Interprofessional Approach to Acute Care of

Matthew Igbinigie SOM, Tracey Isidro SOM, Ennert Manyeza SHP, Kathryn Laskowski SOM,
UT Medical Branch at
Scenario:

Galveston

Mr. Smith is a 65 year old Caucasian male

who presents to the ER with complaints
of cough and difficulty breathing. He
appears confused and unkempt and
reports being homeless. Mr. Smith also
reports a 4 pack per day smoking history
for 20 years. He also reports that he is
not currently taking any prescriptions or
OTC medications. Upon initial
Legend:
Interprofessional
Workassessment, the following
findings
Physicianwere
= Green
Registered Nurse =
noted.
Up
Red
Registration:
Respiratory
Register Pt in the system with identifying
Therapist information
= Blue
and insurance
Check-in Pt, take vitals and initial HPI

Initial Evaluation:
Take HPI and perform Physical Exam.
Put orders in for diagnostic studies/ medications:
CXR for pneumonia
Culture confirm diagnosis and cause of
pneumonia
Blood gas, BMP, and BNP levels
Place order to call respiratory - Pt is
hypoventilating since Pt is hypoxemic (Sat
78%) and hypercapneic (PCO2 = 55 mEq/L)

Physical Exam:
Temp 101.2 F
(Oral)
RR 24 breaths/min

Pulse 110/min
BP 80/68
SPO2 78% on room air

Head and Neck: Alert but disoriented x3. PERRLA. Cyanotic

conjunctiva. JVD.
Respiratory: Tachypnea. Labored breathing w/ retractions.
Tripod position. Bibasilar crackles and wheezes. Productive
cough w/ rust colored sputum.
Cardiovascular: Tachycardic w/ regular rate and rhythm. S3
gallop. Displaced PMI. 1+ peripheral pulses bilaterally in all
extremities. Capillary refill >2 sec bilaterally. Cyanosis and
clubbing of the fingers and toes bilaterally.

Monique Saleh SHP

Quandary:
How will an interprofessional team work
together to improve outcomes for this patient?
Pt. Management:
Meds administered, blood drawn, nasal cannula placed, respiratory
therapy paged
CXR performed by Tech.
Culture and labs performed by CLS personnel; confirms Strep.
pneumoniae.
Consult w/ CLS and Infectious Disease team for proper ABX S.
pneumoniae treatment.
Assess pt. Goal of therapy is to improve patients dyspnea and SpO2
and to prevent respiratory failure.
Assess appropriateness of the O2 being delivered at 2LPM via
nasal cannula:
Pt. appears to fit a clinical picture of COPDemphysema, as indicated by the SOB, dyspnea,
tripod breathing position, peripheral cyanosis, and
mental incoherence.
Monitor pt to ensure sats are improving on this L flow (goal of
SpO2 88%-92%, assuming patient has COPD). If not, increase
L flow on NC until max 6LPM is reached. If still no
improvement consider high-flow venturi mask at 40% FiO2.
Suggest administration of Albuterol 2.5mg QID via a small
volume nebulizer, and/or in combination with a short-acting
Ach, such as atrovent. Together these are called Combivent/
duoneb, to help relieve patients work of breathing and
wheezing caused by bronchoconstriction.
If symptoms persist/worsen, consider adding a long
acting -2 agonist/long acting Musc. antagonist, such
as Brovana or Spiriva.
Place order for medications suggested by respiratory
therapist.
Continue to monitor the patient by performing ABGs at
regular intervals.
Encourage Pt to stop smoking, suggesting a smoking
Labs
cessation program.
Na+ 145mEq/L
K+ 4.0mEq/L Cl 100mEq/L
Ca2+ - 9.0mg/dL BUN 25ng/dL Creat 2.0mg/dL
pH 7.34 PCO2 55mmHg HCO3 29mEq/L
pO2 55mmHg Hgb 13.0u/L Hct 35%
BNP 300pg/mL

Assessment:
Evaluate labs, vitals and physical exam - devise a
differential diagnosis:
BNP is elevated at 300 pg/mL: possible heart
failure
Pt is hypotensive at 80/68 mmHg and
tachycardic at 110 bpm. Possible causes are
bacteremia or sepsis.
Assess renal function: BUN elevated at 25
ng/dL and Cr elevated at 2.0 mg/dL
Pt is hypernatremic: Place order for IV fluids
Place IV line and give fluids
Encourage Pt to stop smoking; Explain the reason
why he should stop smoking i.e. smoking can
cause lung cancer, can decrease the bodys
mucociliary escalator, and increase risk of
pneumonia
Explain to the Pt the reason why he should stop
drinking possible cause of his enlarged liver
i.e. can cause cirrhosis, liver cancer

Disposition:
Maintain open communication with other
health professionals to ensure constant care
and accurate and updated information.
Admit patient for (+) Strep Pneumo, and
further evaluation of sepsis, CHF, and kidney
failure.
Once patients breathing is stable without
assistance, and If no prior medical history is
available, consider having patient undergo
spirometry-> this will indicate the presence of
an obstructive/restrictive defect, the severity,
and if bronchodilator therapy will have a
positive effect in the future.