case study patient with copd
TRANSCRIPT
![Page 1: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/1.jpg)
Case study patient with COPDBY NAWAL GALET
![Page 2: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/2.jpg)
INFORMATION THE PATIENT:
JS is a 74 year old man who presents to your family medicine office with his wife complaining of shortness of breath and fever. They just moved to the area and had been planning to come to your office next week to establish care as new patients.
Due to the onset of symptoms, JS called and was given a walk-in slot today. His wife did bring records from his last physician’s office.
![Page 3: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/3.jpg)
HISTORY OF PATIENT:Past Medical/Surgical History
Heart failure following myocardial infarction at age 68 years
COPD (on 2 L home oxygen) Hypertension Appendectomy
Family History Father died of myocardial infarction at age
59 years (diabetes, hypertension, smoker) Mother alive (atrial fibrillation, heart failure) Healthy siblings
![Page 4: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/4.jpg)
CONT… Social History
Married, 3 children 30 pack year smoking history (quit after MI) Worked on a farm No alcohol or illicit drug use
Medications / Allergies Lisinopril 20 mg twice daily Metoprolol 50 mg twice daily Spironolactone 25 mg daily Furosemide 40 mg daily Salmeterol/fluticasone 50/500 dry powdered inhaler (DPI) one puff
inhaled twice daily Tiotropium DPI one cap inhaled daily Albuterol/ipratropium metered dose inhaler (MDI) or solution for
nebulization every 6 hours as needed Levalbuterol MDI two puffs every 4 to 6 hours as needed Home oxygen
![Page 5: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/5.jpg)
CONT..He is confused about what to use when,
so you are not sure which medications he actually takes.
No known allergies JS Past Record Review (brought by wife)
Echocardiogram with EF of 25%Spirometry with FEV1 35% predicted that
does not change significantly after inhaled bronchodilator
![Page 6: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/6.jpg)
CONT…Records ReviewUnable to determine when last pneumoccal vaccine was givenPatient and wife don’t recall “a
pneumonia shot”Does know he got his “flu shot” last
month at a grocery store
![Page 7: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/7.jpg)
patient symptoms include the following:
JS current symptoms include the following: Unable to speak in full sentences for the past several hours per
wife Cough productive but unknown color of sputum Audible wheezing since last night per wife Mild chest tightness Dyspnea
His wife has noted no change in his alertness or mental status When you inquire, the wife states that JS usually has a cough,
worse in the morning, productive of gray sputum, gets short of breath if he walks more then 10 feet, and has episodes of wheezing if he gets sick (e.g. with an upper respiratory infection).
He usually is able to help around the house with light work and fixing things.
![Page 8: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/8.jpg)
Physical examination Physical examination
Vital Signs: BP 128/74; P 68, reg; RR 32; Ht 5ft 6 in; Wt 122 lbs; T 101.5 °F oral
Unable to speak in full sentences, audible wheezing, alert and oriented
Pertinent positives: General: audible wheezing, no accessory muscle
use Nails: tar stains, clubbing Chest: increased anteroposterior (AP) diameter;
diffuse wheezing to auscultation Heart: regular, no murmurs
![Page 9: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/9.jpg)
Study resultsStudy results
Pulse oximetry 86%Chest x-ray shows hyperinflation and
right lower lobe pneumoniaYou continue his heart failure
medications as per his home regimenNo need to discontinue the
cardioselective beta-blocker
![Page 10: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/10.jpg)
You proceed to record the You proceed to record the patient’s observations patient’s observations
ABG Normal Range Other bloods Normal Range PH 7.236 7.35-7.45 Digoxin Level 0.5 1.0-2.0
nmol/L PO2 4.7 11-15 kPa PCO2 8 4.6-6 kPa HCO3 30.0 22-26 BE +5 -2.4-+2.3 SaO2 70 95-98% Glucose 10.0 3.7-5.2
![Page 11: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/11.jpg)
Factors that increase risk of severe COPD exacerbations Altered mental status At least three exacerbations in the previous 12 months Body mass index of 20 kg per m2 or less Marked increase in symptoms or change in vital signs Medical comorbidities (especially cardiac ischemia, heart
failure, pneumonia, diabetes mellitus, or renal or hepatic failure)
Poor physical activity levels Poor social support Severe baseline COPD (FEV1/FVC ratio less than 0.70 and
FEV1 less than 50 percent of predicted) Underutilization of home oxygen therapy
![Page 12: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/12.jpg)
CONT…Based on this information, JS has the
following clinical factors that increase his risk of a severe COPD exacerbation:Marked increase in symptoms and
change in his vital signs including a low oxygen saturation
a new medical co-morbidity of pneumonia
all combined with his severe baseline COPD
![Page 13: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/13.jpg)
So will you treat JS as an outpatient or inpatient?
