined by their breathing. Frequent rest periods are generally required to breathe. The pathophysiology of emphysema is a destruction of alveolar walls, resulting in permanent overdistention of the air sacs. Due to the lack of elasticity in the alveolar walls, the CASE STUDY: BH 3 air passages are obstructed. Expiration is impaired due to wall destruction, partial airway collapse, and loss of elasticity. As these passages collapse, dead space forms in pockets leading to decreased gas exchange surface area. There is less functional air space for gas exchange therefore increasing breathing workload. Emphysema also causes destruction of the pulmonary capillaries making oxygen perfusion and ventilation even more decreased. The client with emphysema presents with progressive dyspnea on exertion, which over time converts to generalized dyspnea at rest. The AP diameter of the chest tends to be enlarged. ABG values can be normal until later stages when compensated respiratory acidosis is seen. Some clients have an enlarged heart with right ventricular lift. The ECG may show right heart strain and some right axis deviation. Other manifestations can include cyanosis around the lips, pitting peripheral edema, or neck vein distention. Scoliosis is the lateral curvature of the spine at any area. Generally, scoliosis occurs in preadolescents and adolescents, equally in boys and girls. Black and Hawk (2009) state that “adult scoliosis may be the progression of a childhood condition that was undiagnosed or untreated when the person was still growing. It can also be caused by degenerative changes in the spine” (p. 497). Spinal curvature greater than 40-45 degrees can cause cardiopulmonary problems and pain; however, curvatures of less than 20 degrees do not require treatment in the skeletally mature client. Schizophrenia is a mental disorder, more clearly defined as a “psychosis characterized by delusions, hallucinations, apathy, and a ‘split’ between thought and emotion” (Coon & Mitterer, 2011, p S23). Schizophrenic symptoms tend be related to “selective attention” (p. 557). The client may seem to be overwhelmed by a cluttering of thoughts, sensations, images, and feelings at once. It appears they have a hard time focusing on one item of information at time. The causes of schizophrenia are undetermined but are thought to be one or all of the following: environmental, heredity, and brain chemistry. Signs CASE STUDY: BH 4 and symptoms of schizophrenia include but are not limited to delusions, hallucinations, abnormal thoughts, blunted or inappropriate emotions, apathy. Schizoaffective disorder with paranoia and depression is a mental disorder that causes both a loss of contact with reality and mood problems. Its cause is unknown but thought to be caused by brain chemistry and some experts do not separate this disorder from schizophrenia. Symptoms can include delusions, disorganized speech, visual or auditory hallucinations, lack of concern with hygiene, mania or depression, sleeping problems, hopelessness, social isolation, etc. Assessment Data For assessment data, please refer to Table 1. ALLERGIES: PCN VITALS: 141/97, 20R, 84P, 97.1˚F, 90%O2 RA at rest. Pt weighed 85.7kg and height of 71 inches upon admission. A BMI of 26.3. Hx of smoking 1.5-2ppd for approximately 40 years; pt now states smokes 1ppd. Pt admits occasionally ETOH. BH stated he came to the hospital after having cold symptoms that lasted for about one week and progressive shortness of breath for one week. He does not use O 2 therapy at home. Pt ambulated in the hallway on a portable pulse oximeter and after one minute had a pulse ox reading of 84% on RA. At two minutes, BH stopped to take a break and look at some hallway art. We continued for one more minute and returned to his room. Pt c/o dyspnea and the need to rest. His pulse ox reading was 87% on room air. He was visibly short of breath and audibly wheezing. He was not on oxygen therapy in the room because he was being evaluated for home O2 therapy. Pt takes numerous medications for his