Question

Calvin Cooper is an 87-year-old male, brought to ER 9 days ago by paramedics after several falls at home. Initial vital signs on Mr. Cooper were: temp 99.1° F, HR 92, B/P 145/82, RR 24, O2 sat 98%, Pain 0 (on scale 0-10). The nurse completed an assessment on Mr. Cooper and documented the following exceptions to normal findings: patient has bilateral hearing aids, confused and forgetful at times, orientated x 2, diminished breath sounds at bases, bilateral swelling or the knees, 2-inch open laceration on left calf, and generalized weakness. According to Mr. Cooper’s only living relative, his son, he has arthritis in both knees and was diagnosed with Alzheimer’s 4 years ago.

Mr. Cooper is a widower whose wife died 25 years ago from breast cancer. Mr. Cooper’s parents and one sibling are deceased (father died age 72, of MI, mother died age 68, of MS, sister died age 82, of pneumonia). Mr. Cooper has one 64-year-old son who is named on his living will as medical decision maker. Mr. Cooper lives alone in his own home. He mobilizes using a walker and is able to bath, dress and feed himself. He has meals on wheels, a cleaner and assistance from neighbors who do his shopping. Mr. Cooper is Catholic, and the highlight of his week is going to church, which he is able to do thanks to several church members who take turns bringing him to church.

The physician ordered a stat head CT and urinalysis and urine culture. Head CT was negative for injury, UA and culture showed UTI sensitive to ciprofloxacin. Mr. Cooper started complaining of shortness of breath and developed a productive cough confirmed by sputum sample as bacterial pneumonia. It is sensitive to the ciprofloxacin already ordered. His nares were swabbed for MRSA 4 days ago, and the culture came back positive. He is now on contact isolation and has topical mupirocin (Bactroban) for his nares.

His oral intake and urine output has drastically decreased since being admitted to the unit. His IV fluids were increased to 0.9% NS 125 mL/hr to rehydrate Mr. Cooper. He frequently complains of urgency but cannot void any urine, resulting in the need for bladder scanning. Yesterday, he had a new onset of chest pain rating 7 out of 10 burning in his upper chest. A stat EKG was ordered which revealed no myocardial injury. He required 2 back to back doses of nitroglycerin to relieve the chest pain. His son has been to visit several times but due to work restraints, he hasn’t visited in the past few days.

His lung sounds reveal crackles with a wet cough. He complains of difficulty breathing when his head is too flat and ongoing shortness of breath. Bowel sounds hypoactive X 4 quadrants. Peripheral pulses are 3+ bilaterally, capillary refill 3 seconds, and skin turgor poor. 2+ pitting edema is noted in both lower extremities, and the nurses have been elevating them to try and decrease swelling. Mr. Cooper also has JVD on both sides. He is still oriented X2 with occasional agitation towards staff. Because of combativeness and attempting to remove IV overnight, mitt restraints were placed on Mr. Cooper. Despite the mitts, Mr. Cooper’s IV was removed accidently around 0600, and no staff has been successful in inserting a new line. Vital signs were obtained at 0400: temp 98.9® F, RR 24, pulse 104, BP 148/98, pulse ox 94% on 3 L/min nasal cannula, pain 2 out of 10 in chest and bilateral knees. Mr. Cooper is drowsy and fatigued but wakens to stimulation and conversations. His mental status is rapidly declining.

The physician rounds on Mr. Cooper this morning and adds orders into the EHR: furosemide (Lasix) 20 mg PO q 12 hours to be started now, heparin 2500 units SQ q 8 hours, repeat CBC w/diff, CMP, lipid panel, and cardiac panel, chest xray stat, and transesophageal echocardiogram with sedation once CXR completed.

What signs & symptoms listed in Mr. Cooper’s case study relate to the concept of perfusion and what is the clinical significance of each (what might this indicate?)

Answer 1

Perfusion

It is the act of perfusing. Perfusion means the introduction of a drug or nutrients through the bloodstream in order to reach an internal organ or tissues.

Signs and symptoms of aMr. Cooper related to the concept of perfusion.

* Peripheral pulse 3+ bilaterally ( indicates normal pulse rate)

* Capillary refill : 3 seconds ( normal flilling time. In elderly it can be upto 4sevonds.

* Poor skin turgor

* Pitting edema 2+

* Jugular vein distention ( JVD )

* Pulse : 104 tachycardia

*Blood pressure ( 148/98)

Clinical significance of signs and symptoms

* Poor skin turgor indicates dehydration . Usually in case of edema, It is difficult to pinch up the skin.

* Pitting edema 2+: edema is an excessive accumulation of fluid in tissue spaces. 2+ pitting edema means the pressure appled by the physician or nurse leaves a depression or indentation of 3-4 mm It takes a 15 sec to rebound. Pitting edema is caused due to various reasons like severe lung diseases, kidney failure, liver disease or cardiac problems like congestive heart failure.

* Jugular vein distention : It is the bulging or distention of jugular veins of the neck. It is a sign of increased central venous pressure. JVD might be due to pulmonary hypertension or heart failure

* tachycardia (104): Increased pulse rate above 100 beats per minute is due to an underlying health condition ,electrolyte imbalance, fatigue or stress.

* 148/ 98 Blood pressure indicates hypertension. It is common in old age people due to narrowing of arteries and atherosclerosis or arteriosclerosis. It may also caused by Cardiac problems, Diabetes and kidney diseases.