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1 Poornima Diwakaran c3253670 17 Poornima Diwakaran c3253670 Patient presentation Jeff Lyons is 58 years old, a cyclist, who was admitted to ED by wife at 5.30 am due to patient’s agitation, fatigued, severe flu-like symptoms and loss of appetite. One hour before coming to the hospital, around 4.30 am, the subject work up with feeling unwell, chills, agitated and disoraintated. Jeff had been bedridden for 5 days. The subject’s chest was sore from coughing up green phlegm. When coughing and had aches and pains in patient’s joints. Jeff was assessed, and the evaluated vital signs are RR 26, SpO2 94% on RA, BP 95/55 mmHg, HR 100 and T 38.5 ℃. The subject was on a low-fat diet, has a history of high cholesterol, family history of atherosclerosis and father died of MI. No flu vaccination. Jeff was admitted to the acute bed care in the red area of ICU, breathless and talking in broken sentences. Patient’s GCS was 14. Weight 62 kg and height is 183 cm tall. The subject was febrile of 38.5 C. Collect Cues A - E In ED Red area at 6.00 AM Normal range Airways Patient’s airway was patent. He was talking in broken sentences. No airway obstruction found. Normal speech (Chaparro, Parra & Upegui,2018). Breathing Chest wall movement observed to be abnormal (and unequal) and breathing was strenuous, using the accessory muscles as well, actively. He was having shortness of breath. Respiratory rate – 32 breaths per minute. SpO2 is 92%. The decreased entry of air in both the bases was observed. Equal chest wall movement, nil use of accessory muscle to breathe. No shortness of breath Normal RR 15-20 breaths/minute SpO2 95% to 100% (Chaparro, Parra & Upegui, 2018). Circulation Pulses were regular but weak. The capillary Refill rate was 3 seconds and the peripheries are cool to touch. Blood pressure 90/55. HR 115. The patient shows sinus tachycardia. Turgor decreased Nil peripheral or central cyanosis. Venous blood gas results are: PH 7.32, PCO2 42 mmHg pO2 25 mmHg Hb 148 g/l, K+ 4.3mmol/L. Na+ 143 mmol/L Gluc 10.0mmol/L, HCO3 28mmo/L, BE 2 mmol/L Lactate 3.2 mmol/L. 18guage cannula was inserted on the Right posterior forearm. Strong and regular pulses 60-100 bpm. CRT < 3 seconds blood pressure 120/80 mmhg no skin discolouration, warm peripheries. turgor normal. nil peripheral or central cyanosis. the standard values are : ph 7.32-7.42 pco2 41 – 51 mmhg, po2 is 30-40mmhg hb 130 to 180g/l k+ 3.5 to 5 mmol/l na+ 135 to 145mmol/l, gluc 4-10 mmol/l, hco3 24-28 mmo/l, be -2 to 3 mml/l lactate 0 to 2 mmo/l. (chaparro, parra & upegui, 2018). disability gcs 14 (orientation to place, not present) patient’s orientation to place is fluctuating during the examination as he seemed to be in acute confusion. bgl: 10.0 mmol/l. listlessness observed. the patient has moderate pain score of 4/10 when coughing. normal gcs is 15. in normal gcs scale response, the subject is oriented to place, time and person. glucose level 4-8mml/l is normal (chaparro, parra & upegui, 2018). pain score should be ( scale of 0 or no pain). exposure skin intact. skin turgor decreased. body temperature 38.6 °c. the skin should be intact (goucher et al., 2019). normal skin turgor temperature range should 36 –37°c (french, 2019). process information the patient had a fever with temperature varying from 38.5 to 38.6 c. as per the readings, the values signify mild to severe form of fever. the patient was admitted to the emergency department and after half an hour when the nurses checked patient’s temperature, it was found temperature had not reduced as it was still 38.6 c. the normal range is 36 –37 °c (wei et al., 2017). initially, the respiratory rate was found to be 26 breaths per minute. after taken to the red area of the ed, the rr recorded as 32 which meant the subject was hyperventilating due to anxiety, confusion and other issues as well. normal breathing rate ranges from 12 to 20 breath per minute. therefore the subject was suffering from severe respiratory distress. in the red area of an emergency department, the patient was having shortness of breath and the oxygen saturation of the patient was found be 92 per cent that is anormal ( normal po2 range is 30 to 40 mmhg). the patient’s heart rate was 100 during admission and later at 6 am, the heart rate was recorded as 115 as he has having severe sinus tachycardia in addition to shortness of breath (wei et al., 2017). the blood pressure of the subject on admission was 95/55 and on moving to the red area of the emergency department, patient’s blood pressure fell further and was 