multiple diagnoses refer to Table 3 for further details. Pt had abnormal laboratory test results on multiple days refer to CASE STUDY: BH 5 Table 2 for further details. Pt underwent a chest radiograph, ECG, and an arterial blood gas. For results, refer to Table 2-1. Table 1 Assessment data Neurological A&Ox3, No trouble communicating, speech clear. No HOH, No visual trouble. PERRLA 3mm brisk. Emotions Affect appropriate, wanting to go home and not stay in hospital. Integument Warm, Dry, Pink, intact. Clubbing present on fingertips. Mucus membranes moist. IV 20G R forearm heplock, without redness/swelling. RRR, Cap Refill <3sec, no edema present, pedal and radial pulses palpable strong +2/+2 Cardiovascular Respiratory Bladder Dyspnea, audible wheezing. Lung sounds diminished and wheezes bilaterally anteriorly and posterior More diminished in lower lobes. O2 sats continuous pulse ox ranging 87-90% RA at rest. Productive cough with sputum. Continent, voiding without difficulty Bowel Abdomen distended and round, Bowel sounds active in all 4 quadrants, passing flatulence, last BM 9/23, no c/o abdominal pressure, appetite good. Musculoskeletal MAE AROM, gait steady, hand grasps strong and equal bilaterally. Foot push/pull strong and equal bilaterally. Denies any pain in legs. Activity is up as tolerates. Regular diet, no restrictions. Diet CASE STUDY: BH 6 Lab Values/Diagnostic Tests For laboratory values, please refer to Table 2. For diagnostic test results, please refer to Table 2-1. Table 2 Lab Values and Results Tests Patient’s low/high Range 9/23 9/24 RBC 5.40 5.11 4.6-6.0 Hgb 17.9 16.6 13.518g/dL Hct 51.5 49.2 40-54% Platelets 157 159 150-400 WBC 6.4 6.5 4.5-10 Neutrophils (Segs) 5.8 6.0 2.5-7.0 Blood Serum Glucose 106 144 FBS 70110 Abnormal Results CBC WBC Normal Range Reason CHEM This could be due to what and when the pt ate and when the BS was drawn. PPBS <140 BUN 7 9 5-25 Creatinine 0.641 0.636 0.51.5mg/dL BUN/Creat Ratio 11 14 Avg 15:1 Calcium 8.7 8.4 ABG Hgb -- 911mg/dL Heparin use decreases Calcium serum levels 18.6 13.5-18 This is slightly elevated. COPD can cause an elevated level; as well as dehydration/hemoconcentration pH 7.41 7.35-745 pCO2 41.4 35-45 pO2 60 75-100 ABG Pt is COPD sufferer and has impaired gas exchange. In addition, pt is not oxygenating CASE STUDY: BH 7 effectively due to acute exacerbation of disease process. BiCarb 25.4 24-28 Base Excess 0.7 -2 to +2 NC O2 Sat ABG 86.2 >92% Pt is suffering from acute exacerbation of COPD. Note: Normal ranges were obtained Prentice Hall Handbook of Laboratory and Diagnostic Tests with Nursing Implications, 6th edition, LeFever Kee, J. 2009, Prentice Hall. Table 2-1 Diagnostic Test Results PROCEDURE RESULT Portable Chest X-Ray (9/23) PE is identified. Note is made that inferior most aspect of right costophrenic angle has been omitted from field of view. No acute C.P. process Streptococcus pneumonia Gram (pos) Gram (neg) Moderate WBCs Normal sinus Septal infarct Inferior infarct Abnormal ECG T-wave inversion now evident on inferior leads Sputum Culture (9/23) ECG Medication Information Medications Albuterol MDI Pt Dosage Dose, route Classification 2 puffs q4h/q2h PRN INH Preg (C) INH 2 puffs q15min before exercising or 2 puffs q4h or PRN ROUTE: MDI INH Bronchodilator, adrenergic β2agonist,sympathomi meometic Mechanism of Action Causes bronchodilation by action on B2 receptors by increasing levels of cAMP, which relaxes smooth muscle; produces bronchodilation, CNS, cardiac stimulation, as well as increased dieresis and gastric acid secretion; longer acting than isoproterenol Indications for use Patient Reason for Use Prevention of exercise-induced asthma, acute bronchospasm, bronchitis, emphysema, Bronchiectasis, or other reversible airway obstruction Pt has COPD Possible side effects Tremors, anxiety insomnia, HA, palpitations, tachycardia, angina, hypo/hypertension, dry nose, heartburn, N&V, cough, wheezing, dyspnea, flushing, sweating CASE STUDY: BH ipratropium bromide INH 0.5mg q4h/q2h PRN, (INH) ROUTE: INH, SOL, NEB, Intranasal 