Unit 3.1 case studiesUnit 3.1 case studiesPEFR and Pulse PEFR and Pulse

oximetryoximetryBy Elizabeth Kelley Buzbee AAS, By Elizabeth Kelley Buzbee AAS,

RRT-NPS, RCPRRT-NPS, RCP

Your patient is Mr. Rogers who presents in Your patient is Mr. Rogers who presents in the ER with shortness of breath. To the ER with shortness of breath. To assess him further, you recommend:assess him further, you recommend:

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Getting a pulse oximetry reading to assess Getting a pulse oximetry reading to assess his level of hypoxemiahis level of hypoxemia

Listening to breath sounds to assess the Listening to breath sounds to assess the presence and degree of bronchospasmpresence and degree of bronchospasm

Inspecting him for use of accessory Inspecting him for use of accessory muscles, for his vital signsmuscles, for his vital signs

Interviewing him for s/s of confusion or Interviewing him for s/s of confusion or LOCLOC

Mr. Rogers pulse oximetry reading is Sp02 Mr. Rogers pulse oximetry reading is Sp02 88%. His respiratory rate 28 bpm and his 88%. His respiratory rate 28 bpm and his heart rate is 119 bpm.heart rate is 119 bpm.

You: You:

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Suggest we start him on 1 lpm nasal Suggest we start him on 1 lpm nasal cannula and repeat the pulse oximetry cannula and repeat the pulse oximetry readingreading

How do you assess the effectiveness of How do you assess the effectiveness of the oxygen?the oxygen?

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Repeat the pulse oximetry and reassess Repeat the pulse oximetry and reassess the vital signs. Both heart rate and the vital signs. Both heart rate and respiratory rates should slow down a bitrespiratory rates should slow down a bit

look at his work of breathing and listen to look at his work of breathing and listen to his breath sounds to assess his respiratory his breath sounds to assess his respiratory distressdistress

The doctor orders 2 lpm nasal cannula The doctor orders 2 lpm nasal cannula and you see that the heart rate and the and you see that the heart rate and the respiratory rate are both decreased a bit. respiratory rate are both decreased a bit. In 5 minutes, you see that the Sp02 rises In 5 minutes, you see that the Sp02 rises from 88% to 90%.from 88% to 90%.

Has the pulse oximetry been justified?Has the pulse oximetry been justified?

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Yes, Yes, the patient has s/s of hypoxemia which you the patient has s/s of hypoxemia which you

have monitored and documented with the have monitored and documented with the pulse oximeter pulse oximeter

You have successfully assess the You have successfully assess the effectiveness of the supplementary 02 by use effectiveness of the supplementary 02 by use of serial pulse oximetry readingsof serial pulse oximetry readings

What further assessment do you need for What further assessment do you need for this patient?this patient?

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While you reassessed the vital signs, you While you reassessed the vital signs, you also need to assess the breath sounds also need to assess the breath sounds which might tell us why the patient is which might tell us why the patient is hypoxichypoxic

On auscultation, you hear diffuse On auscultation, you hear diffuse inspiratory and expiratory wheezes to all inspiratory and expiratory wheezes to all lobes. lobes.

You hear a prolonged expiratory timeYou hear a prolonged expiratory time

What do you suggest now?What do you suggest now?

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Measure a PEFR to document the Measure a PEFR to document the bronchospasmbronchospasm

The patient tries to follow your directions The patient tries to follow your directions but coughs so much that she must stop. but coughs so much that she must stop. You suggest?You suggest?

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Give the inhaled bronchodilator drugs and Give the inhaled bronchodilator drugs and try to get the PEFR post bronchodilatortry to get the PEFR post bronchodilator

Case study # 2Case study # 2

Your patient is Mr. Croder who has a Your patient is Mr. Croder who has a history of COPD. history of COPD.

You would like to assess the following?You would like to assess the following?

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1.1. Vitals signsVitals signs

2.2. Interview the patient for his chief Interview the patient for his chief complaint: why is he in the hospital? complaint: why is he in the hospital?

3.3. Inspection for s/s of shortness of breathInspection for s/s of shortness of breath

4.4. Breath sounds to assess the level of Breath sounds to assess the level of bronchospasmbronchospasm

5.5. Pulse oximetry if s/s of SOBPulse oximetry if s/s of SOB

he in the hospital to have cardiac surgeryhe in the hospital to have cardiac surgery

He is using accessory muscles to breath He is using accessory muscles to breath and is retractingand is retracting

His breath sounds are diminished and His breath sounds are diminished and there is scattered wheezingthere is scattered wheezing

Pulse oximetry shows 89% on room airPulse oximetry shows 89% on room air

What do you suggest?What do you suggest?

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1.1. Start him on supplementary 02 by 1-2 Start him on supplementary 02 by 1-2 lpm nasal cannulalpm nasal cannula

2.2. Reassess with a pulse oximetryReassess with a pulse oximetry

3.3. Assess his bronchospasm before and Assess his bronchospasm before and after a bronchodilator with a peak flow after a bronchodilator with a peak flow metermeter

The doctor orders a PEFR before and The doctor orders a PEFR before and after administration of .5 mg Albuterol [a after administration of .5 mg Albuterol [a bronchodilator]bronchodilator]

You need the following information to do You need the following information to do this PEFR?this PEFR?

