Case study patient with COPDBY NAWAL GALET

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.

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

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

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

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

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.

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

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

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

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

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

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

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.

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.

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.

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

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

DIFNATION: Chronic obstructive pulmonary disease is a disease characterized by airflow limitation that is not fully reversible.

ANTOMY OF LUNG:

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

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

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

SIGNS & SYMPTOMS:

In book and in patient:1. chronic cough2. sputum production3. dyspnea on exertion4. Weight loss is common

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.

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.

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.

CONT..Review educational information and

have patient demonstrate correct metered-dose inhaler (MDI) use before discharge, during follow-up visits, and during home visits.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Cont…Provide safety measures to prevent injury or cuts (electricrazor, soft toothbrush).

Apply pressure to venipuncture sites to minimize bleeding.

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.

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.

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.

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.

NURSING CARE PLAN

REFERENCES:Brunner and Suddarth's

Textbook of Medical-Surgical Nursing, 12th Edition-Suzann

CHAPTER 24PAGE 601 TO 620

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