Nursing Case Study: Mrs. Kelly's Airway

AIRWAY:

Mrs. Kelly’s s airway is patent. No signs of airway obstruction demonstrated by talking in full sentences. However, Maintaining airway by keeping the patient on an upright position will help eliminate the risk for potential risk of airway obstruction (Dao Le, L.K, 2016). It is a low priority nursing intervention in this case study.

BREATHING:

Mrs. Kelly is Tachypneic as evidence of shortness of breathes due to lack of blood oxygen in the blood called hypoxemia. In which the body is trying to compensate by breathing more. Hypoxemia is taken from an artery to detect the oxygen level in the blood (arterial blood gas). Her ABG results showed a 75 mmHg (normal 80-100mHg). Hypoxemia has many reasons, most often related to respiratory disorders,

Because the heart is failing to pump enough blood to support the blood supply of the vital organs there will be an increase of systemic vascular resistance, thereby decreasing supply of blood going to non-vital organs such skin but increasing blood flow to vital organs. Her bilateral oedema represents fluid leakage from the blood and lymphatic vessels into the soft tissues. The feet and ankles predisposed to oedema because of gravity, its stimulate pooling of fluids in the areas of the body. This indicates Mrs. Kelly is having a systemic disorder such as heart failure (Evers, Vaneker, & Biert,

CHEST XRAY

Chest x-ray is useful in determining the presence of cardiomegaly, pulmonary oedema, pleural effusions, and other criteria of heart failure

It is often used in patients having chest pain to know if there is a presence of pulmonary congestion or cardiac enlargement. It will help to evaluate the finding and prognosticate of early and late mortality of myocardial infarction.

In this case study Mrs Kelly has pulmonary vascular congestion and pulmonary oedema. The fluids in the air spaces and the parenchyma of the lungs accumulate, may cause to impaired gas exchange and lead to respiratory failure, affecting left ventricle of the heart to adequately remove blood from the pulmonary circulation, compromising the cardiac output. This pulmonary oedema can lead to respiratory failure, cardiac arrest due to hypoxia that can lead to death (Morales, Prediletto, Rossi, Catapano, Lombardi, & Rovai, 2012).

The size of the heart is still normal because the cardiomediastinal contours are usually normal in the onset of myocardial infarction.

2. ARTERIAL BLOOD GAS (ABG)

It measures the acidity and the levels of oxygen and carbon dioxide in the blood from an artery. This analysis is used to detect how the oxygen from lungs move in the blood and how carbon dioxide removed from the