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Copy of COPD Exacerbation Case Study NURS 372 Rhode Island College

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aramide oso

on 22 April 2014

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Transcript of Copy of COPD Exacerbation Case Study NURS 372 Rhode Island College

COPD Exacerbation Case Study NURS 372Rhode Island College
Presented By
Aramide Oso

Risk factors
Patient: RR, a 61 year-old female
Admission date: February 18, 2014 Admission diagnosis: Chronic Obstructive Pulmonary Disease (COPD) exacerbation
Weight: 102 kg

Past Medicai and Surgical History

RR is presented with many comorbidities which include:
HTN, Dysrhythmia, High cholesterol, Asthma GERD, MI, Pneumonia, Sleep-apnea, Blood transfusion, UTI, IDDM, Obesity, Renal Calculi
Appendectomy, C-Section,
Tubal-ligation, Gallbladder removal,Cardiac surgery

Nursing Care Plan

COPD, a progressive long-term lung disease that refers to both chronic bronchitis and emphysema. It is associated with inflammation of the lungs as they respond to noxious particles or gases.
Chronic obstructive pulmonary disease (COPD) is the fourth-leading cause of chronic morbidity and mortality in the United States and is projected to rank fifth worldwide in 2020 as burden of disease according to the World Health Organization (Ade-Oshifogun, 2012)

Etiology of illness

RR came to the Emergency department complaining of severe abdominal pain. Assessment revealed symptoms of COPD exacerbation:
•Chronic cough
•Shortness of breath
•Frequent clearing of throat
•O₂ sat of 86%

Prolonged exposures to harmful particles and gases from:
Smoking: RR smoked for 20 years before quitting 15 years ago
Air pollution
Occupational exposure Second hand smoke
Chemical gases

Increasing age: RR is 61 years old
Obesity: RR has a BMI of 41.1, she weighs 102 kg , and according to Jordan & Mann (2010), when patients with COPD present with obesity as a comorbid condition, or vice versa, their morbidity and mortality risks are increased because obesity has been found to alter pulmonary function and diminish exercise capacity by its adverse effect on respiratory mechanics, resistance, and respiratory muscle function (Ade-Osifogun, 2012).

Medications Prior to Hospitalization

Medications prior to hospitalization
Aspirin 81 mg for MI prophylaxis, Advair Diskus for asthma maintenance, Gabapentin 100 mg neuropathic pain, Imdur 30 mg as an antianginal, Lipitor 40 mg for hyperlipidemia, Lisinopril 20 mg for hypertension, Metformin 500 mg for diabetes, Nifedipine 90 mg for chest pain, Novolin N 100 unit/ml for diabetes, Plavix 75 mg as an antiplatelet, Albuterol Sulfate 90 mcg, Spiriva 18 mcg, and Symbicort 80 mcg for COPD
Medications During Hospitalization
Relevant laboratory diagnostics
Glucose 320 H (67-99): Due to the prolong corticosteroid therapy (Prednisone), the patient glucose level is high.
V TCO₂ 31 H (24-29): Due to COPD disease process, there is impaired oxygen and carbon dioxide exchange resulting in increased vascular carbon dioxide
WBC 16.0 (3.5-11.0): COPD exacerbation may be caused by infection resulting in increased WBC
Chest X-ray: no evidence of pulmonary embolus, but there was right lower lung atelectasis with small amount of fluid in left pleural.