Indications for hospitalizationRisk of death from an exacerbation
increases with:Development of respiratory acidosisPresence of significant comorbidities,Need for ventilatory support
![Page 14: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/14.jpg)
History of Exacerbations
Upon questioning his wife, you find out that he has had 5 exacerbations in the past year, three of which were treated with antibiotics and oral steroids
Amoxicillin x2 courses, doxycycline x1 course Most recent course 6 weeks ago No hospitalizations within the last 6 months
Based on this information, and his chest x-ray findings, you initiate treatment for community acquired pneumonia.
![Page 15: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/15.jpg)
Preparation for dischargeOver 3 days, JS has significantly improved
and has weaned back to his home oxygen regimen.
He is taking the albuterol/ipratropium nebulized treatments every 6 hours, and is ready to switch back to bronchodilators via inhaler device.
Along with antibiotics for a total of 7 days, you need to determine the dose and duration of treatment for oral corticosteroids.
![Page 16: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/16.jpg)
Preparing for dischargeIn completing the medication
reconciliation forms, you see that JS had a complex medication regimen upon admission
It is clear, during discussions with him, that he is unable to comply with this expensive, complex and potentially unnecessary regimen.
![Page 17: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/17.jpg)
Medications on admission Lisinopril 20 mg twice daily Metoprolol 50 mg twice daily Spironolactone 25 mg daily Furosemide 40 mg daily Salmeterol/fluticasone 50/500 dry powdered inhaler
(DPI) one puff inhaled twice daily Tiotropium DPI one cap inhaled daily Albuterol/ipratropium metered dose inhaler (MDI)
or solution for nebulization every 6 hours as needed
Levalbuterol MDI two puffs every 4 to 6 hours as needed
![Page 18: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/18.jpg)
Discharge Medications
Streamline regimenNo need for levalbuterolContinue salmeterol/fluticasone 50/500
DPI and/or tiotropium DPIShort-acting bronchodilator MDI as
neededPatient given pneumococcal vaccine
prior to discharge
![Page 19: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/19.jpg)
DIFNATION: Chronic obstructive pulmonary disease is a disease characterized by airflow limitation that is not fully reversible.
![Page 20: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/20.jpg)
ANTOMY OF LUNG:
![Page 21: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/21.jpg)
PHYSIOLOGY:In COPD, the airflow limitation is both progressive
and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.
The inflammatory response occurs throughoutthe airways, parenchyma, and pulmonary vasculatureBecause of the chronic inflammation and the body’s attemptsto repair it, narrowing occurs in the small peripheral airways.Over time, this injury-and-repair process causes scar
tissue formation and narrowing of the airway lumen. Airflow obstruction may also be due to parenchymal
destruction as seen
![Page 22: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/22.jpg)
ETIOLOGY/CAUSES:IN THE PATIENT IN THE BOOK
THICKENENG OF AIRWAY WALL THICKENENG OF AIRWAY WALL
PERIBRONCHIAL FIBROSIS PERIBRONCHIAL FIBROSIS
EXUDATE IN THE AIRWAY EXUDATE IN THE AIRWAY
SMOKING OVERAL AIRWAY NARROWING(OBSTRUCTIVE BRONCHIOLITIS)
AMBIENT AIR POLLUTIO THINCKENING OF THE LINING OF THE VESSEL AND HYPERTOPHY OF SMOOTH MUSCLESMOKING
AMBIENT AIR POLLUTIO
![Page 23: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/23.jpg)
Pathophysiology the airflow limitation is both progressive and associatedwith an abnormal inflammatory response of the lungs to
noxious particles or gases. The inflammatory response occurs throughoutthe airways, parenchyma, and pulmonary vasculature Because of the chronic inflammation and the body’s
attempts to repair it, narrowing occurs in the small peripheral airways.