8 Inhibits interaction of acetylcholine at receptor sites on the bronchial smooth muscle, resulting in decreased cGMP and bronchodilation COPD, rhinorrhea in children 6-11yr (nasal spray) Fluticasone: decreases inflammation by inhibiting mast cells, macrophages, and leukotrienes; antiinflammatory, and vasoconstrictor properties Salmeterol: Causes bronchodilation by action on B2 receptors by increasing levels of cAMP, which relaxes smooth muscle with very little effect on HR, maintains improvement in FEV from 3-12hr; prevents nocturnal asthma symptoms Corticosteroid, bronchodilator Inhibits synthesis of prostaglandins in body tissues by inhibiting at least 2 cyclooxygenase isoenzymes-(COX-1), (COX-2); may inhibit chemotaxis, may alter lymphocyte activity, decrease proinflammatory cytokine activity, and may inhibit neutrophil aggregation. These effects may contribute to its anti-inflammatory activity Pain, fever, inflammatory disease, dysmenorrhea, osteoarthritis, RA, vascular headache, cystic fibrosis acts by inhibiting the action of serotonin (5HT); has shown little potential for abuse, a Mgmt and short term relief of generalized anxiety disorders Pt has COPD anticholinergic, bronchodilator, synthetic quaternarary ammonium compound Advair 250/50 (fluticasone 250mcg; salmeterol 50 mcg) Preg (C) 1 puff BID Treatment of asthma in patients ≥12 years: 1 inhalation of ADVAIR DISKUS twice daily ROUTE: INH Corticosteroid, bronchodilator Ibuprofen 400mg PO BID with meals Normal dosage: 300800mg PO q6h for pain; 100-200mg PO q4-6h PRN; not to exceed 3200mg/day ROUTE: PO NSAIDs Buspar (busPIRone) 15mg BID PO 5mg tid; may increase by 5my/day Pt has COPD CNS: Anxiety, dizziness, HA, nervousness CV: Palpitation EENT: Dry mouth, blurred vision GI: N&V, cramps INTEG: rash RESP: cough, worsening of symptoms, bronchospasms** Candida albicans infection, pneumonia, immunosuppression, hypercorticism, adrenal suppression, growth effects, glaucoma, cataracts NSAIDs increase risk of CV thrombotic events, MI and stroke; stomach irritation Pt has COPD, inflammatory response and occasional pain CNS: Dizziness, headache, depression, stimulation, insomnia, nervousness, light- CASE STUDY: BH q2-3 days, max 60mg/day ROUTE: PO 9 good choice in substance abuse Pt has dx of schizoaffective d/o with paranoia and depression Antianxiety, sedative Azaspirodecanedione heparin 5000units SC q8h Prophylaxis DVT/PE: Adults SC 5000units q8-12h ROUTE: SC Anticoagulant, antithrombotic UNLABELED USES: Autism Prevents conversion of fibrinogen to fibrin and prothrombin to thrombin by enhancing inhibitory effects of antithrombin III Prevention of DVT, PE, MI, open heart surgery, disseminated intravascular clotting syndrome, a-fib with embolizations, as an anticoagulant in transfusion and dialysis procedures, prevention of DVT/PE, to maintain patency of indwelling venipuncture devices; dx and tx of DIC Pt is majority bedridden due to condition, DVT/PE prophylaxis headedness, numbness, paresthesia, incoordination, nightmares, tremors, excitements, involuntary movements, confusion, akathesia, hostility CV: Tachycardia, palpitations, hypo/hypertension EENT: Sore throat, tinnitus, blurred vision, nasal congestion; red, itching eyes, change in taste, smell GI: Nausea, dry mouth, diarrhea, constipation, flatulence, increased appetite, rectal bleeding GU: Frequency, hesitancy, menstrual irregularity, change in libido INTEG: Rash, edema, pruritus, alopecia, dry skin MISC: Sweating, fatigue, weight gain, fever MS: Pain, weakness, muscle cramps, spasms RESP: Hyperventilation, chest congestion, SOB Fever, chills, HA, hematuria**, hemorrhage**, thrombocytopenia**, anemia**, rash, dermatitis, urticaria, pruritus, delayed transient alopecia, cutaneous necrosis (SC), anaphylaxis** CASE STUDY: BH Levaquin (levofloxacin) 10 500mg PO q daily AC Adult: 500mg q24h x 7 days (acute bacterial exacerbation of chronic bronchitis) Interferes with conversion of intermediate DNA fragments into highmolecular weight DNA in bacteria; DNA gyrase inhibitor; inhibits