Physical assessment
Activity and Safety: During hospitalization RR ambulated with one assist and was on standard precaution
Risk factors: Fall precaution was followed due to lower extremities nerve damage
Sleep and comfort: HOB was elevated to increase lung expansion and minimized SOB, and pain medication administered as prescribed
Nutritional Status: RR is obese with a BMI of 41 at 5’2” tall and 225 lbs. she was on Cardiac diabetic comp. carb to help manage her cholesterol, blood pressure and blood sugar thereby preventing further complications of heart disease and diabetes

Nursing diagnoses
On the day of care nursing diagnoses pertaining to RR include;
Ineffective airway clearance related to presence of secretions in respiratory tract, Impaired gas exchange related to ventilation-perfusion inequality, Ineffective breathing pattern related to shortness of breath, and bronchoconstriction, Activity intolerance related to fatigue , Risk for Injury related to neuropathy, Risk for fall related to unsteady gait and skeletal weakness, Acute pain related to abdominal hernia, Imbalanced nutrition: More than body requirements related to BMI of 41.1
Cultural/psychosocial/spiritual assessments
RR is of Hispanic heritage, speaks English, Spanish, and a little Italian. She is a widower, husband died from cancer thirteen years ago and lives with her son, major role in family is to take care of her grandchildren. She is a Catholic, and celebrates Easter, Christmas, and Thanksgiving. RR believes her faith in God has broughtthis far with all her medical conditions.She quit smoking fifteeen years ago. She is on Medicare, and demonstrated ability to perform respiratory treatment at home and understanding of the prescribed medications. She has a a positive attitude to live and a strong family support system.

Nursing Goals
Teaching needs
Nursing Interventions

• Assess patient’s pain Q4H using pain-rating scale
• Monitor patient’s respiratory status continuously
• Encourage patient to use nebulizer as ordered even after discharged from the hospital
• Assist patient to ambulate, turn, cough, and deep breath Q4H
• Encourage patient to change position frequently
• Monitor patient’s blood sugar as ordered, and administer insulin as indicated
• Educate patient about low-calorie, nutritious foods
• Perform activity as tolerated and monitor for falls
• Put bed in low level with brakes locked

Patient airway patency with the ability to breathe comfortably, demonstration of correct use of nebulizer device, ability to state the importance of deep breathing and position changes, and shows no evidence of shortness of breath. RR blood sugar will be within normal range, she and her family will verbalize the ability to plan nutritious diet to maximize weight loss and improve cardiac and diabetes symptoms
The patient was taught how to recognize early warning signs of COPD exacerbation when she gets back home; worsening of symptoms than usual is a cause to seek medical attention. Research by Brandt (2013) illustrated that teaching self-observation/symptom monitoring is critical. Patients should be instructed to keep a daily symptom log, at least until they are familiar with their baseline dyspnea and other symptoms.
Patient was advised to include period of physical exercises with activities of daily living but with period of rest. Exercises with diet control will assist the patient with weight loss and improve function; Ade-Oshifogun, 2012 said, “When obesity is described in terms of central adiposity, total body fat and central adiposity were found to be inversely associated with lung function”. There were no teaching barriers with this patient because she understands and speaks fluent English, she demonstrated how to perform respiratory therapy efficiently, and she was receptive to all information disseminated.
As suggested by Brandt (2013), “Patients must learn about their medications’ effects and how to take them”, the patient received teachings on pain medication administration; she was encouraged to take pain meds whenever she is in pain and not wait until it got worse to maintain therapeutic level. She was aso informed about the benefits of yeraly influenza vaccination to prevent infection
Evaluation of care/reflective practice
During the shift period prescribed nebulizer therapy was administered twice, RR received the annual flu vaccine, and a head-to-toe system assessment was performed. RR was cooperative and pleasant during care, she was AAOx3, and did not display any sign of shortness of breath. Patient verbalized satisfaction with the care she received at the end of the shift, and I was able to meet my goal for patient care satisfaction. With this particular patient if I have the opportunity to follow up, I will refer the patient and her family for dietician consults to assist with proper nutrition teachings to facilitate weight loss.

