CASE STUDY #1: Pulmonary Disease
By Quennie Asi, Francis Carabeo, Reinne Lim, Kristen Quijano,
& Vince De La Luna
Key
Case Study Information
Etiology/Risk Factors
Pathophysiology
Clinical Manifestations
Diagnostic Tests
Nursing Interventions
Treatment
Roy Diagnoses
Concept Map Questions
Complications
References
DISCUSSION QUESTION:
What in D.B.’s history is commonly associated with pulmonary problems?
Case Study
CASE STUDY
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.
DIAGNOSIS: COPD
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
- 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%
Etiology/Risk Factors
ETIOLOGY/RISK FACTORS
- Smoking is the major cause of COPD
- Occupational and environmental exposures
- Genetic susceptibility
- Intravenous drug abuse
- Connective tissue diseases
DISCUSSION QUESTION:
Discuss the Pathophysiology of COPD.
Pathophysiology
PATHOPHYSIOLOGY
- COPD is a combination of chronic bronchitis, emphysema, and hyperreactive airways
- Continual damage leads to mucus and fibrosis in the bronchioles, loss of alveolar elastic recoil and smooth muscle hypertrophy
- D.B.'s history of smoking causes excessive damage
Clinical
Manifestations
Discussion Question:
What complication associated with this diagnosis does D.B. also have? What clinical manifestation led you to that?
CLINICAL MANIFESTATION
- include those of chronic bronchitis, emphysema, and asthma
- Dyspnea
- Cough or wheezing
- Hypoxia, and cyanosis
- Right ventricular failure can occur due to high resistance against the right ventricle overtime
- Complication association with diagnosis of COPD: right heart failure
Diagnostic Testing
DIAGNOSTIC TEST
- Pulmonary function tests (PFTs)
- EV1/FVC ratio of lower than 70%.
- A complete blood count (CBC)
- Blood chemistry panel
- Chest x-ray shows hyperinflation
- Flattened, low diaphragm borders and hyperinflation of both lung fields caused by retained air
- Right ventricular failure
- ABGs: pH 7.32, SaO2 86%, PaCO2 55 mm Hg, PaO2 70 mm Hg
- O2 Saturation: 86%
- Electrocardiogram (ECG)
DISCUSSION QUESTIONS:
Interpret D.B.’s arterial blood gases.
DISCUSSION QUESTION:
What assessment data and diagnostic study results led you to this diagnosis?
Diagnoses
ROY DIAGNOSES
D.B. likely has COPD
1. Impaired gas exchange related to SOB while walking and elevation of head while sleeping as evidenced by increased respirations, decreased oxygen saturation, and decreased partial pressure of oxygen.*
2. Activity intolerance related to SOB upon exertion as evidenced by labored respirations, signs of muscle wasting, and 2+ peripheral edema bilateral lower extremities.
DISCUSSION QUESTION:
Using the Roy Model, identify two priority nursing diagnosis. Select one. What would be your goal and nursing interventions for that diagnosis? How would you evaluate if your interventions were successful?
Goals
The patient’s oxygen saturation will be 90% or above by the end of my shift.
Interventions
Elevating patient’s head of bed, encourage patient to ambulate, administering any ordered pain medications to promote comfort, diaphragmatic breathing, pursed- lip breathing, ensure adequate hydration, teach and encourage use of incentive spirometer
Check in on patient’s pulse oximeter to see if oxygen saturation has reached goal of 90% or above.
Evaluation
DISCUSSION QUESTION:
What interventions are indicated for D.B. and what outcome is expected for each intervention?
Nursing Intervention
NURSING INTERVENTIONS
- Avoid all smoke and other inhalants that can irritate bronchial tree/lungs
- Monitor ABGs
- Teach breathing techniques
- Administer O2
- Monitor heart function via ECG (in case of cor pulmonale)
- Provide adequate nutrition to decrease risk of infection
- Hand washing to prevent condition from worsening
Treatment
- Inhaled bronchodilators
- Monotherapy
- Oral corticosteroids
- When the patient has an acute exacerbation and is not responding adequately to bronchodilators.
- Smoking Cessation
- Oxygen therapy
- Mechanical ventilator support via an endotracheal tube
- Lung volume reduction surgery (LVRS)
- Remove the most severely diseased areas of
- emphysematous lung and to decrease the degree of lung hyperinflation
TREATMENT
DISCUSSION QUESTION:
What other teaching needs would you review with D.B. while he is hospitalized?
Patient Teaching
DISCUSSION QUESTION:
As part of patient teaching, is it “too late” to encourage D.B. to stop smoking? Why?
Patient Teaching
- Never too late!
- Decreasing frequency of smoking will help slow down the disease process and improve values.
- Smoking cessation
- Identify symptoms of COPD early
- Importance of regular activity
- Importance of adequate hydration
DISCUSSION QUESTION:
What complication associated with this diagnosis does D.B. also have?
Complications
COMPLICATIONS
- Cor pulmonale RHF due to increased resistance caused by pulmonary hypertension
- Secondary Respiratory Diseases such as
- Pneumonia
- Pneumothorax (weak and damaged lung tissue can cause gas aggregation)
- Increased susceptibility for lung infection leading to sepsis
- Sleep Apnea due to difficulty breathing
References
- Capriotti, T. & Frizzell, J.P. (2016) Pathophysiology: Introductory Concepts and Clinical Perspectives. Philadelphia: F.A. Davis Company.
- Potter, P., & Perry, A. (2017). Fundamentals of Nursing (9th ed.). St. Louis, MO: Elsevier.
- Roy, Sr. C., & Andrews, H. (2009). The Roy adaptation model (3rd ed.). Upper Saddle, New Jersey: Pearson Education.
- Roy Model Holistic Assessment Tool
REFERENCES