Case study

patient with
COPD
BY NAWAL
GALET
JS is a 74 year old man who presents to your
family medicine office with his wife complaining
of shortness of breath and fever. They just
moved to the area and had been planning to
come to your office next week to establish care
as new patients.
Due to the onset of symptoms, JS called and
was given a walk-in slot today. His wife did
bring records from his last physician's office.
 oo
HISTORY OF PATIENT: \
o Past Medical/Surgical History
o Heart failure following myocardial infarction at age 68
years
o COPD (on 2 Lhome oxygen)
o Hypertension
o Appendectomy
o Family History
o Father died of myocardial infarction at age 59 years
(diabetes, hypertension, smoker)
o Mother alive (atrial fibrillation, heart failure)
0 Healthy siblings
 CONT... ;
© Social History
| © Married, 3 children
© 30 pack year smoking history (quit after MI)
o Worked on a farm
© No alcohol or illicit drug use
o Medications / Allergies
© Lisinopril 20 mg twice daily
© Metoprolol 50 mg twice daily
© Spironolactone 25 mg daily
o Furosemide 40 mg daily
© Salmeterol/fluticasone 50/500 dry powdered inhaler (DPI) one puff
inhaled twice daily
© Tiotropium DPI one cap inhaled daily
© Albuterol/ipratropium metered dose inhaler (MDI) or solution for
nebulization every 6 hours as needed
o Levalbuterol MDI two puffs every 4 to 6 hours as needed
o Home oxygen
a C O nM T. nD i@
oHe Is confused about what to use when,
SO you are not sure which medications he
actually takes.
ONo known allergies

oJS Past Record Review (brought by wife)

o Echocardiogram with EF of 25%
oSpirometry with FEV1 35% preelenye that
does not change significantly after inhaled
bronchodilator
CONT... L
oRecords Review
oUnable to determine when last
pneumoccal vaccine was given
oPatient and wife don’t recall “a
oneumonia shot’
oDoes know he got his “flu shot’ last
month at a grocery store
JS current symptoms include the following:
ee to speak in full sentences for the past several hours per
wife
Cough productive but unknown color of soutum
Audible wheezing since last night per wife
Mild chest tightness
Dyspnea
His wife has noted no change in his alertness or mental status
When you inquire, the wife states that JS usually has a
cough, worse in the morning, productive of gray sputum, gets
short of breath if he walks more then 10 feet, and has
episodes of wheezing if he gets sick (e.g. with an upper
respiratory infection).
He usually is able to help around the house with light work
and fixing things.
Physical examination
o Physical examination e
o Vital Signs: BP 128/74; P 68, reg; RR 32; Ht Sft 6 in; Wt
122 lbs; T 101.5 °F oral
o Unable to speak in full sentences, audible wheezing, alert
and oriented
© Pertinent positives:
o General: audible wheezing, no accessory muscle use
o Nails: tar stains, clubbing
o Chest: increased anteroposterior (AP) diameter; diffuse
wheezing to auscultation
© Heart: regular, no murmurs
Study results
ostudy results
o Pulse oximetry 86%
o Chest x-ray shows hyperinflation and right
lower lobe pneumonia
o You continue his heart failure medications as
per his home regimen
ONo need to discontinue the
cardioselective beta-blocker
 You proceed to record the You
proceed to record the patient's
patient’s observations observations
os Ly ga a2

o ABG Normal Range Other bloods Normal Range

© PH 7.236 7.35-7.45 Digoxin Level 0.5 1.0-2.0 nmol/L
| o PO2 4.7 11-15 kPa
| © PCO2 8 4.6-6 kPa |
o HCO3 30.0 22-26 |
My OBE +5 -2.4-+2.3 |
me © SaQ2 70 95-98% XQ
"| © Glucose 10.0 3.7-5.2 |
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o Altered mental status

o At least three exacerbations in the previous 12 months
o Body mass index of 20 kg per m2 or less
o Marked increase in symptoms or change in vital signs
© Medical comorbidities (especially cardiac ischemia, heart
failure, pneumonia, diabetes mellitus, or renal or hepatic
failure)
© Poor physical activity levels
o Poor social support
o Severe baseline COPD (FEV1/FVC ratio less than 0.70 and |
FEV1 less than 50 percent of predicted) os
] | © Underutilization of home oxygen therapy |
5) CONT... ;
| oBased on this information, JS has the
following clinical factors that increase his
risk of asevere COPD exacerbation:
o Marked increase in symptoms and change in
his vital signs including a low oxygen
saturation
oa new medical co-morbidity of pneumonia
© all combined with his severe baseline COPD
| So will you treat JS as an
outpatient or inpatient? 7
olndications for hospitalization
oRisk of death from an exacerbation
increases with:
o Development of respiratory acidosis
oPresence of significant comorbidities,
o Need for ventilatory support
History of Exacerbations

