1. Gross anatomy of the chest case study Elizabeth Kelley Buzbee AAS,NPS-RRT, RCP

2. Case study # 1 Your patient is an 18 year-old Latin American male [LAM] who has about a liter of fluid in the plural spaces secondary to renal [kidney] failure and congestive heart failure. Your patient is an 18 year-old Latin American male [LAM] who has about a liter of fluid in the plural spaces secondary to renal [kidney] failure and congestive heart failure. His respiratory rate is 35 bpm. His respiratory rate is 35 bpm. His heart rate is 125 bpm. His heart rate is 125 bpm. Are his Vital Signs within normal limits? Are his Vital Signs within normal limits?

3. answer No, his RR should be between 12-20 bpm. He is breathing fast—tachypnic No, his RR should be between 12-20 bpm. He is breathing fast—tachypnic Nor is his heart rate normal. It should be between 60-100 bpm and it also is too fast--tachycardia Nor is his heart rate normal. It should be between 60-100 bpm and it also is too fast--tachycardia

4. The patient complains of pain on deep breathing. Why? The patient complains of pain on deep breathing. Why?

5. answer The parental pleura is filled with pain receptors and the swelling irritates them The parental pleura is filled with pain receptors and the swelling irritates them

6. How could this problem effect his ability to breathe? How could this problem effect his ability to breathe?

7. answer The fluid pressing on the lung will cause it to collapse. Collapsed air sac are harder to re- inflate The fluid pressing on the lung will cause it to collapse. Collapsed air sac are harder to re- inflate The interface between the pleura and the lung is filled with fluid so that the lung doesn’t follow the rib cage out during inspiration. To compensate for this, the patient must create more negative pressure in his chest. This, too, increases the WOB The interface between the pleura and the lung is filled with fluid so that the lung doesn’t follow the rib cage out during inspiration. To compensate for this, the patient must create more negative pressure in his chest. This, too, increases the WOB

8. How does increased WOB cause him to have the retractions you see on his chest wall? How does increased WOB cause him to have the retractions you see on his chest wall?

9. answer Retractions of the soft tissue of the ribs, and sternum and clavicles result from excessive negative pressure in the thorax created by the patient to get air into a stiff lung. Retractions of the soft tissue of the ribs, and sternum and clavicles result from excessive negative pressure in the thorax created by the patient to get air into a stiff lung.

10. You note that this patient’s skin is cool and damp [diaphrotic] Why is he sweating? You note that this patient’s skin is cool and damp [diaphrotic] Why is he sweating?

11. answer He is sweating because he is working hard to breath He is sweating because he is working hard to breath

12. Before the chest tube was placed and 500 ml of fluid removed from the thoracic cavity, this patient’s Sp02 was 88%. Before the chest tube was placed and 500 ml of fluid removed from the thoracic cavity, this patient’s Sp02 was 88%. What is the significance of the 02 saturation? What is the significance of the 02 saturation?

13. answer He has lower than normal 0xygen bound to his blood hemoglobin. He has lower than normal 0xygen bound to his blood hemoglobin. He is hypoxic He is hypoxic

14. What would you suggest for this condition? What would you suggest for this condition?

15. answer Give him supplementary 02 to get his Sp02 back to 90% Give him supplementary 02 to get his Sp02 back to 90%

16. Do you think that the presence of this fluid could interfere with this patient’s ability to take a deep breath and cough? Do you think that the presence of this fluid could interfere with this patient’s ability to take a deep breath and cough?

17. answer Yes, he cannot take a deep breath with all the fluid taking up space where lung should be Yes, he cannot take a deep breath with all the fluid taking up space where lung should be

18. When we listen to his breath sounds, we hear crackles in the upper lobes and diminished breath sounds in the lower lung fields. When we listen to his breath sounds, we hear crackles in the upper lobes and diminished breath sounds in the lower lung fields. Why? Why?

19. answer We hear crackles because we are hearing the air sac pop open on inspiration We hear crackles because we are hearing the air sac pop open on inspiration We hear diminished breath sounds in the basal areas because gravity causes the fluid to move down to the lower portion of the chest. The fluid is causing the lung to collapse and the fluid is damping down the breath sounds We hear diminished breath sounds in the basal areas because gravity causes the fluid to move down to the lower portion of the chest. The fluid is causing the lung to collapse and the fluid is damping down the breath sounds

20. What would be your expectations regarding his Sp02 and his Vital Signs after the chest tube has been placed in his chest and the extra fluid drained off? What would be your expectations regarding his Sp02 and his Vital Signs after the chest tube has been placed in his chest and the extra fluid drained off?

21. answer We expect that his RR to drop closer to normal We expect that his RR to drop closer to normal We expect the HR to drop closer to normal We expect the HR to drop closer to normal We expect the Sp02 to rise closer to normal We expect the Sp02 to rise closer to normal We expect the sweating and the retractions to return to normal We expect the sweating and the retractions to return to normal