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Chronic Obstructive Pulmonary Disease
Mia Palencia
Abby Sengco
Vanessa Roman
Hannah Knapp
Medical Surgery Case Study
COPD
D.B. is a 63-year-old electrician who comes to the emergency department complaining of shortness of breath, difficulty exhaling, morning cough, and swelling in his lower extremities.
SUBJECTIVE DATA
- Has smoked one pack of cigarettes daily for over 30 years
- Has difficulty breathing when he walks
- Has been sleeping in a recliner to make it easier to breathe
- His shoes are tight at the end of the day
OBJECTIVE DATA
Physical Examination
Blood pressure 125/90, pulse 90, temperature 98.4° F, respirations 32
Increased anterior-posterior diameter
Breath sounds diminished with prolonged expiration
2+ peripheral edema bilateral lower extremities
Thin with muscle wasting
Respirations labored
Diagnostic Studies
Arterial blood gases: pH 7.32, SaO2 86%, PaCO2 55 mm Hg, PaO2 70 mm Hg
Chest x-ray shows hyperinflation of lungs
FEV1 65%
SIGNS AND SYMPTOMS
- Short of Breath
- Wheezing
- Dry cough
- Produce phlegm (colorless, white)
- Chest tightness
- Frequent respiratory
- Swelling in ankles, feet, legs
- Tachypnea
- Cyanosis
- Course crackles with inhalation
- Prolonged exhalations
- Diffuse breath sounds
PATHOLOGY
Cellular and Tissue Changes
Cellular and Tissue Changes
- Inhalation of noxious gases or particles such as cigarette smoking triggers the inflammatory process.
- Inflammatory cells are introduced such as eosinophils, mast cell, neutrophils, lymphocytes, and macrophages causing the inflammation of central airways.
- Oxidants (contained in tobacco) inhibit antiproteases and increases proteases.
- Destroys parenchyma of the lungs preventing elastic recoil of the alveoli.
- Inability to expire CO2. Residual air becomes greatly increased, air is trapped in lungs, chest hyper-expands.
- Inhibiting antiproteases also increases mucus production and fluid in the lungs.
- Bronchioles loose shape from becoming clogged with mucus.
- Cilia does no function properly.
- Due to the lack of oxygen, there is vasoconstriction in the small pulmonary arteries.
- Vascular smooth muscle thickens increasing the pressure in the pulmonary artery.
- Result in pulmonary hypertension and underlying potential risk for cardiovascular problems.
DIAGNOSTIC STUDIES
DIAGNOSTIC STUDIES
Spirometry
Spirometry
Patient has a score of FEV1 65%
FEV- 65%: MODERATE classification of COPD based on post bronchodilator FEV
COPD can be classified based on a FEV/FEV ratio less than 70%.
COPD STAGE CLASSIFICATION CHART
- Spirometry is required to confirm COPD diagnosis
- determines if there is a presence of airflow obstruction and the severity of the disease
- Pt is given a short acting bronchodialator.
- Post bronchodialator values are compared with normal reference to diagnosis of COPD
- Diagnosis is made when ratio is <70%
Arterial Blood Gas
PT Values
Normal Values
Arterial Blood Gas
Normal pH (7.35-7.45)
Sa02: >95%
PaCO2: (35-45mmHg)
PaO2: (80-100mmHg)
pH 7.32,
SaO2 86%,
PaCO2 55mm Hg, PaO2 70mm Hg
D.B. is in Respiratory Acidosis due to his high PaCO2 level and a low pH. Patient is experiencing hyperventilation thus, oxygen levels are low.
Chest X Ray
Chest X Ray
anteroposterior diameter of chest may be increased, "barrel chest"
Hyperinflated lungs occur when air gets stuck in lungs and causes them to overinflate
largely seen in people with COPD, asthma, and cystic fibrosis
X-RAY Results of Case Study Patient: Hyper-inflation
Mere X-Ray cannot sufficently diagnose COPD
Figure above shows an image of a hyperinflated lung and a flat diaphram
COMPLICATIONS
COPD COMPLICATIONS:
- Cor pulmonale (Right sided Heart Failure)
- Acute exacerbations
- Acute respiratory failure.
COMPLICATIONS
hinted by edema in ankles found on physical assessment.
2+ peripheral edema bilateral lower extremities
His shoes are “tight” at the end of the day
NURSING DIAGNOSIS
Ineffective breathing pattern related to SOB as evidence by labored respirations
GOAL: D.B. will be able to maintain a regular breathing pattern.
NURSING DIAGNOSIS
Interventions
1. encourage the use of incentive spirometer, slow inhalation and prolong exhalation to develope sustained breaths
2. Encourage diaphragmatic breathing
3. Place pt. with proper body alignment for max breathing pattern
4. Avoid high concentration levels of oxygen
5. Encourage ambulation
Evaluation:
1. D.B. demonstrates effective breathing pattern's when performing ADLs.
2. D.B.'s ABG levels returned within established limits, performs diaphragmatic, and pursed-lip breathing.
NURSING INTERVENTION
1. Encourage abdominal or pursed-lip breathing exercises
rationale: will reduce D.B.’s hyperinflation, and significantly improve his walking tolerance, breathing patterns, and arterial oxygen.
2. Teach effective huff coughing
rationale: an effective forced expiratory technique that brings out the secretions to the central airway to exporatate and allows patient to develope effective breathing patterns
NURSING INTERVENTION
3. Drug Therapy
Beta-Agonists: Such as albuterol work as bronchodilators
Anticholinergics: Such as Ipratropium work to relax bronchospasms
Corticosteroids: Such as Fluticasone work as an anti-inflammatory
4. Couensling the patient in smoking cessation
rationale: only way to slow progression of COPD.
5. Avoid (O2 toxcitity)
rationale: High levels of 02 concentration can result in severe inflammaotry response, because of 02 radicals & damage to aveoli leading to --> severe pulpmary edema, hypoxemia.
KEY
: Patient of case study
:Main Ideas
:Details/Supporting Ideas