Medications during hospitlization
Prednisone 10 mg as an anti- inflammation for her lungs, Heparin 500 units subcutaneous as a blood thinner, DuoNeb Albuterol sulfate 2.5 mg + Ipratropium bromide 0.5 mg for COPD, Ibuprofen 600 mg for pain, Azithromycin 250 mg as an anti- infective agent for COPD exacerbation, Clopidogrel Bisulfate 75 mg to prevent clot, Isosorbide Mononitrate 30 mg for angina prophylaxis, Oxycodone 5 mg for severe pain, and Albuterol as a bronchodilator for COPD. She was continued on Atorvastatin 40 mg, Symbicort INH 160/4.5 mcg, Insulin Humulin N 15 units, and Gabapentin 100 mg

Ade-Oshifogun, J. (2012). Model of functional performance in obese elderly people. Journal of Nursing Scholarship, 232-241.
Brandt, C. (2013). Study of older adults’ use of self-regulation for copd self- management informs an evidence- based patient teaching plan. Rehabilitation Nursing, 11-23.
Ralph S. S., Taylor C. M. (2009). Nursing diagnosis reference manual. Philadelphia: Lippincott Williams & Wilkins.
Smeltzer, S.C., Bare, B.G., Hinkle, J.L., Cheever, K.H. (2010). Brunner & Suddarth's textbook of medical-surgical nursing (12th ed., Vol. 1). Philadelphia: Lippincott Williams & Wilkins.
Lacharity, L.A., Kumagai, C.K., Bartz, B. (2014)
Prioritization, delegation, and assignment. Practice exercises for the NCLEX examination. ((3rd ed). Evolve Elsevier

The most important collaboration for RR on the day of care would have been with a nutritionist meeting with her family. RR being of Hispanic heritage would require teachings on how to modify traditional Hispanic foods in enhancing weight loss. RR is obese, which contributes to her frequent COPD exacerbation and hospitalization.

COPD causes impairement in airway patency due to hyperinflation of the lung tissues that results in dyspnea, respiratory acidosis, circulatory impairement, and other respiratory discomforts. During an exacerbation, the ABC model should be followed to improve circulation; positioning the client in high-Fowler's to maximize ventilation, administering bronchodilator to provide rapid relief and providing oxygenation at 1-4 L via nasal cannula are the priority nursing care actions. Remember that low arterial levels of oxygen serve as the primary drive for breathing with COPD patients, therefore administering too much oxygen causes hypercarbia which has a devastating effects on the patients
ATI Review

The patient with COPD tells the UAP that he did not get his annual flu shot this year, and has not had a pneumonia vaccination. you would be sure to instruct the UA to report which vital sign value?
1. Blood pressure of 152/84 mm Hg
2. Respiratory rate of 27 breaths/min
3. Heart rate of 92 beats/min
4. Oral temperature of 101.2⁰ F
(38.4⁰ C)
Mr.W's arterial blood gas results include the following: pH, 7.37; PaCO₂, 55.4 mm Hg; PaO₂, 51.2 mm Hg; HCO3¯, 38 mEq/L

Based on the patient's arterial blood gas results,what are your nursing priority actions at this time? (Select all that apply.)Then, interpret the ABG results as either compensated or not

1. Administer oxygen at 2 L/min via nasal cannula
2. Initiate a rapid response
3. Teach the patient how to cough and deep breath
4. Begin IV normal saline at 100 mL/hr
5. Arrange a transfer to the intensive care unit (ICU)
6. Remind the patient to practice incentive spirometry every hour while awake
Answer: 4
A patient who did not have the pneumonia vaccination or flu shot is at risk for developing pneumonia or influenza. An elevated temperature indicates some form of infection, which may be respiratory in origin
Answer: 1,2,3,6
The patient's major problem at this time is impaired gas exchange with hypoxemia. Administration of low oxygen, having the patient cough and deep breath, and perform incentive spirometry will improve gas exchange. These interventions may improve the patient's condition and prevent the need to initiate a code and/or transfer to the ICU. The patient's symptoms call for initiation of a rad response to treat himnow and prevent the need for a code. A saline lock is a good idea, but giving the patient toomuch fluid may worsen his condition by producing a fluid overload

The ABG results signify a fully compensated respiratory acidosis with
pH, 7.37; PaCO₂, 55.4 mm Hg; PaO₂, 51.2 mm Hg; HCO3¯, 38 mEq/L

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