Over time, this injury-and-repair process causes scar tissueformation and narrowing of the airway lumen. Airflow obstruction may also be due to parenchymal
destruction as seen
![Page 24: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/24.jpg)
SIGNS & SYMPTOMS:
In book and in patient:1. chronic cough2. sputum production3. dyspnea on exertion4. Weight loss is common
![Page 25: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/25.jpg)
Complications: respiratory failure Respiratory insufficiency and failure may be chronic
(with severe COPD) or acute (with severe
bronchospasm or pneumonia in the patient with severe
COPD. Acute respiratory insufficiency and failure may necessitate ventilatory
support until other acute complications, such as infection, can be
treated.
![Page 26: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/26.jpg)
HEALTH EDUCTION:Promoting Home- and Community-Based CareTeaching Patients Self-CareProvide instructions about self-management;
assess the knowledge of patients and family members about self-care and the therapeutic regimen.
Teach patients and family members early signs and symptoms of infection and other complications so that they seek appropriate health care promptly.
Instruct patient to avoid extremes of heat and cold and air pollutants (eg, fumes, smoke, dust, talcum, lint, and aerosol sprays). High altitudes aggravate hypoxemia.
![Page 27: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/27.jpg)
CONT…pollutants (eg, fumes, smoke, dust,
talcum, lint, and aerosol sprays). High altitudes aggravate hypoxemia.
Encourage patient to adopt a lifestyle of moderate activity
ideally in a climate with minimal shifts in temperature and humidity; patient should avoid emotional disturbances and stressful situations; patient should be encouraged to stop smoking.
![Page 28: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/28.jpg)
CONT..Review educational information and
have patient demonstrate correct metered-dose inhaler (MDI) use before discharge, during follow-up visits, and during home visits.
![Page 29: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/29.jpg)
CONT...Continuing Care
Refer patient for home care if necessary.
Direct the patient to community resources (eg, pulmonary rehabilitation programs and smoking cessation programs); remind the patient and family about the importance of participating
in general health promotion activities and health screening.
![Page 30: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/30.jpg)
Nursing ManagementThe nurse plays a key role in identifying potential
candidates for pulmonary rehabilitation and in facilitating and reinforcing the material learned in the rehabilitation program.
PATIENT EDUCATIONBreathing Exercises.Inspiratory Muscle Training.Activity Pacing.Self-Care Activities.Physical Conditioning.Oxygen Therapy.Nutritional Therapy.Coping Measures.
![Page 31: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/31.jpg)
CONT…Achieving Airway Clearance Monitor the patient for dyspnea and hypoxemia. If bronchodilators or corticosteroids are prescribed, administerthe medications properly and be alert for potential sideeffects. Confirm relief of bronchospasm by measuring improvementin expiratory flow rates and volumes (the force of expiration,how long it takes to exhale, and the amount of airexhaled) as well as by assessing the dyspnea and making surethat it has lessened. Encourage patient to eliminate or reduce all pulmonary irritants,particularly cigarette smoking. Instruct the patient in directed or controlled coughing. Chest physiotherapy with postural drainage, intermittentpositive-pressure breathing, increased fluid intake, and blandaerosol mists (with normal saline solution or water) may beuseful for some patients with COPD.
![Page 32: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/32.jpg)
CONT…Improving Breathing Patterns Inspiratory muscle training and breathing retraining
may help improve breathing patterns.
Training in diaphragmatic breathing reduces the
respiratory rate, increases alveolar ventilation, and
sometimes helps expel as much air as possible
during expiration. Pursed-lip breathing helps slow expiration, prevent
collapse of small airways, and control the rate and depth of respiration; it also promotes relaxation.
![Page 33: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/33.jpg)
CONT…Improving Activity Tolerance Evaluate the patient’s activity tolerance and limitations
anduse teaching strategies to promote independent activities ofdaily living. Determine if patient is a candidate for exercise training
tostrengthen the muscles of the upper and lower extremitiesand to improve exercise tolerance and endurance. Recommend use of walking aids, if appropriate, to
improveactivity levels and ambulation. Consult with other health care professionals
(rehabilitationtherapist, occupational therapist, physical therapist) asneeded.