o Upon questioning his wife, you find out that he has had
9 exacerbations in the past year, three of which were
treated with antibiotics and oral steroids
o Amoxicillin x2 courses, doxycycline x1 course
© Most recent course 6 weeks ago
© No hospitalizations within the last 6 months
o Based on this information, and his chest x-ray findings,
you initiate treatment for community acquired pneumonia.
Over 3 days, JS has significantly improved
and has weaned back to his home oxygen
regimen.
He Is taking the albuterol/ipratropium
nebulized treatments every 6 hours, and Is
ready to switch back to bronchodilators via
inhaler device.
Along with antibiotics for a total of 7 days, you
need to determine the dose and duration of
treatment for oral corticosteroids.
»| Preparing for discharge
oln completing the medication
reconciliation forms, you see that JS had
a complex medication regimen upon
admission
olt is clear, during discussions with him,
that he is unable to comply with this
expensive, complex and potentially
unnecessary regimen.
 Medications on admission
0 Lisinopril 20 mg twice daily
© Metoprolol 50 mg twice daily
© Spironolactone 25 mg daily
o Furosemide 40 mg daily
© Salmeterol/fluticasone 50/500 dry powdered inhaler
(DPI) one puff inhaled twice daily
0 Tiotropium DPI one cap inhaled daily
0 Albuterol/ipratropium metered dose inhaler (MDI) or
solution for nebulization every 6 hours as needed
© Levalbuterol MDI two puffs every 4 to 6 hours as
needed
Discharge Medications

oStreamline regimen
oNo need for levalbuterol
o Continue salmeterol/fluticasone 50/500 DPI
and/or tiotropium DPI
0 Short-acting bronchodilator MDI as needed
oPatient given pneumococcal vaccine
prior to discharge
 a
DIFNATION: Chronic obstructive
pulmonary disease is a disease
characterized by airflow limitation
that is not fully reversible.
*
DT antomy oF LUNG
ANTOMY OF LUNG:
| Normal Lungs of a -.
———

\W
ex |, } Bronchioles Walls
of alveoll
5 Sf se theirshape ae destroyed, forming
[mA () and \ fewer larger alveod
A) of become
[|
rg |
i busine - is, :
iw ™ ‘ :
: i ‘ E id
\ Ai Wd +f. is
PHYSIOLOGY:
oln COPD, the airflow limitation is both progressive
and associated with an abnormal inflammatory
response of the lungs to noxious particles or gases.
o The inflammatory response occurs throughout
the airways, vege Seok Ha and pe nonary vasculature
Because of the chronic inflammation and the body’s
attempts
to repair it, narrowing occurs in the small peripheral
airways.
o Over time, this injury-and-repair process causes scar
tissue formation and narrowing of the airway lumen.
o Airflow obstruction may also be due to parenchymal
destruction as seen
 |
SS
= TIOLOGY/CAUSES:
IN THE BOOK a eV

THICKENENG OF AIRWAY WALL THICKENENG OF AIRWAY WALL

_ PERIBRONCHIAL FIBROSIS PERIBRONCHIAL FIBROSIS

EXUDATE IN THE AIRWAY EXUDATE IN THE AIRWAY

OVERAL AIRWAY SMOKING

NARROWING(OBSTRUCTIVE
BRONCHIOLITIS)
THINCKENING OF THE LINING OF AMBIENT AIR POLLUTIO
THE VESSEL AND HYPERTOPHY OF
SMOOTH MUSCLE
SMOKING

AMBIENT AIR POLLUTIO

 ‘eke
o the airflow limitation is both progressive and associated
with an abnormal inflammatory response of the lungs to
noxious particles or gases.
The inflammatory response occurs throughout
the airways, parenchyma, and pulmonary vasculature
© Because of the chronic inflammation and the body’s
attempts to repair it, narrowing occurs in the small
| peripheral airways. |
_ jo Over time, this injury-and-repair process causes scar tissue —
formation and narrowing of the airway lumen.
__| Airflow obstruction may also be due to parenchymal
destruction as seen

vy
 Lo
|

JSIGNS & SYMPTOMS:

