<p> Case studies in A & P Unit 4-1: the heart Key Name: roster # Date: 2007 Case study # 1 1. You have a 68 year old black male patient with a long-time history of chronic obstructive lung disease. His RR is 23 bpm and his HR is 115 bpm. He has distant breath sounds and </p><p> wheezing diffusely. His Pa02 is 48 mmHg on 2 lpm nasal cannula; his Sp02 is 86%.</p><p>He has an increased A-P diameter and on X-ray you see that his diaphragms are at the level of the 10th intercostal in the anterior. One third of the heart is located right of the sternum and 2/3 is located left of the sternum. His Hematocrit and Hb are both increased to compensate for his chronic hypoxemia. a. What are the effects of these disorders on his airways? </p><p>This patient has increased RAW. The diaphragms are too low [normal is around the 6th ribs in anterior] and this will interfere with effective inspiration, as well as coughing. b. What is the effect of these disorders on his heart? The heart is in the correct place but it could be effected by [1] hypoxemia will cause pulmonary HTN secondary to widespread vasoconstriction of the pulmonary capillaries [2] polycythemia secondary to chronic hypoxemia will make the blood more viscose and harder to flow [3] the myocardial cells will be more irritable in the face of tissue hypoxia c. How would you correct this situation? Prevent or treat pulmonary HTN by treating hypoxemia [get Pa02 55-65 torr or Sp02/Sa02 above 90%]. </p><p>Giving medication to reverse the increased RAW will decrease the WOB</p><p>Case study # 2 2. Your patient presents with the following s/s: He has trouble lifting his head and turning it. His VC [Vital Capacity] is 50% of predicted. His RR is 36 bpm and his HR is 148 bpm. He is febrile. On X-ray you see evidence of basal atelectasis [collapsed alveoli]. You also see that the entire heart is located left of the sternum. His Sp02 is 89% on room air. a. What are the effects of these disorders on his airways? This patient is unable to protect his upper airways. His supra-glottic structures may be collapsing, and he is at risk of choking if his swallowing is hampered. He cannot take a deep-enough breath to cough effectively so he is at risk for atelectasis. His X-ray findings of basal atelectasis suggest decreased lung compliance. This will increased his WOB--- just when his muscles lack the ability to work harder. His increased WOB is evidenced by the increased RR and HR.</p><p> b. What is the effect of these disorders on his heart? The heart has moved into the left because of the atelectasis. This alone may or may not interfere with cardiac function, but the pulmonary HTN resulting from widespread pulmonary capillary vasoconstriction secondary to </p><p> decreased alveolar hypoxia [low PA02] can result in right heart failure The hypoxemia associated with the low Sp02 will make his heart muscle more irritable. The rapid HR shows increased work of the heart with a possible decreased SV [stroke volume.] The fever has increased his metabolism and his need for 02.</p><p> c. How would you correct this situation? Accommodate the increased WOB and the increased work of the heart by giving enough supplementary 02 to raise the Sp02 above 90%. We may need to protect his airway. We do need to re-inflate the collapsed alveoli and reverse the atelectasis. We need to treat the infection that is increasing his metabolism </p><p>Case study # 3 3. Your patient presents with the following s/s. She is 24 hours post-op recent chest surgery for Coronary Artery Disease. [CAD] Her breath sounds are diminished in the bases and she has rhonchi in the upper lobes. Her ABG shows mild hypoxemia. On X-ray, you see that the heart only fits into the chest 1.5 times because it is so big. One third of the heart is located right of the sternum and 2/3 located left of the sternum a. What are the effects of these disorders on his airways? Diminished breath sounds imply that there is decreased movement of air into the alveoli, causing atelectasis which will lower the lung compliance.</p><p>The rhonchi imply that the bronchi are filling with secretions which will </p><p> increase the RAW</p><p>Both of these situations will increase the WOB and may decrease air flow and the entry of 02 into the body—causing hypoxemia.</p><p>The pain associated with chest surgery can interfere with the patient’s ability to take a deep breath and cough—secretions will build up.</p><p>The unstable chest wall [the sternum has been cut for surgery] will make taking a deep breath more difficult. b. What is the effect of these disorders on his heart? The heart should be able to fit into the chest twice—even three times, so this heart is enlarged. It is not shifted. </p><p>The enlarged heart might mean that there is decreased SV, so that blood builds up inside the pulmonary bed instead of going forward in to the left side of the heart—this increased blood volume in the lung will increase the WOB as the interstitial spaces gets stiffer and the compliance drops.</p><p> c. How would you correct this situation? Treat documented hypoxia & decrease the work of the heart and the WOB with supplementary 02. Get the Sp02 above 90% Treat the atelectasis and the increased secretions to decrease the WOB Give drugs to increase the ability of the heart to work effectively to decrease the blood volume in the pulmonary bed and return the lung compliance to its proper level. </p><p>Case study # 4 4. Your patient presents with the following s/s. Pa02 is 46 mmHg, the Sp02 is having trouble reading & displays ‘decreased perfusion.’ The systemic blood pressure is 183/95. RR is 29 bpm and HR is 130 bpm. On auscultation you hear diminished breath sounds over the LLL and crackles in the LUL. On X-ray you see that there is increased prominence of blood vessels in the hilar area with effusion present in the left side of the chest. One third of the heart is located right of the sternum and 2/3 located left of the sternum. The heart is enlarged. a. What are the effects of these disorders on his airways? The effusion in the pleural space will make breathing less effective so that the </p><p>WOB must increase to get the same VT. </p><p>The effusion in the pleural space will press on the alveoli adjacent to it so they start to collapse as their compliance goes down. </p><p>Atelectasis will decrease the amount of 02 available to be diffused into the capillaries so that Pa02 will drop</p><p> b. What is the effect of these disorders on his heart? The heart is located in the right place. </p><p>Pt has systemic HTN-- which will increase work on the left ventricle and could lead to left heart failure</p><p>Blood has backed up in the pulmonary bed so that it will fill up the interstitial spaces particularly in Zone III alveoli, making them less compliant. </p><p> c. How would you correct this situation? Treat the heart with drugs that make the heart’s SV more effective; and give drugs to get rid of excess fluid. </p><p>Give drugs to lower the HTN </p><p>Give supplementary 02 to correct the increased work on the heart & breathing and watch for refractory hypoxemia—02 may not be enough.</p>