topoisomerase IV ROUTE: PO/IV Anti-infective, fluoroquinolone Acute sinusitis, acute chronic bronchitis, communityacquired pneumonia, uncomplicated skin infections, complicated UTI, cellulitis, PID, prostatitis, postexposure inh anthrax, acute pyelonephritis caused by Strep pneumoniae, H. influenzae, H. parainfluenzae, M. catarrhalis, E. coli, S. marcescens, K. pneumoniae, C. pneumoniae, L. pneumophilia, M. pneumoniae, E. faecalis, S. epidermidis, S. pyogenes HA, dizziness, insomnia, anxiety, seizures**, encephalopathy, paresthesia, chest pain, palpitations, vasodilation, QT prolongation, dry mouth, visual impairment, N&V, flatulence, diarrhea, abdominal pain, pseudomembranous colitis**, hepatotoxicity**, eosinophilia, rash, pruritus, pneumonitis, tendonitis Pt has positive sputum culture for Strep pneumoniae, gram + and gram – flora. Nicoderm TD (nicotine patch) 21mg TD qdaily 21mg/day x 4-8 wk; 14mg/day x 2-4 wk; 7mg/day x 2-4wk ROUTE: Transdermal patch Haldol (haloperidol) 5mg PO BID Adult 0.5-5mg bid or tid initially depending on severity of condition; dose increased to desired dose, max 100mg/day Agonist at nicotinic receptors in peripheral, CNS systems; acts at sympathetic ganglia, on chemoreceptors of aorta carotid bodies; also affects adrenalin=releasing catecholamines Deter cigarette smoking Depresses cerebral cortex, hypothalamus, limbic system, which control activity and aggression; blocks neurotransmission produced by dopamine at synapse; exhibits strong α-adrenergic, anticholinergic blocking action; mechanism for antipsychotic effects Psychotic disorders, control of tics, vocal utterances in Tourettes, ST tx of hyperactive children showing excessive motor activity, prolonged parenteral tx in chronic schizophrenia, organic mental Pt a smoker with COPD Dizziness, vertigo, insomnia, HA, confusion, seizures, depression, euphoria, numbness, tinnitus, strange dreams, dysrhythmias, tachycardia, palpitations, edema, flushing, HTN, jaw ache, N&V, indigestion, diarrhea, abdominal pain EPS, seizures***neuroleptic malignant syndrome**, confusion, orthostatic hypertension, HTN cardiac arrest**, ECG changes, tachycardia**, QT prolongation**, sudden death**, blurred vision, glaucoma, dry eyes, dry mouth N&V, diarrhea, constipation, CASE STUDY: BH 11 unclear syndrome with psychotic features, hiccups (ST), emergency sedation of severely agitated or delirious pt. ileus**, hepatitis**, rash, urinary retention, gynecomastia, impotence, dyspnea, respiratory depression** risk for death (dementia)** Pt has dx of schizophrenia, schizoaffective d/o with paranoia and depression mirtazapine (Remeron) 60mg hs PO 15mgday hs, maintenance to continue for 6mo titrate up to 45mg/day ROUTE: PO Blocks reuptake of norepinephrine, serotonin into nerve endings, increasing action of norepinephrine, serotonin in nerve cells, antagonist of central α2-receptors, blocks histamine receptors Depression, dysthymic d/o, bipolar disorderdepressed, agitated depression Increases the amounts of serotonin and norepinephrine, natural substances in the brain that help maintain mental balance. Treats depression. Blockade of central acetylcholine receptors Parkinson’s symptoms, EPS associated with neuroleptic products, acute dystonic reactions, hypersalivation Antidepressant, tetracyclic Pristiq (desvenlafaxine succx) 100mg PO qdaily ROUTE: PO Antidepressant, SNRI benztropine mesylate 1mg PO BID Adult: 1-2mg/day tid Cholinergic blocker, antiparkinson’s agent, tertiary amine Pt has dx of schizophrenia, schizoaffective d/o with paranoia and depression Pt has dx of schizophrenia, schizoaffective d/o with paranoia and depression Unsure of why pt takes this. Possibly Dizziness, drowsiness, confusion, HA, anxiety, tremors, stimulation, weakness, nightmares, EPS, increased psychiatric symptoms, seizures**, orthostatic hypotension, ECG changes, tachycardia, HTN**, palpitations, blurred vision, tinnitus, mydriasis, diarrhea, dry mouth, N&V, paralytic ileus**, urinary retention, acute renal failure, rash, urticaria, sweating, pruritus. Constipation, loss