In book and in patient:

i. chronic cough
2. sputum production
3. dyspnea on exertion
4. Weight loss is common
Complications:
1 respiratory failure
1 Respiratory insufficiency and failure may be chronic
(with severe COPD) or acute (with severe
bronchospasm or pneumonia in the patient with severe
COPD.
4 Acute respiratory
4 insufficiency and failure may necessitate ventilatory
support until
4 other acute complications, such as infection, can be
treated.
Sy
 HEALTH EDUCTION:
o Promoting Home- and Community-Based Care
o Teaching Patients Self-Care
o Provide instructions about self-management; assess
the knowledge of patients and family members about
self-care and the therapeutic regimen.
o Teach patients and family members early signs and
symptoms of infection and other complications so that
they seek appropriate health care promptly.
o Instruct patient to avoid extremes of heat and cold and
air pollutants (eg, fumes, smoke, dust, talcum, lint, and
aerosol sprays). High altitudes aggravate hypoxemia.
CONT...
opollutants (eg, fumes, smoke, dust, talcum, lint,
and aerosol sprays). High altitudes aggravate
hypoxemia.
© Encourage patient to adopt a lifestyle of
moderate activity
oldeally in a climate with minimal shifts in
temperature and humidity; patient should avoid
emotional disturbances and stressful
Situations; patient should be encouraged to
stop smoking.
CONT..
oReview educational information and have
patient demonstrate correct metered-dose
inhaler (MDI) use before discharge, during
follow-up visits, and during home visits.
 CONT...
“Continuing Care
oRefer patient for home care If necessary.
o Direct the patient to community
resources (eg, pulmonary rehabilitation
orograms and smoking cessation
orograms); remind the patient and family
about the importance of participating
oin general health promotion activities and
health screening.
Nursing Management
The nurse plays a key role in identifying potential
candidates for pulmonary rehabilitation and in
facilitating and reinforcing the material learned in the
rehabilitation program.
PATIENT EDUCATION
Breathing Exercises.
Inspiratory Muscle Training.
Activity Pacing.
Self-Care Activities.
Physical Conditioning.
Oxygen Therapy.
Nutritional Therapy.
Coping Measures.
CONT...
Achieving Airway Clearance
© Monitor the patient for dyspnea and hypoxemia.
o If bronchodilators or corticosteroids are prescribed, administer
the medications properly and be alert for potential side
effects.
© Confirm relief of bronchospasm by measuring improvement
in expiratory flow rates and volumes (the force of expiration,
how long It takes to exhale, and the amount of air
exhaled) as well as by assessing the dyspnea and making sure
that it has lessened.
o Encourage patient to eliminate or reduce all pulmonary irritants,
particularly cigarette smoking.
o Instruct the patient in directed or controlled coughing.
o Chest physiotherapy with postural drainage, intermittent
positive-pressure breathing, increased fluid intake, and bland
aerosol mists (with normal saline solution or water) may be
useful for some patients with COPD.
CONT...
Improving Breathing Patterns
o Inspiratory muscle training and breathing retraining may
help improve breathing patterns.

o Training in diaphragmatic breathing reduces the respiratory

rate, increases alveolar ventilation, and sometimes helps

expel as much air as possible during expiration.

o Pursed-lip breathing helps slow expiration, prevent collapse
of small airways, and control the rate and depth of
respiration; it also promotes relaxation.
CONT...
Improving Activity Tolerance
o Evaluate the patient's activity tolerance and limitations and
use teaching strategies to promote independent activities of
daily living.
o Determine if patient is a candidate for exercise training to
strengthen the muscles of the upper and lower extremities
and to improve exercise tolerance and endurance.
o Recommend use of walking aids, if appropriate, to improve
activity levels and ambulation.
o Consult with other health care professionals (rehabilitation
therapist, occupational therapist, physical therapist) as
needed.
Monitoring and Managing Complications

