Case Study, Chapter 21, Assessment of Respiratory Function

Objective: 4

John April is 24 years oI age and is a male patient who was admitted to the surgical unit
aIter a successIul repair oI an inguinal hernia. He is 5 Ieet 10 inches tall and weighs 120
kg. He has a neck circumIerence oI 21 inches. The patient has meperidine (Demerol) 100
mg IM every 6 hours Ior pain, as ordered. He has no known drug allergies. The vital
signs are as Iollows: BP 122/70, R 26, P 88, and T 98.6F. The patient complains oI
incision pain and rates it on the pain scale as 7 out oI 10. His Iamily is visiting at the
bedside. One-halI hour aIter administering the pain medication, a Iamily member enters
the hallway and yells, 'We need help in here! John is not breathing. The nurse Iinds
John having periods oI apnea lasting a Iew seconds Iollowed by a short snorting gasp and
then he begins breathing at a rate oI 12 breaths per minute. His lips are bluish in
coloration and so are his nail beds. The patient is lying supine in the bed. He awakens as
the nurse enters, but is very lethargic and somnolent.

Which assessment parameters are appropriate to determine the characteristics and
severity of the symptoms that the patient is exhibiting?
The weight oI the patient: 120 kg
Neck circumIerence oI 21 inches
Used oI meperidine Ior pain
Pain scale oI 7/10
RR oI 26 - APNEA
SKIN AND NAIL COLOR, NEURO V/S LETHARGIC,


Which nursing interventions should the nurse institute? Which intervention must be
provided immediately?
Administer oxygen.
Take the ECG tracing.
Mechanical ventilate the patient. AND HOOK TO MECHANICAL VENTILATOR
Give antibiotics iI ever the patient has inIection
Give steroids

GIVE THE ANTEDOTE FOR THE PAIN MEDICATION INTOXICATION, FLUID
BOLUS TO INCREASE SPEED OF ELIMINATION OF MEDICATION,
HYPERVENTILATE THEN INTUBATION.


Explain the possible reasons for the patient`s sudden decline in the respiratory
status.
Because oI the pain that the patient experience and maybe the misused oI meperidine
because it is an opiod, it can cause depression oI the CNS AND RESPIRATION that`s
why the experience periods oI apnea. Maybe the patient has inIection because oI the
incision site. Or maybe because oI the traumatized tissue.???