of appetite, dry mouth, dizziness, extreme tiredness, unusual dreams, yawning, sweating, uncontrollable shaking of a part of the body, pain, burning, numbness, or tingling in part of the body, enlarged pupils (black circles in the centers of the eyes), blurred vision, changes in sexual desire or ability, difficulty urinating Anxiety, restlessness, irritability, delusions, hallucinations, HA, sedation, depression, incoherence, confusion, palpitations, tachycardia, hypotension, Bradycardia, blurred vision, photophobia, CASE STUDY: BH prednisone 12 60mg PO with meals 5-60mg/day or divided bid or qid ROUTE: PO Corticosteroid, intermediate-acting glucocorticoid 100mg TID Tessalon perles(benzonatate) due to other medications producing EPS side effects. dilated pupils, difficulty swallowing, dry eyes, N&V, rash urticaria, increased temperature, flushing, numbness of fingers, muscular weakness, cramping Decreases inflammation by suppression of migration of polymorphonuclear leukocytes, fibroblasts, reversal to increase capillary permeability, and lysomal stabilization, minimal mineralocorticoid activity Severe inflammation, immunosuppression , neoplasms, MS, collagen disorders, dermatologic disorders. Depression, flushing, sweating, HA, mood changes, HTN, circulatory collapse**, embolism**, tachycardia**, fungal infections, increased IOP, blurred vision, nausea, abdominal distention, acne, poor wound healing, hyperglycemia Not listed in resource. Non-productive cough. 100mg up to TID, max 600mg/day Pt suffering from acute exacerbation of COPD, antiinflammatory response required. N/A Pt has cough result from infection and COPD ROUTE: PO Antitussive, nonopioid Humalog(lispro) sliding scale SC qid ROUTE: SC Rapid acting insulin Antidiabetic, pancreatic hormone Modified structures of endogenous human insulin Decreases blood glucose; by transport of glucose into cells and the conversion of glucose to glycogen, indirectly increases blood pyruvate and lactate, decreases phosphate and potassium Analysis Planning Intervention Documentation Nursing Care Plan Type 1 DM, Type 2 DM, gestational diabetes, insulin lispro may be used in combo with sulfonlyureas in children >3y Pt has had repeat elevated blood glucose levels. EENT: blurred vision, dry mouth INTEG: flushing, rash, urticaria, warmth, lipodystrophy, lipohypertrophy, swelling, redness META: hypoglycemia, rebound hyperglycemia MISC: peripheral edema CASE STUDY: BH 13 Nursing Diagnosis #1: Activity intolerance related to inadequate oxygenation AEB dyspnea, oxygen saturation <90% at rest on RA and as low as 84% RA during ambulation. Short-Term Goal: BH will demonstrate energy conservation techniques to improve activity tolerance during ambulation q 4 hours. Long-Term Goal: Pt will demonstrate improved activity tolerance by maintaining a realistic activity level as evidenced by less complaint of dyspnea on exertion by the monthly follow up appointment. Interventions: 1. Monitor severity of dyspnea and O2 sats with and following activity a. Rationale: activity increases the demand for oxygen, and the inability to meet the demand may result in dyspnea and desaturation. (Black, J.M., & Hawk , J.H., 2009). 2. Stop or slow any activity that leads to significant change in respiratory rate, failure of pulse to return to near resting rate within 3 minutes of activity, and/or changes in mental status. a. Rationale: significant changes in respiratory, cardiac, or circulatory status signal activity intolerance (Sandland, Morgan, & Singh, 2008). 3. Maintain supplemental oxygen therapy as needed during activity. a. Rationale: supplemental oxygen helps alleviate exercise-induced hypoxemia, thus improving activity tolerance (Sandland, Morgan, & Singh, 2008). 4. Schedule activity after respiratory treatment. CASE STUDY: BH 14 a. Rationale: Lung function is maximized during peak periods of medication and drug effect (Black, J.M., & Hawk , J.H., 2009). 