o Assess patient for complications (respiratory insufficiency

and failure, respiratory infection, and atelectasis).
o Monitor for cognitive changes, increasing dyspnea, tachypnea,
and tachycardia.
© Monitor pulse oximetry values and administer oxygen as
prescribed.
o Instruct patient and family about signs and symptoms of
infection or other complications and to report changes in
physical or cognitive status.
o Encourage patient to be immunized against influenza and
Streptococcus pneumonia.
CONT... Es
oCaution patient to avoid going outdoors if
the pollen count is high or if there is
significant air pollution and to avoid
exposure to high outdoor temperatures
with high humidity.
o If a rapid onset of shortness of breath
occurs, quickly evaluate the patient for
potential pneumothorax by assessing the
symmetry of chest movement, differences
in breath sounds, and pulse oximetry.
Promoting Rest:
oPosition bed for maximal respiratory
efficiency; provide oxygen If needed.
0 Initiate efforts to prevent respiratory,
circulatory, and vascular disturbances
oEncourage patient to increase activity
gradually and plan rest with activity
and mild exercise.
 es
Improving Nutritional Status:
oProvide a nutritious, high-protein diet
Supplemented by Bcomplex vitamins and
others, including A, C, and K.
oEncourage patient to eat: Provide small,
frequent meals, consider patient
preferences, and provide protein
supplements, If indicated.
oProvide nutrients by feeding tube or total
PN if needed.
Cont...
oProvide patients who have fatty stools
(steatorrhea) with water-soluble forms of fat
soluble vitamins A, D, and E, and give folic | -
acid and iron to prevent anemia. i
o Provide a low-protein diet temporarily if
patient shows signs of impending or
advancing coma; restrict sodium if needed.
 Providing Skin Care:
oChange patient's position frequently.
Avoid using Irritating soaps and aghesive
tape. Provide lotion to soothe irritated skin;
take measures to prevent patient from
scratching the skin.
Reducing Risk of Injury:
oUse padded side rails if patient
becomes agitated or restless.
oOrient to time, place, and procedures
to minimize agitation.
olnstruct patient to ask for assistance
to get out of bed.
oCarefully evaluate any injury because
of the possibility of internal bleeding.
1Cont...
oProvide safety measures to prevent
injury or cuts (electricrazor, soft
toothbrush).
o Apply pressure to venipuncture sites
to minimize bleeding.
Cont...
o Administer oxygen if oxygen desaturation
occurs; monitor for fever or abdominal pain,
which may signal the onset of bacterial peritonitis
or other infection.

o Assess cardiovascular and respiratory status;

administer diuretics, implement fluid restrictions,
and enhance patient positioning, if needed.
Monitoring and Managing
Complications:

© Monitor for bleeding and hemorrhage.

o Monitor the patient’s mental status
closely and report changes so that
treatment of encephalopathy can be
initiated prompily.
oCarefully monitor serum electrolyte levels
are and correct if abnormal.
Cont...
oAdminister oxygen if oxygen desaturation |—
occurs; monitor for fever or abdominal
pain, which may signal the onset of
bacterial peritonitis or other infection.
oAssess cardiovascular and respiratory
status; administer diuretics, implement
fluid restrictions, and enhance patient
positioning, if needed.
Cont...
o Monitor intake and output, daily weight
changes, changes in abdominal girth, and
edema formation.
o Monitor for nocturia and, later, for oliguria,
because these states indicate increasing
severity of liver dysfunction.
 Expected Outcomes
1. Smoking causes permanent dama «|
to the lung and diminishes the ae
; See Sa
Protective mechanisms. Airflow is e|
obstructed, sectetions are increased, sation es 1% SMOKING Ce
and lung capacity is reduced. Contin- © Enrolls in smoking cessation progra
ued smoking increases morbidity * Reports success in stopping smoki
and mortality in COPD and is also a * Verbalizes types of inhaled toxins
risk factor for lung cancer. * Minimizes or eliminates exposures
fevious smoking cessa- ® Monitors public announcements
e: s regarding air quality and minimizes ¢
tal materials. eliminates exposures during episotk
of severe pollution
2. Evaluate current exposure to . Chronic inhalation of both indoor and
tional toxins or pe sand outdoor toxins causes damage to the
door/outdoor pollutic airways and impairs gas exchange.
a. Evaluate current expos: |
cupational tox
door air polluti
furnes, chemic

