Question

RC 200 Cardiopulmonary Pathology

SOAP Assignment #3

Case Study: Flail Chest

Name:___________________________________   Date:___________________________________________

ADMITTING HISTORY

A car had hit a 10-year-old girl, and the right back tire of the vehicle had run over the left side of her chest. She had immediately been rushed to the nearby hospital by neighbors who had witnessed the accident. The patient was conscious, crying, and in obvious respiratory distress. Paradoxical movement of her left chest was unmistakable. She appeared cyanotic. Her vital signs were blood pressure 65/45, heart rate 150, respiratory rate 25/min and shallow. Auscultation revealed wheezes over the right lung and no breath sounds over the left lung. Other than some minor abrasions across her chest, arms, and face, there appeared to be no other remarkable injuries.

While waiting for the mechanical ventilator to be set up, the respiratory care practitioner inserted an oral airway and started to manually bag the patient with an Fio2 of 1.0. Immediately, the patient relaxed and her skin started to pink up a bit. A stat chest x-ray examination revealed double fractures of ribs 3, 4, 5, and 6 on her anterior left thorax. Her entire left lung was opaque from atelectasis. On an Fio2 of 1.0, her arterial blood gases were pH 7.53, Paco2 26, HCO3- 20, Pao2 46, and Sao2 86%.

Her mother reported that the patient had a long history of asthma. She had been taking a variety of MDI bronchodilators since about 2 years of age. Presently she was taking an albuterol MDI tid. She was lightly sedated with propofol.

Based on these clinical data, how would you SOAP this patient?

SOAP 1

S:

O:

A:

P:

Over the Next 30 Minutes

Over the next 30 minutes the patient was sedated, transferred to the ICU, and placed on a mechanical ventilator. Her initial ventilator settings were assist/control with a VT of 450 mL, a respiratory rate of 12 breaths per minute, a PEEP of 5 cm H2O, and an Fio2 of 1.0. An in-line nebulizer was started with 0.5 mL albuterol and 2 mL normal saline. As soon as she was placed on the ventilator her chest movement was symmetrical during each positive pressure breath—that is, she had no paradoxical movement of her anterior left thorax during each mechanical inspiration.

Because of the sedation, she had no spontaneous breaths. Auscultation revealed wheezing over the right lung and diminished breath sounds and crackles over the left lung. Her blood pressure was 85/60, and her heart rate was 105. Her arterial blood gases were pH 7.50, Paco2 30, HCO3- 23, and Pao2 61. A second chest x-ray examination showed atelectasis throughout the patient's left lung fields.

Based on these clinical data, how would you SOAP this patient?

SOAP 2

S:

O:

A:

P:

Over the Next 10 Days

Over the next 3 days, the patient's respiratory status rapidly improved. Pain control was easily achieved. The patient's left lung fully reexpanded after the first 24 hours on the ventilator. Within 48 hours, the Fio2 was weaned to 0.40 and the PEEP level was decreased to 5 cm H2O. Her vital signs and arterial blood gases were all in the normal range. She remained on the assist/control mode, at a rate of 12 breaths per minute, for a total of 7 days. Although her breath sounds were good and no wheezing could be detected, she continued to receive 0.5 mL albuterol and 2 mL normal saline qid for maintenance purposes. On day 7 her chest x-ray film showed that her ribs were healing appropriately and her lungs appeared normal. On day 8 she readily triggered assisted mechanical ventilations and was taken off the ventilator. On day 9 she was moved out of the ICU to the pediatric floor. On day 10, she was discharged.

Answer 1

cardio pulmonary pathology
Flail chest:
SOAP 1
S -subjective(information)
collect the history of the patient with present and past illness..child met with accident in the car.she brought to the hospital by neighbors..
O-Objective:(data gathered by health provider, should include vital signs,physical exam,lab test etc..)
Patient was conscious,crying and had respiratory distress..
Vital signs: Blood pressure 65/4, heart rate 150,respiration rate 25/min and shallow
Auscultation=wheezes over the right lung.Left lung -no breath sound
Minor abrasions across her chest,arms and face..
X ray chest
Arterial blood gas
Assessment:
Health situation revealed the final diagnosis which patient experiencing..
Health issues 1:
double fracture of ribs 3,4,5 and 6 on anterior left thorax
Health issues 2:
left lung atelectasis
Health issues 3:
Long history of Asthma
Plan:
Recommendation:
-oral airway started to manually bag
-Patient PH value increased more than 7.45,paco2 decreased <35 mmHg, HCO3 decreased <22mEq/L it indicate respiratory alkalosis..
Avoid the underlying factors like psychological condition should be stabilized..
Prevent hyperventilation
Administer Narcotic analgesics as per doctor instruction to reduce the pain and for sedation
Bronchodilators and nebulization should be continued
Wound closure should be done
Avoid complication like pheumothorax
child should be preoxygenated with BMV and 100% oxygen prior to mechanical ventilation
Soap 2:
s-subjective:
patient sedated and transferred to the ICU and placed on a ventilator
O-objective
Auscultation revealed wheezing over right lung and diminished breath sounds and crackles over the left lung.
Vital signs:
Blood pressure 85/60,heart rate 105,
ABG
X ray chest
A-Assessment
Chest movement was symmetrical during each positive pressure breath
No paradoximal movement on anterior left thorax
No spontaneous breaths due to sedation
Plan:
Recommendation
-continue nebulization
-Respiratory compensation done..ABG level improved.
-continue narcotic analgesics and nebulization to decrease the wheezing
-adjust the ventilator settings as per lung improvement..