13 May Evelyn Thompson, a 72-year-old female client (DOB: 7/12/1951), presents to the emergency department with a productive cough and difficulty breathing for the past few days.
CASE STUDY:
Evelyn Thompson, a 72-year-old female client (DOB: 7/12/1951), presents to the emergency department with a productive cough and difficulty breathing for the past few days. She is febrile on arrival with substernal and supraclavicular retractions and difficulty speaking in full sentences. Wheezes and rales are auscultated bilaterally. After initial oxygen therapy and albuterol with ipratropium (DuoNeb) fail to improve her work of breathing, and her pulse oxygenation falls to 81%, the providers decide to intubate. RSI is given (etomidate and rocuronium), and she is intubated with a 7.5 ETT, 21 cm at the lip, with placement confirmed via portable chest x-ray, auscultation, and colorimetric capnography. Oxygen saturation levels rise to 93% on the ventilator. The chest x-ray reveals pneumonia, and antibiotics are ordered. Continuous sedation infusion is considered as she is prepared for admission to the ICU with pneumonia and acute respiratory failure.
Past Medical History: COPD
Allergies: None
Medications: olodaterol 2.5 mcg/tiotropium 2.5 mcg (Stiolto Respimat) Respimat two puffs once daily
Social History: She quit smoking 20 years ago and does not drink alcohol.
Physical Exam:
• Height: 5 feet 7 inches
• Weight: 161 lbs
• Body Mass Index (BMI): 25.2
• Blood Pressure (BP): 134/81
• Heart Rate (HR): 110
• Respiratory Rate (RR): 20
• Oxygen Saturation (O2 Sat): 93% on 100% FiO2 via ventilator
• Temperature (TEMP): 102.1 rectal
An appropriate order for Evelyn is:
Name: Evelyn Thompson
Date Of Birth: 7/12/1951
Medication Name and Strength: propofol (Diprivan) 1g/100mL
Date Prescribed: Current Date
Dose: Start dose at 5 mcg/kg/min
Route: IV
Directions/Parameters: Titrate by 5 mcg/kg/min to desired sedation level. Therapeutic infusion rates are typically 25-75 mcg/kg/min.
Priority: Now
Frequency: Continuous
Rationale: This client is intubated and mechanically ventilated and requires sedation. Light sedation is preferred over deep sedation to reduce the duration of mechanical ventilation and ICU stay, as light sedation is associated with shorter times to extubation and lower tracheostomy rates. Nonbenzodiazepine sedatives, such as propofol, are preferred over benzodiazepines (midazolam or lorazepam) due to better short-term outcomes, including reduced ICU length of stay,
Step 1: Assess the client’s case, the applicable clinical practice guideline (CPG), and the prescription information provided.
Step 2: Answer the discussion prompts below with explanation and detail, providing complete references for all citations. Refer to the lesson for client information.
Include the following sections:
1. Application of Course Knowledge: Answer all questions/criteria with explanations and detail.
a. Describe your assigned client’s situation. Why are they presenting to the clinic? What medications are they currently taking?
b. Assess the applicable clinical practice guideline (CPG) for your assigned client linked on the same page in the lesson where the client case is located. What treatment is recommended by the CPG for your client’s situation?
c. Discuss your personal professional assessment of the client’s situation provided in the scenario. What pharmacological treatment is necessary and why?
d. Reflect on additional questions you have about your assigned client that may influence treatment. What else do you need to know? What follow-up assessments, labs, or conversations are required to ensure optimal health outcomes?
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