Rachel Neale
NSG 640
Dr. Hartranft
October 23, 2022
Case Study 2
What is the likely pathophysiological process that is occurring with her leg?
The likely process that is occurring with her leg is a Deep Vein Thrombosis (DVT). Due
to her immobility and smoking history, she is at a high risk for poor perfusion in her extremities
and poor venous return (venous stasis), making it more likely to develop a thrombus. In addition,
the DVT is creating an inflammatory response in her leg, causing swelling and redness to occur.
The poor perfusion causes hair loss, which is why the skin has such a shiny, waxy appearance.
This DVT can occur at any time, but it can be triggered during certain times of
hypercoagulability (such as pregnancy which is not this case) or during times of increases stress
on the body, which could be in the case of infection/disease. If her likely pneumonia infection
could be considered trauma, she exhibits all three factors of the triad of Virchow: 1) venous
stasis from immobility, 2) venous intimal damage from trauma, and 3) hypercoagulable states
(from smoking) (page 1060). The Triad of Virchow places a patient at high likelihood of
developing a DVT.
Explain the pathophysiological events that occur with a fever and chills
The fever and chills reported by the patient are part of the inflammatory process, the
body’s response to an infection. In response to an antigen, mast cells by the endothelium release
a variety of inflammatory markers to signal WBCs to arrive at the antigen. The WBCs then
secrete IL-1 and TNF-alpha which produce the fever, creating a harsher environment for bacteria
and viruses to survive; the fever also increases the body’s metabolism (Murphy, 2017). The
chills are the body’s physical response to the fever via “involuntary muscle contractions that
occur in response to a sudden lowering of body temperature below the prevailing set point”
(Stanford, 1990).
What occurs from a pathophysiological standpoint to produce this patient’s sputum?
The sputum is yellow in color per the photograph due to an increase in white blood cells
in the lungs in response to a likely infection. The “rust” colored sputum report by the patient
sounds like old blood mixed with sputum, and is likely old red blood cells related to the infection
(Papanikolau & Tsenempi, 2020). Sputum is produced in an attempt by the pulmonary system to
rid itself of bacteria and antigens, and is propelled via the cough reflex.
Describe what your next steps are in managing this patient. Will she be discharged to
home, or the hospital? What are your next initial concerns for this patient?
This patient definitely needs to be sent to the hospital for further evaluation and testing,
especially to rule out the most life-threatening concerns. Due to her SOB and chest pain she will
need a cardiac work-up, though that likely is not the cause of all her symptoms. She will also
need further evaluation for pneumonia (prevent sepsis) and rule out a pulmonary embolism (due
to the DVT), placed on anticoagulants and monitored closely.
The next initial concerns for this patient would be ensuring adequate oxygen perfusion, as
93% is low for someone who has otherwise not been diagnosed with COPD or emphysema. In
addition, a person who smokes may have an imprecisely high oximetry reading, which means the
patient’s true oxygen saturation is likely lower than 93% (Fahy et al., 2011).
Discuss two areas of this case you would want to know more information about before
determining your plan of care.
I would like to know if she has been around anyone lately diagnosed with pneumonia, or
if she has had any episodes of aspiration. A diagnosis of pneumonia would be made more easily
if a known resident in the patient’s home had a case of pneumonia. And because she has a
diffuse area on the right side of her lungs, she may have aspirated some kind of food particle or
gastric contents that led to her pneumonia-the right lung is more likely to take in aspirated
contents. Finally, the assessment revealed wheezing and rhonchi on the right lower chest, another
symptom of possible aspiration.
Secondly, as the provider I would want to know what her current medication list is prior
to determining next steps-does she need to be on an anticoagulant or at the very least a daily
aspirin? Is her antihypertensive therapy adequate for her? Does she have any allergies that need
to be conveyed to the next provider such as an antibiotic?
References
Fahy, B., Lareau, S., Sockrider, M. (2011). Pulse Oximetry. American Thoracic Society, 184.
Murphy, Z. (2017, March 30). Immunology: Inflammation: Vascular Events: Part 1 [video].
Ninja Nerd [YouTube]. https://youtu.be/LArxUakFsFs
Papanikolaud, I.C., Tsenempi, X.A. (2020). Hunter’s Tropical Medicine and Emerging
Infectious Diseases (10th edition).
Stanford, D.L. (1990). Clinical Methods: The History, Physical, and Laboratory Examinations
(3rd edition).