90/55. the subject has hypotension. the patient had a family history of atherosclerosis and it has been reported that patient’s father expired of myocardial infarction and it can be considered that the subject can have a predisposition for the cardiovacular problem and in fact, the patient has high cholesterol issue for which is having medications. it can be considered that the subject has hypertension too but patient is taking antihypertensives because of which patient’s blood pressure is revealed to be as fallen below the normal range as well (chandrasekhar et al., 2017). the subject has a history of present illness as flu-like symptoms that patient is suffering for five days and patient is having chills and cough because of which the subject is not being able to get up from the bed. the tachycardia can be caused due to two reason – firstly due to fever as the body tries to release the heat by increasing the heart rate, the respiratory rate and by increasing the skin circulation resulting in more perspiration and release of excessive heat from the body. secondly, hypotension is a reflex physiological response to tachycardia, which has happened in this case (urden et al. 2017). similarly, it was reported that the pulse of the patient was weak and during the nursing assessment, it was revealed that the capillary refilling was observed to be 3 seconds, which is slower than the normal (up to 2seconds). both the problems have arisen as because the patient has an underlying cardiovascular problem as the patient’s cholesterol levels, the history of a family having atheroscleosis and myocardial infraction and the current severe hypotension suggests. due to hypotension, there is a decrease in the vascular resistance to the blood blow, causing low pulse (lat 2018). the increased capillary refill time signifies poor tissue perfusion. it is to be critically noted that the patient was an avid competitive cyclist and was undergoing a cycling training of 80-100 of km for the last 5 months that has aggravated the subject’s cardiovascular symptoms and presented the current clinical situation (urden et al. 2017). from the venous blood gas analysis, three readings were found to be abnormal. firstly, the partial pressure of oxygen was found to be 25 mmhg while the normal level is 30 to 40mmhg which means that the patient is having less oxygenation due to shortness of breath but there are no signs of cyanosis. however, the glucose level is increased than the normal physiological range and this has caused hyperglycemia in the subject. when insulin is not produced or produced in very less amount, hyperglycemia results with the additional symptoms of rapid breathing, weak pulse and tachycardia as well (tran et al., 2018). the same has happened in this case. the high lactate level signifies anaerobic respiration and oxygen debt in his body as he has shortness of breath (collazo & smith 2020). moreover, the patient coughed out green sputum which means the patient has some form of lung infection that can cause sepsis, the heart rate can be increased and hypotension and hyperpyrexia are the common feature in sepsis(janakiraman & dellinger 2017). hence, there is a possibility that the patient is having a sepsis. the level of haemoglobin is less in number, which can be another cause of less oxygen circulation or low oxygen saturation rate in the blood(zimmerman et al., 2017). identify critical problems in this patient, three significant problems have been identified, such as respiratory distress, hypotension due to septic shock and fever and fever due to infection with pain. the patient also had a severe throat soreness, and was reported with green colouration in cough (singh et al., 2019). the patient has infections because of which he is suffering from fever and arthralgia due to fever. the patient suffers from respiratory infection as the patient had fever along with chest soreness and shortness of breathing. the high respiratory rate and heart rate and fever are due to the presenting sepsis. the respiratory disorders such as acute respiratory distress 3="" seconds="" blood="" pressure="" 120/80="" mmhg="" no="" skin="" discolouration,="" warm="" peripheries.="" turgor="" normal.="" nil="" peripheral="" or="" central="" cyanosis.="" the="" standard="" values="" are="" :="" ph="" 7.32-7.42="" pco2="" 41="" –="" 51="" mmhg,="" po2="" is="" 30-40mmhg="" hb="" 130="" to="" 180g/l="" k+="" 3.5="" to="" 5="" mmol/l="" na+="" 135="" to="" 145mmol/l,="" gluc="" 4-10="" mmol/l,="" hco3="" 24-28="" mmo/l,="" be="" -2="" to="" 3="" mml/l="" lactate="" 0="" to="" 2="" mmo/l.