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1.1. From his chart get his age, height and From his chart get his age, height and sexsex

2.2. On the PEFR, look up the patient’s On the PEFR, look up the patient’s predicted PEFR based on this datapredicted PEFR based on this data

How do you explain the use of the Peak How do you explain the use of the Peak flow meter to the patient?flow meter to the patient?

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Tell him to:Tell him to:

1.1. Put his lips and teeth on the mouth piecePut his lips and teeth on the mouth piece

2.2. Exhale as fast as he can into the meterExhale as fast as he can into the meter

3.3. Read the meter Read the meter

4.4. Repeat steps 1-3 until you get 2 readings Repeat steps 1-3 until you get 2 readings that are within 5% of each otherthat are within 5% of each other

Why do these readings have to be within Why do these readings have to be within 5% of each other?5% of each other?

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For reproducibility, you must have two For reproducibility, you must have two readings that are close togetherreadings that are close together

PEFR readings are patient-dependent and PEFR readings are patient-dependent and patient effort can drastically alter the patient effort can drastically alter the reading so if you get two reading within reading so if you get two reading within 5% of each other, you can trust the data5% of each other, you can trust the data

The patient follows your directions but The patient follows your directions but there is no reading on the peak flow meter. there is no reading on the peak flow meter. What has happened?What has happened?

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1.1. Place nose clips on the patient to make Place nose clips on the patient to make sure he is exhaling through the peak sure he is exhaling through the peak flow meter flow meter

2.2. Double check that he has his lips tight Double check that he has his lips tight around the mouth piece and that his around the mouth piece and that his teeth aren’t in the wayteeth aren’t in the way

3.3. Make sure the one-way valve is pointed Make sure the one-way valve is pointed toward the metertoward the meter

You see that the peak flow meter is not You see that the peak flow meter is not attached to the mouthpiece tightly so you attached to the mouthpiece tightly so you tighten the connection and repeat the tighten the connection and repeat the instructions. You get the following results:instructions. You get the following results: 385385 388388 400400 Which of these PEFR measurements do you Which of these PEFR measurements do you

record?record?

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400 lpm. It is the highest one and is within 400 lpm. It is the highest one and is within 5% of the next lowest5% of the next lowest

On the peak flow meter instructions, you On the peak flow meter instructions, you see that this patient’s predicted PEFR is see that this patient’s predicted PEFR is 645 lpm. 645 lpm.

What is his % predicted? What is his % predicted?

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400/645 = 62%400/645 = 62%

His PEFR is 62% of predictedHis PEFR is 62% of predicted

You give the .5 mg of Albuterol and You give the .5 mg of Albuterol and reassess the patient. His respiratory rate is reassess the patient. His respiratory rate is decreased and his retractions are decreased and his retractions are decreased. On auscultation, you hear the decreased. On auscultation, you hear the scattered wheezing has decreased, but scattered wheezing has decreased, but there are diminished breath sounds. there are diminished breath sounds. When you repeat the PEFR you are not When you repeat the PEFR you are not surprised to see the followingsurprised to see the following

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The PEFR is now 445 lpmThe PEFR is now 445 lpm

If you calculate the % of predicted, you will If you calculate the % of predicted, you will discover that it has risen from 62% to 69% discover that it has risen from 62% to 69% of predictedof predicted

445 / 645 = 69% of predicted445 / 645 = 69% of predicted

Case study # 3Case study # 3

Your patient Miss Otis, is a 25 year old Your patient Miss Otis, is a 25 year old who has been admitted to the ER who has been admitted to the ER secondary to injuries sustained during a secondary to injuries sustained during a fire. fire.

What do you assess?What do you assess?

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Her state of consciousness is critical. If Her state of consciousness is critical. If she is altered she may be in significant she is altered she may be in significant hypoxemia.hypoxemia.Her work of breathing is important. She Her work of breathing is important. She may have upper airway swelling or may have upper airway swelling or bronchospasmbronchospasmAuscultation of the chest for wheezingAuscultation of the chest for wheezingHer PEFR might demonstrate the Her PEFR might demonstrate the presence of significant bronchospasmpresence of significant bronchospasm

The patient is alert and anxious. She is The patient is alert and anxious. She is using accessory muscles to breath and using accessory muscles to breath and you hear wheezing bilaterally. you hear wheezing bilaterally.

The nurse suggests we place a pulse The nurse suggests we place a pulse oximeter on her finger. oximeter on her finger.

You:You:

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Disagree, and recommend drawing blood Disagree, and recommend drawing blood for a co-oximetry reading. The Sp02 for a co-oximetry reading. The Sp02 reading will be off.reading will be off.

Why is the Sp02 off with this patient?Why is the Sp02 off with this patient?

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The presence of HbCO [carbon monoxide] The presence of HbCO [carbon monoxide] in the blood would rise the color of the in the blood would rise the color of the blood and fool the pulse oximeter which blood and fool the pulse oximeter which uses only two lights. You need all five uses only two lights. You need all five lights of the co-oximeter to be sure of the lights of the co-oximeter to be sure of the presence of carbon monoxidepresence of carbon monoxide

The doctor orders supplementary 02 by The doctor orders supplementary 02 by non-rebreathing mask and you see that non-rebreathing mask and you see that the patient’s respiratory rate decreases, the patient’s respiratory rate decreases, and her heart rate decreases after she is and her heart rate decreases after she is placed on extra 02. placed on extra 02.

What do you want to do for her?What do you want to do for her?

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Assess her PEFR to document the Assess her PEFR to document the presence of wheezingpresence of wheezing