Nursing Case Study Copd
The term chronic obstructive pulmonary disease (COPD) refers to a number of conditions, such as emphysema and chronic bronchitis. Although common, preventable and treatable, COPD was projected to become the third leading cause of death globally by 2020. The projected level of disease burden poses a major public-health challenge and primary care nurses can be pivotal in the early identification, assessment and management of COPD. The masses should be educated on the major topics surrounding COPD to raise awareness and enhance manageability. This study delves into major questions and answers about COPD.
What is the main risk factor of COPD and why?
Smoking: Long term exposure to irritants associated with smoking causes an inflammatory response within the respiratory tract.
What are 2 other risk factors for COPD that Mary may have had?
Genetics (brother, sister and mum died from COPD)
Exposure to environmental/air irritants (smoke, chemicals)
How might Genetics play a role in COPD
AAT deficiency: protein that protects the lungs and other body tissues from being damaged by infection-fighting agents released by its immune system
List 8 S&S of COPD that Mary experienced:
Breathlessness
Labored breathing
Pursed lip breathing
Barrel-shaped chest
Increased expiratory effort
Use of accessory muscles
Blue/purple-tinged lips
Coughing up mucus
Explain emphysema
Inflammatory destruction to the lower respiratory tract such as alveoli and capillaries -> decrease surface area -> reduced gas exchange. Destruction of the alveoli tissue included the breakdown of elastin. Loss of elastic fibers and increased compliance -> Lungs are unable to build up pressure to let the air out on expiration because there isn’t enough elastic recoil/ collapsing airway ->hypercapnia and Hypoxemia
Explain chronic bronchitis
inflammation occurring in the bronchioles leading to mucus build-up, bronchial edema, and decreased ciliary action -> narrowing of the airways -> increased airway resistance -> reducing airflow and lengthening her expiration time -> decrease gas exchange -> hypercapnia and Hypoxemia.
What Laboratory tests (samples) can be done for COPD?
Blood gases and pH (testing oxygen and Carbon dioxide moving in and out of blood).
Sputum sample (finding the bacteria or fungi causing the inflammatory response).
What Investigations for COPD can be done (1)?
Chest X-ray (have her lungs expanded, has her heart been pushed out of position, has her clavicles been pulled superiorly, and flattened diaphragm)
What Investigations for COPD can be done (2)?
ECG (establishing that hypoxia is not resulting in cardiac ischemia)
What Investigations for COPD can be done (3)?
Spirometry (records inspiratory and expiratory lung volumes and how fast a patient can inhale/exhale.
How does a blood test indicate COPD?
In COPD patients, blood tests often reveal an increased hemoglobin level with an increased red blood cell count. This is the body’s attempt to try compensate for the low levels of oxygen in the blood by increasing the oxygen-carrying capacity of the blood.
What are three fast tests to do to test lung function?
Pulse oximetry, Peak flow, and lung sounds.
What pharmacological agents could be used for patients with COPD?
Beta-agonist bronchodilator (Salbutamol): binds to beta2 adrenergic receptors on bronchial smooth muscle, stimulating bronchodilation.
What’s another pharmacological agent that could be used for patients with COPD?
Corticosteroids (Seretide): anti-inflammatory agents used to decrease the inflammatory response.
3rd pharmacological agent, that could be used for patients with COPD?
Anticholinergics (Spiriva): blocks certain receptors on bronchial smooth muscle, stopping bronchoconstriction
List 2 other important things to manage COPD
Oxygen therapy and opioids (morphine).
What are some ways to manage COPD (not medication)?
Smoking cessation
Vaccination
What does increased residual volume mean?
the amount of air left in the lungs
What does decrease vital capacity?
the greatest volume of air that can be expelled
What are some complications of COPD?
Tissue emaciation
Right-sided heart failure
Acute respiratory failure.
Acidosis
Briefly define COPD. What pathophysiology is occurring in the lungs of a client with emphysema?
Chronic obstructive pulmonary disease (COPD) is a group of common chronic respiratory disorders, such as chronic bronchitis, emphysema, and chronic asthma, characterized by progressive tissue degeneration and obstruction in the lungs’ airways.
Emphysema occurs when the air sacs (alveoli) at the end of the smallest air passages (bronchioles) in the lungs are gradually destroyed, which leads to large, permanently over-inflated alveolar air spaces.
What are five signs and symptoms of respiratory distress the nurse may observe in a client with COPD?
There is dyspnea on exertion, hyperventilation with prolonged expiratory phase, use of accessory muscles, coughing, and expiratory wheezes.
respiratory rate more significant than the client’s baseline, dyspnea on exertion or at rest, difficult speech, nasal flaring, cyanosis, chest pain, pursed-lip breathing
Describe the physical appearance characteristics of a client with emphysema.
