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CASE STUDY #1: Pulmonary Disease

By Quennie Asi, Francis Carabeo, Reinne Lim, Kristen Quijano,

& Vince De La Luna

NUR_62 T

Payzant

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

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