" eccupational ex
best achieved |
duction of expos
 ee |

n
' n gos gas wn related to ventilation-perfusion inequality

pentio Rationale Expected Outcomes

Dronchodilators as pre- 1, Bronchodilators dilate the airways. —* Verbalizes need for bronchodilators
———

bed: De eseation dosage is carefully and for taking them as prescribed

Obsen ‘is the preferred ae
a em 0 side effects: tachyc hw
7
nee i oF0 each pat ent, inaccor-
4 ot -

sina _—
* Evidences minimal side effects; heart
rate near normal, abse
-_

of n
dys
c rhy
e th-
F mias, central ne ou , | Bi uN mias, normal mentation
—=——

hd ® Reports a decrease in dyspnea

-
Se

* Shows an improved expiratory flow

=

rate
_ © Uses and cleans respiratory therapy
equipment as applicable |
ion with © Demonstrates diaphragmatic breath-
ydilators is typi- ing and coughing
bronchoc ¢ Uses oxygen equipment appropriately
when indicated
¢ Evidences improved arterial blood
gases or pulse oximetry
¢ Demonstrates correct technique for
use of MDI

eae ple eo
Lo ~ f
hare
C - bt,
Continued on following page
So ee ee aL: ii ait AE ae iz
 J

inability to work
GOAL: Attainment of an optima
l level of coping
Nursing Interventions Rationale Expected Outcomes
|. Help the patient develop realistic
. Developing realistic goals will pro-
goals. * Expresses interest in the futur.
mote a sense ofhopeandaccom- —* Participates in the ascharge plan
plishment rather: thar defeat and * Discusses activities or methods that
2. Encourage activity to level of symp-
hopelessness, can be performed to ease shortness
2. Activity reduces tension and de-
tom tolerance, of breath
creases degree of dyspnea as pa- * Uses relaxation techniques
3. Teach relaxation technique or provide
tient becomes conditioned. appropriately
_—3. Relaxation reduces Stress, anxiety,
2 relaxation tape for patient. © Expresses interest in 2 pul vonary te
and dyspnea and helps patient to habilitation program
4. Enroll patient in pulmonary rehabilita- Cope with disability,
4. Pulmonary rehabilitation programs
tion program where available. have been shown to promote a sub-
Pig Wikies status and se-esteem as well as in-
Moet eh SINGS GIT |
 am Respiratory failure
peg Of respiratory fallre; no evidence of respiratory falure on laboraton tasty —

ra
functi
Fesp to
on will ry
evert futher patient with *¢ scu'e osv ess
Oreath Souncs °0 signs and symp Comipications, Such 8s resoretory re otoms of hyena

ond stere Dood

ees gasesipuise owen) o” etuTs %
. and and-ese blac wi ude cor Dasenne ves
 — — a

\uRSING DIAGNOSIS;
doe ilar Ineffectiv e breathin
Ng pattern ne to shortness of breath, mucus, bronchoconstriction,
goat: Improvement in breathing pattern 7 we |
Nursing Interventions Rationale Expected Outcomes
Teac os diaphragmatic and |, This helps patienprot Hong expiration —_* Practices pursedtip and diaphragmatic
pursed breathing, time and decreasesait trapping, With breathing and uses them when short
these techniques
patient ,wil breathe of breath and with activity
more efficientl
and effectively
y. » Shows sions of decreased respiratory
2 Encourage alternating activity with 2, Paginglactiv
permitiies
patient to effort and paces activities
fest penods. Allow patient to make | PRAFOMMVaCtIitIes without excessive © Uses inspiratory muscle trainer as pre-°
iptecion (bath, shaving) about| | distress, | scribed
are Das eae toweance ve. d —
pia pen oe 3 Tis stenthns and condtns te
i
,

<>

aks” in vag is
git gina
 ee
WURSING DIAGNOSIS: Self-Care deficits relate
d to fatigue secondary to Can
abiton and oaygeaton g TY to increased work of breathing and insufficient

Expected Outcomes
* Uses controled breathing whil
‘end avoid Dk atigue bathing, bending, and walking
a apnea cingQ activity + Paces activities of dally Iving to alter
etic, | 2. As condition resolves, patient wild Nate with rest period
sel, dress self, waandldrkin, s to reduce
k flu | able todo more but neds to een fatigue and dyspnea
ds,Discuss energy conservation aged to avoid increasing de * Describes energy conservation strate
measures, ojes
3 ‘athpostal deel ngropit. 3 Ts nna ptt become + Performs same self-care activities as
oh eer: before
+ Performs postural drainage correcth
REFERENCES: ee
Brunner and Suddarth's
Textbook of Medical-Surgical Nursing,
12th Edition-Suzann
CHAPTER 24
PAGE 601 TO 620
rr
Textbook of —
Vlecical- urs gic al
Nursing
THANK YOU