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Meet Our Patient:

COPD & DM Nursing Care
by

Rachel Lowe

on 28 November 2014

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Transcript of Meet Our Patient:

Clinical Treatment and Care for Our Patient: Mr. A.D.
Sophia, Kayla, Rachel, Brandy, Ashley, Karen, Emily, Darlene & Lisa
Personal & Social History
A.D. is a 69 y/o Caucasian male who has been married to his wife for 46 years. He is a retired Army veteran and Florida native who loves fishing, traveling, American History and playing cards. He has two adult children and three grandchildren. He lives in Port St. Lucie and attends the local Catholic church every Sunday.
Past Health, Mental & Psychosocial History
Type 2 Diabetes Mellitus
Cholecystectomy
Appendectomy
Hernia Repair
Insomnia
Hypertension
Pancreatitis
GERD
Diverticulitis
Kidney Stones
Irritable Bowel Syndrome
Emphysema
Hard of Hearing
Other Pertinent History
One year history of suboptimal diabetes control and diagnosed with COPD 5y ago
Starting smoking in mid-twenties and has smoked 40 packs of cigarettes per year with a recent decrease to 3-5 cigarettes per day
Does not monitor BGL at home and denies following a diabetic diet regimen with expressed doubt in medication and treatment of DM
Current A1C is 9%
Reason for visit:
Severe dizziness and shortness of breath with increasing fatigue when standing or walking
Trace edema in right ankle and +1 edema in left ankle
Productive cough with moderate to large amounts of thick, tenacious, green sputum
Initial Assessment
Vital Signs:
T: 101.4*F
P: 115 bpm, irreg
RR: 36 breaths/min
BP: 186/60 mmHg
O2 sat: 87%
Auscultation reveals diminished breath sounds with expiratory wheeze and rhonchi throughout all lung fields
ABG Results:
pH- 7.19
PaO2- 54 mmHg
PaCO2- 59 mmHg
HCO3- 30 mg/dL
Admission Dx:

SOB, COPD Exacerbated

Diagnostic Tests
Plan Of Care
Includes:
Diet/nutrition, oxygen therapy, exercise regimen, patient education on disease and risk factors for exacerbation, lifestyle modifications, education and management of diabetes mellitus
Medication Regimen
Aspirin
Clindamycin
Lisinopril
Temazapam
Atenolol
Furosemide
Diet Regimen
American Diabetic Association recommends:
Carbohydrates (individualized) 45-65%
Protein Intake 15-20%
Dietary Fats (low in sat. fat & cholesterol) <10%
Fiber Intake 20-35 g/day
Sodium 1000mg/1,000 kcal (avoid table salt)
Low sugar or use of sweeteners (if necessary)
No more than 2 alcoholic beverages/day
Treatment
Respiratory: Albuteral Sulfate (3 mL) performed Q6H by respiratory therapist and Solu-Medrol PO daily
Patient Education
Medication regimen: indication for use, side effects, administration
Discharge Planning:
Priority Plan of Care for Mr. A.D.
Ineffective Breathing Pattern
By EOS, patient will maintain effective respiratory rate and pattern, within acceptable range of 12-20 breaths per minute
By EOS, patient will clear secretions effectively and reduction of congestion with clear breath sounds.
Risk for Ineffective Therapeutic Regimen Management
By EOS, patient will initiate necessary lifestyle changes and participate in treatment regimen.
1. Administer 2L oxygen via NC, as ordered, and follow prescribed respiratory treatments to improve patients breathing and prevent hypoxia.
3. Increase PO fluid intake to 2,000 mL/day to loosen viscosity of sputum.
1. Explain/reinforce explanations of disease process and ways to prevent exacerbations of COPD and uncontrolled diabetes mellitus.
Questions?
THANK YOU!
Current Dx:

COPD, Pneumonia, Uncontrolled Type 2 DM

S/S:

productive cough, SOB, low O2 sat, diminished breath sounds with rhonchi and wheeze, BLE trace edema, dyspnea, pursed lip breathing and BGL of 298 mg/dL
Nurse
Physical
Assessment