="" (chaparro,="" parra="" &="" upegui,="" 2018).="" disability="" gcs="" 14="" (orientation="" to="" place,="" not="" present)="" patient’s="" orientation="" to="" place="" is="" fluctuating="" during="" the="" examination="" as="" he="" seemed="" to="" be="" in="" acute="" confusion.="" bgl:="" 10.0="" mmol/l.="" listlessness="" observed.="" the="" patient="" has="" moderate="" pain="" score="" of="" 4/10="" when="" coughing.="" normal="" gcs="" is="" 15.="" in="" normal="" gcs="" scale="" response,="" the="" subject="" is="" oriented="" to="" place,="" time="" and="" person.="" glucose="" level="" 4-8mml/l="" is="" normal="" (chaparro,="" parra="" &="" upegui,="" 2018).="" pain="" score="" should="" be="" (="" scale="" of="" 0="" or="" no="" pain).="" exposure="" skin="" intact.="" skin="" turgor="" decreased.="" body="" temperature="" 38.6="" °c.="" the="" skin="" should="" be="" intact="" (goucher="" et="" al.,="" 2019).="" normal="" skin="" turgor="" temperature="" range="" should="" 36="" –37°c="" (french,="" 2019). ="" process="" information="" the="" patient="" had="" a="" fever="" with="" temperature="" varying="" from="" 38.5="" to="" 38.6="" c.="" as="" per="" the="" readings,="" the="" values="" signify="" mild="" to="" severe="" form="" of="" fever.="" the="" patient="" was="" admitted="" to="" the="" emergency="" department="" and="" after="" half="" an="" hour="" when="" the="" nurses="" checked="" patient’s="" temperature,="" it="" was="" found="" temperature="" had="" not="" reduced="" as="" it="" was="" still="" 38.6="" c.="" the="" normal="" range="" is="" 36="" –37="" °c="" (wei="" et="" al.,="" 2017).="" initially,="" the="" respiratory="" rate="" was="" found="" to="" be="" 26="" breaths="" per="" minute.="" after="" taken="" to="" the="" red="" area="" of="" the="" ed,="" the="" rr="" recorded="" as="" 32="" which="" meant="" the="" subject="" was="" hyperventilating="" due="" to="" anxiety,="" confusion="" and="" other="" issues="" as="" well.="" normal="" breathing="" rate="" ranges="" from="" 12="" to="" 20="" breath="" per="" minute.="" therefore="" the="" subject="" was="" suffering="" from="" severe="" respiratory="" distress.="" in="" the="" red="" area="" of="" an="" emergency="" department,="" the="" patient="" was="" having="" shortness="" of="" breath="" and="" the="" oxygen="" saturation="" of="" the="" patient="" was="" found="" be="" 92="" per="" cent="" that="" is="" anormal="" (="" normal="" po2="" range="" is="" 30="" to="" 40="" mmhg).="" the="" patient’s="" heart="" rate="" was="" 100="" during="" admission="" and="" later="" at="" 6="" am,="" the="" heart="" rate="" was="" recorded="" as="" 115="" as="" he="" has="" having="" severe="" sinus="" tachycardia="" in="" addition="" to="" shortness="" of="" breath="" (wei="" et="" al.,="" 2017).="" the="" blood="" pressure="" of="" the="" subject="" on="" admission="" was="" 95/55="" and="" on="" moving="" to="" the="" red="" area="" of="" the="" emergency="" department,="" patient’s="" blood="" pressure="" fell="" further="" and="" was="" 90/55.="" the="" subject="" has="" hypotension.="" the="" patient="" had="" a="" family="" history="" of="" atherosclerosis="" and="" it="" has="" been="" reported="" that="" patient’s="" father="" expired="" of="" myocardial="" infarction="" and="" it="" can="" be="" considered="" that="" the="" subject="" can="" have="" a="" predisposition="" for="" the="" cardiovacular="" problem="" and="" in="" fact,="" the="" patient="" has="" high="" cholesterol="" issue="" for="" which="" is="" having="" medications.="" it="" can="" be="" considered="" that="" the="" subject="" has="" hypertension="" too="" but="" patient="" is="" taking="" antihypertensives="" because="" of="" which="" patient’s="" blood="" pressure="" is="" revealed="" to="" be="" as="" fallen="" below="" the="" normal="" range="" as="" well="" (chandrasekhar="" et="" al.,="" 2017).="" the="" subject="" has="" a="" history="" of="" present="" illness="" as="" flu-like="" symptoms="" that="" patient="" is="" suffering="" for="" five="" days="" and="" patient="" is="" having="" chills="" and="" cough="" because="" of="" which="" the="" subject="" is="" not="" being="" able="" to="" get="" up="" from="" the="" bed.="" the="" tachycardia="" can="" be="" caused="" due="" to="" two="" reason="" –="" firstly="" due="" to="" fever="" as="" the="" body="" tries="" to="" release="" the="" heat="" by="" increasing="" the="" heart="" rate,="" the="" respiratory="" rate="" and="" by="" increasing="" the="" skin="" circulation="" resulting="" in="" more="" perspiration="" and="" release="" of="" excessive="" heat="" from="" the="" body.