![Page 34: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/34.jpg)
Monitoring and Managing Complications
Assess patient for complications (respiratory insufficiency
and failure, respiratory infection, and atelectasis). Monitor for cognitive changes, increasing dyspnea,
tachypnea,and tachycardia. Monitor pulse oximetry values and administer oxygen
asprescribed. Instruct patient and family about signs and symptoms
ofinfection or other complications and to report changes inphysical or cognitive status. Encourage patient to be immunized against influenza
andStreptococcus pneumonia.
![Page 35: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/35.jpg)
CONT…Caution patient to avoid going
outdoors if the pollen count is high or if there is significant air pollution and to avoid exposure to high outdoor temperatures with high humidity.
If a rapid onset of shortness of breath occurs, quickly evaluate the patient for potential pneumothorax by assessing the symmetry of chest movement, differences in breath sounds, and pulse oximetry.
![Page 36: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/36.jpg)
Promoting Rest:Position bed for maximal respiratory efficiency; provide oxygen if needed.
Initiate efforts to prevent respiratory, circulatory, and vascular disturbances.
Encourage patient to increase activity gradually and plan rest with activity and mild exercise.
![Page 37: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/37.jpg)
Improving Nutritional Status:Provide a nutritious, high-protein diet
supplemented by Bcomplex vitamins and others, including A, C, and K.
Encourage patient to eat: Provide small, frequent meals, consider patient preferences, and provide protein supplements, if indicated.
Provide nutrients by feeding tube or total PN if needed.
![Page 38: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/38.jpg)
Cont…Provide patients who have fatty stools
(steatorrhea) with water-soluble forms of fat-soluble vitamins A, D, and E, and give folic acid and iron to prevent anemia.
Provide a low-protein diet temporarily if patient shows signs of impending or advancing coma; restrict sodium if needed.
![Page 39: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/39.jpg)
Providing Skin Care:Change patient’s position frequently.Avoid using irritating soaps and adhesive tape. Provide lotion to soothe irritated skin; take measures to prevent patient from scratching the skin.
![Page 40: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/40.jpg)
Reducing Risk of Injury:Use padded side rails if patient becomes agitated or restless.
Orient to time, place, and procedures to minimize agitation.
Instruct patient to ask for assistance to get out of bed.
Carefully evaluate any injury because of the possibility of internal bleeding.
![Page 41: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/41.jpg)
Cont…Provide safety measures to prevent injury or cuts (electricrazor, soft toothbrush).
Apply pressure to venipuncture sites to minimize bleeding.
![Page 42: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/42.jpg)
Cont…Administer oxygen if oxygen desaturation
occurs; monitor for fever or abdominal pain, which may signal the onset of bacterial peritonitis or other infection.
Assess cardiovascular and respiratory status; administer diuretics, implement fluid restrictions, and enhance patient positioning, if needed.
![Page 43: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/43.jpg)
Monitoring and Managing Complications: Monitor for bleeding and
hemorrhage. Monitor the patient’s mental status
closely and report changes so that treatment of encephalopathy can be initiated promptly.
Carefully monitor serum electrolyte levels are and correct if abnormal.
![Page 44: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/44.jpg)
Cont…Administer oxygen if oxygen
desaturation occurs; monitor for fever or abdominal pain, which may signal the onset of bacterial peritonitis or other infection.
Assess cardiovascular and respiratory status; administer diuretics, implement fluid restrictions, and enhance patient positioning, if needed.
![Page 45: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/45.jpg)
Cont… Monitor intake and output, daily
weight changes, changes in abdominal girth, and edema formation.
Monitor for nocturia and, later, for oliguria, because these states indicate increasing severity of liver dysfunction.
![Page 46: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/46.jpg)
NURSING CARE PLAN
![Page 47: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/47.jpg)
![Page 48: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/48.jpg)
![Page 49: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/49.jpg)
![Page 50: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/50.jpg)
![Page 51: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/51.jpg)
![Page 52: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/52.jpg)
![Page 53: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/53.jpg)
REFERENCES:Brunner and Suddarth's
Textbook of Medical-Surgical Nursing, 12th Edition-Suzann
CHAPTER 24PAGE 601 TO 620
![Page 54: Case study patient with copd](https://reader036.vdocuments.site/reader036/viewer/2022062316/5873390f1a28abf21b8b505d/html5/thumbnails/54.jpg)
THANK YOU