Cardiovascular Status
Vital Signs
T: 99.5*F
P: 76 bmp
R: 18 breaths/min
BP: 164/78
O2 Sat: 99% (2L via NC)
Respiratory Status
RR:
18, even, labored
Lung Sounds:
diminished, shallow with bilat lower lobe rhonchi and expiratory wheeze
Cough:
moist, productive cough with moderate, thick, green sputum, present mostly in the morning
O2 Tx:
2L O2 via nasal cannula
Integumentary & Musculoskeletal Status
Integumentary
Color consistent with race/pale and dusky
Dry, warm, intact & elastic skin
IV Site: #20 RAC, CDI
0.9% NS @ 60ml/hr + Cleocin Phosphate
Gastrointestinal & Genitourinary Status
Gastrointestinal
Abdomen round, soft, non-tender
Hypoactive bowel sounds
Last BM 9/16/14: formed, soft, brown
PT denies flatus, N/V
Diet: diabetic/heart healthy; well tolerated
Neurological & Psychosocial Status
Neuro:
AOx3
Eyes 5mm, brisk, PERRLA
Equal bilateral upper & lower extremity strength
Patient is on a Heart Healthy/Diabetic Diet
Moderate carbohydrate, low sugar
Small meals & frequent snacks at regular, scheduled times
Monitor blood glucose AC & HS
Tolerated meals well; consumed 80%
Tobramycin
Methylprednisolone
Metformin
Albuteral Sulfate
Tramadol
Respiratory Infection: Clindamycin, Tobramycin
IV Fluids: Sodium Chloride (0.9% NS) at 125ml/hr with Lasix PO 20mg daily
Oxygen: 2 L 02 via NC
Psychosocial:
Calm, cooperative, pleasant
Interacted well
Pain: 2/10 -- low back d/t bed rest
Pulses
Apical: 66, regular
Periph: +2 equal bilat
Pedal: +1 equal bilat

Edema
BUE: trace edema
Right Ankle: trace
Left Ankle: +1
CRT < 3 sec.
Negative Homan's
Musculoskeletal
Bedrest, unable to assess gait
UE/LE full ROM
No swelling or tenderness in joint
PT wearing SCDs
Genitourinary
Voiding with urinal
Urine clear, yellow
No burning, pain, difficulty urinating
Periods of incontinence
ABG Values:
pH 7.19
PaO2: 54mmHg
HCO3: 30mg/dL
Sputum C&S:
identified Streptococcus pneumoniae, the causative agent for respiratory infection
Hgb A1C:
9% with estimated average BGL at 212 mg/dL
Chest X-Ray:
Flattening of the diaphragm as result of hyperinflation and evidence of pulminary infection
Slight cardiac enlargement
Lab Values
Hgb
14-18
12.7
LAB
NORM
PATIENT
Hct
42-52%
35.6%
WBC
11.4
5k-10k
Glucose
70-110
298
Na
135-145
139
K
3.5-5.3
4.8
BUN
8-20
53
CR
0.6-1.3
1.49
Goal:
improve oxygenation, control blood glucose levels, improve quality of life
Diabetic diet and exercise regimen
Prevention of infection and foot safety
Blood glucose monitoring
Smoking cessation
Signs and symptoms of COPD exacerbation
Incentive spirometer and TCDB breathing exercises
R/T SOB, secondary to disease process
AEB dyspnea, pursed lip breathing
3. Keep head of bed elevated to increase diaphragm and monitor pulse oximetry Q4H/PRN to verify if treatment is effective.
2. Encourage use of respiratory adjuncts, such as incentive spiratory and TCDB to facilitate a deeper respiratory effort and improve breathing pattern.
Home Care 2x/week
Oxygen Therapy
Focus will be on ensuring a diabetic diet and glucose monitoring is being incorporated, as well as, ways to prevent exacerbation and infection.
Mr. A.D. will be sent home with oxygen therapy (2 L via NC) to be used as needed. He will be educated on proper use and safety with oxygen therapy.
Ineffective Airway Clearance
R/T smoking, retained secretions, COPD disease process AEB excessive sputum, labored breathing, rhonchi/wheeze
1. Monitor respirations and breath sounds, noting rate and adventitious sounds for distress and/or accumulation of secretions.
2. Instruct patient to TCDB every 2-4 hours and ambulate early, as tolerated.
R/T chronic disability, secondary to COPD, smoking and lack of knowledge of diabetic condition
3. Discuss importance of avoiding those with active respiratory infections and stress need for routine influenza and pneumococcal vaccines.
2. Review the harmful effects of smoking and advise ways to start a smoking cessation program.
With successful education and active participation in care, Mr. A.D. will maintain a stable blood glucose level and prevent future COPD exacerbation.
References
The Joint Commission (2013).
2014 National Patient Safety Goals.
Retrieved from http://www.jointcommission.org/assets/1/6/2014_HAP_NPSG_E.pdf
Keltner, N.L., Bostrom, C.E.& McGuinness, T.M. (2011).
Psychiatric nursing
(6th ed.) St. Louis, MO: Elsevier/Mosby
North Carolina Concept-Based Learning Editorial Board (2011).
Nursing: A concept-based approach to learning
(Vol. 2) Upper Saddle River, NJ: Pearson
Deglin, J. (2013).
Davis's drug guide for nurses
(13th ed.) Philadelphia, PA: FA Davis
Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2013).
Nurse's pocket guide: Diagnoses prioritized interventions and rationales
(13th ed.). Philadelphia, PA: F.A. Davis
Full transcript