="" secondly,="" hypotension="" is="" a="" reflex="" physiological="" response="" to="" tachycardia,="" which="" has="" happened="" in="" this="" case="" (urden="" et="" al.="" 2017).="" similarly,="" it="" was="" reported="" that="" the="" pulse="" of="" the="" patient="" was="" weak="" and="" during="" the="" nursing="" assessment,="" it="" was="" revealed="" that="" the="" capillary="" refilling="" was="" observed="" to="" be="" 3="" seconds,="" which="" is="" slower="" than="" the="" normal="" (up="" to="" 2seconds).="" both="" the="" problems="" have="" arisen="" as="" because="" the="" patient="" has="" an="" underlying="" cardiovascular="" problem="" as="" the="" patient’s="" cholesterol="" levels,="" the="" history="" of="" a="" family="" having="" atheroscleosis="" and="" myocardial="" infraction="" and="" the="" current="" severe="" hypotension="" suggests.="" due="" to="" hypotension,="" there="" is="" a="" decrease="" in="" the="" vascular="" resistance="" to="" the="" blood="" blow,="" causing="" low="" pulse="" (lat="" 2018).="" the="" increased="" capillary="" refill="" time="" signifies="" poor="" tissue="" perfusion.="" it="" is="" to="" be="" critically="" noted="" that="" the="" patient="" was="" an="" avid="" competitive="" cyclist="" and="" was="" undergoing="" a="" cycling="" training="" of="" 80-100="" of="" km="" for="" the="" last="" 5="" months="" that="" has="" aggravated="" the="" subject’s="" cardiovascular="" symptoms="" and="" presented="" the="" current="" clinical="" situation="" (urden="" et="" al.="" 2017).="" from="" the="" venous="" blood="" gas="" analysis,="" three="" readings="" were="" found="" to="" be="" abnormal.="" firstly,="" the="" partial="" pressure="" of="" oxygen="" was="" found="" to="" be="" 25="" mmhg="" while="" the="" normal="" level="" is="" 30="" to="" 40mmhg="" which="" means="" that="" the="" patient="" is="" having="" less="" oxygenation="" due="" to="" shortness="" of="" breath="" but="" there="" are="" no="" signs="" of="" cyanosis.="" however,="" the="" glucose="" level="" is="" increased="" than="" the="" normal="" physiological="" range="" and="" this="" has="" caused="" hyperglycemia="" in="" the="" subject.="" when="" insulin="" is="" not="" produced="" or="" produced="" in="" very="" less="" amount,="" hyperglycemia="" results="" with="" the="" additional="" symptoms="" of="" rapid="" breathing,="" weak="" pulse="" and="" tachycardia="" as="" well="" (tran="" et="" al.,="" 2018).="" the="" same="" has="" happened="" in="" this="" case.="" the="" high="" lactate="" level="" signifies="" anaerobic="" respiration="" and="" oxygen="" debt="" in="" his="" body="" as="" he="" has="" shortness="" of="" breath="" (collazo="" &="" smith="" 2020).="" moreover,="" the="" patient="" coughed="" out="" green="" sputum="" which="" means="" the="" patient="" has="" some="" form="" of="" lung="" infection="" that="" can="" cause="" sepsis,="" the="" heart="" rate="" can="" be="" increased="" and="" hypotension="" and="" hyperpyrexia="" are="" the="" common="" feature="" in="" sepsis(janakiraman="" &="" dellinger="" 2017).="" hence,="" there="" is="" a="" possibility="" that="" the="" patient="" is="" having="" a="" sepsis.="" the="" level="" of="" haemoglobin="" is="" less="" in="" number,="" which="" can="" be="" another="" cause="" of="" less="" oxygen="" circulation="" or="" low="" oxygen="" saturation="" rate="" in="" the="" blood(zimmerman="" et="" al.,="" 2017).="" identify="" critical="" problems="" in="" this="" patient,="" three="" significant="" problems="" have="" been="" identified,="" such="" as="" respiratory="" distress,="" hypotension="" due="" to="" septic="" shock="" and="" fever="" and="" fever="" due="" to="" infection="" with="" pain.="" the="" patient="" also="" had="" a="" severe="" throat="" soreness,="" and="" was="" reported="" with="" green="" colouration="" in="" cough="" (singh="" et="" al.,="" 2019).="" the="" patient="" has="" infections="" because="" of="" which="" he="" is="" suffering="" from="" fever="" and="" arthralgia="" due="" to="" fever.="" the="" patient="" suffers="" from="" respiratory="" infection="" as="" the="" patient="" had="" fever="" along="" with="" chest="" soreness="" and="" shortness="" of="" breathing.="" the="" high="" respiratory="" rate="" and="" heart="" rate="" and="" fever="" are="" due="" to="" the="" presenting="" sepsis.="" the="" respiratory="" disorders="" such="" as="" acute="" respiratory="">