5. Assist the client in scheduling a gradual increase in daily activities and exercise. a. Rationale: gradual increases in physical activity improve respiratory and cardiac conditioning, improving activity tolerance (Black, J.M., & Hawk , J.H., 2009). 6. Advise client to avoid conditions that increases oxygen demand, like smoking, temperature extremes, excess weight, and stress. a. Rationale: These factors increase peripheral vascular resistance, which increases cardiac workload and oxygen requirements (Black, J.M., & Hawk , J.H., 2009). 7. Instruct the client on energy conservation techniques, like pacing activities throughout the day, interspersed with adequate rest periods, and alternating high energy and low energy tasks. a. Rationale: Conservation techniques allow the client to accomplish more tasks with a limited energy supply (Black, J.M., & Hawk , J.H., 2009). 8. Teach the client to use pursed-lip and diaphragmatic breathing techniques during activities. a. Rationale: Breathing retraining ensures maximal use of available respiratory function. Purse lip breathing leaves PEEP in the lungs and helps keep airways open (Black, J.M., & Hawk , J.H., 2009). Evaluation: Pt ambulated in the hallway for 2 minutes; he rested after 1 minute of ambulation due to increased dyspnea. He continued for 1 minute more of ambulation, then returned to his CASE STUDY: BH 15 room to rest. STG was met. LTG not met, will take longer in meeting this goal. Home O 2 therapy recommended due to amount of dyspnea and desaturation upon exertion. Nursing Diagnosis #2: Impaired gas exchange r/t decreased ventilation AEB wheezing, diminished lung sounds, O2 sats >90% RA at rest. Short-Term Goal: Pt will maintain adequate gas exchange as evidenced by ABG (pH within normal limits, PaO2 equal to or greater than 60mmHg) in 24 hours. Long-Term Goal: Pt will maintain his pulse ox at >92% at rest on room air. Interventions: 1. Regularly monitor client’s RR, pattern, pulse ox, ABG results, and manifestations of hypoxia or hypercapnia. Report any significant changes or a lack of response promptly a. Rationale: Prompt recognition of deteriorating respiratory function can reduce potentially lethal outcomes (Black, J.M., & Hawk , J.H., 2009). 2. Administer low flow O2 (1-3L/min on 24%-31%FiO2) s needed via NC or high-flow Venturi mask. a. Rationale: oxygen corrects existing hypoxemia (Black, J.M., & Hawk , J.H., 2009). 3. Assist the client into the high Fowler position. a. Rationale: The upright position allows full lung excursion and enhances air exchange (Black, J.M., & Hawk , J.H., 2009). 4. Administer bronchodilators, if ordered. Monitor for side effects. CASE STUDY: BH 16 a. Rationale: Bronchodilators relax bronchial smooth muscle facilitating airflow. Common side effects include tremor, tachycardia, and other cardiac dysrhythmias. (Black, J.M., & Hawk , J.H., 2009). 5. Use caution when administering opioids, sedatives, and tranquilizers. a. Rationale: These medications are respiratory depressants and can further impair ventilation (Black, J.M., & Hawk , J.H., 2009). Evaluation: Pt’s ABG values met the criteria, his PaO2 was 60mmHg and his ABG pH was 7.41. These should be redrawn and analyzed again. However, his LTG was not met; his O2 sats on room air at rest were never greater than 90%. Evidence-Based Practice/Nursing Research Article Please refer to attached article. CASE STUDY: BH 17 References Black, J.M., & Hawk , J.H. (2009). Medical-Surgical Nursing: Clinical Management for Positive Outcomes (8th ed.). St. Louis: Saunders Elsevier. Coon, D., & Mitterer, J. O. (2011). Psychology. Mason: Cengage Learning. LeFever Kee, J. (2009). Prentice hall handbook of laboratory and diagnostic tests with nursing implications (6 ed.). upper saddle river: Pearson Prentice Hall. Roth-Skidmore, L. (2011). Mosby's nursing drug reference (24 ed.). St. Louis: Elsevier Mosby. Sandland, C. J., Morgan, M. D., & Singh, S. J. (2008). Patterns of domestic activity and ambulatory oxygen usage in COPD. CHEST , 134 (4), 753-760. Wilkinson, J. M., & Ahern, N. R. (2009). Prentice Hall nursing diagnosis handbook (9 ed.). New Jersey: Pearson Prentice Hall.