The patient will have a pink complexion; he will be in a tripod sitting position, hyperinflation leading to a “barrel chest,” clubbing of the fingers, diminished breath sounds, and hyper resonance upon percussion.
clubbing of fingers, peripheral cyanosis, jugular vein distention, anorexia, and weight loss
Are Mr. Cohen’s oxygen saturation readings normal? Explain your answer.
Mr. Cohen’s oxygen saturation readings are normal for a patient with COPD. Patients with COPD do not reveal O2 saturation of 95% or greater. Therefore, it is normal for Mr. Cohen’s O2 sat to be between 90-94% on oxygen. He has dyspnea on exertion, which is why his O2 saturation drops when he walks to the nurse’s station (and returns to the room), and it increases once he is at rest. It is also normal to rise after a nebulizer treatment because it opens up the airways.
Explain the effects of acute pain on an individual’s respiratory pattern and cardiovascular system.
Acute pain can cause an individual’s respiratory rate and blood pressure to increase because of the activation of the sympathetic nervous system. It also causes the heart rate to increase. In addition, the SNS causes blood vessels to constrict, thus raising blood pressure.
List five nonpharmacologic interventions that the nurse could implement to help decrease Mr. Cohen’s difficulty breathing.
Assist patient into the tripod position
Relaxation techniques to decrease the work of breathing
Encourage/teach pursed-lip breathing
Small, frequent feedings (avoid compromising the respiratory effort
Encourage ambulation (as tolerated) to prevent the build-up of secretions
small frequent meals, distraction, rest periods, smoking cessation, emotional support, fan for air circulation, relaxation technique
How would the nurse measure the effectiveness of the nonpharmacologic interventions that help decrease dyspnea?
Measure respiratory rate
Patients subjective SOB
Assess characteristics of sputum and if cough is productive
Measure O2 saturation
Able to demonstrate pursed-lip breathing, relaxation, and coughing techniques
Please explain why the nurse did not increase Mr. Cohen’s oxygen to help ease his shortness of breath
Adding oxygen won’t necessarily help Mr. Cohen because his main problem is getting CO2. This is why COPD patients are taught to breathe out with pursed lips. This way, they can prolong their exhale and get rid of more CO2. Another reason why the nurse did not increase the level of O2 is that if there is too much O2 being administered, the patient loses the need/desire to breathe; doing so would only worsen his hypoxia.
this is not true for all patients with COPD- patients with Hypoxemia and respiratory failure need oxygen
Discuss the cultural/spiritual considerations the nurse should keep in mind while creating a plan of care for Mr. Cohen’s pain management
Have to keep in mind his culture-Judaism and what his nonpharmacological pain management activities are.
A nurse must keep in mind the Sabbath and that he may not want to do any “work” from Friday sundown to Saturday sundown
Patients diet of kosher food should be kept in mind
What are three nonpharmacologic nursing interventions to help manage Mr. Cohen’s pain?
This Patient would likely benefit from relaxation techniques. This may include meditation or guided imagery to help divert his attention from his pain. Mr. Cohen may also benefit from alternative forms of medicine, such as acupuncture or reiki.
How would the nurse measure the effectiveness of the nonpharmacologic interventions to manage Mr. Cohen’s pain?
Pain should be measured primarily through subjective means, such as the pain scale and Mr. Cohen’s self-report. However, they can also be measured through objective signs, such as a rise in blood pressure and heart rate, guarding, grimacing, positioning, affect, and behaviors, such as Mr. Cohen isolating himself from others and inactivity.
Should the nurse be concerned about the adverse effects of respiratory depression and hypotension when giving oxycodone/ acetaminophen (Percocet) to Mr. Cohen? Why or why not?
Yes, there is a risk for respiratory depression that can compromise his already fragile respiratory status. In addition, given his COPD, his lungs are already having difficulty keeping up with oxygen demands, as evidenced by his shortness of breath; depressing his respiratory rate can further exacerbate this problem.
The patient already has an unsteady gait and requires assistance, so the dizziness that comes with hypotension would make him even more of fall risk. Moreover, the risk of these potentially harmful side effects is even higher given his age and slowed drug metabolism.
Three nursing diagnoses that address physical and or physiological safety concerns for Mr. Cohen?
Activity intolerance is related to an imbalance between oxygen supply and demand
Ineffective airway clearance related to increased mucus and bronchoconstriction
Ineffective self-health management is related to the inability to meet increased oxygen demand and dyspnea on exertion.
Impaired gas exchange r/t ventilation-perfusion imbalance, the risk for falls, impaired physical mobility
Mr. Cohen will be returning home with oxygen. List at least five safety considerations that nurses should include in discharge teaching regarding the use of oxygen in the home.
Don’t smoke while using oxygen tank; Keep the tank at least 15 feet away from matches, candles, gas stove, or other sources of flame; Place no smoking signs on doors
Notify local fire department and an electric company of oxygen use in the home
Keep oxygen tank 5 feet away from television, radio, and other appliances
Keep tank away from direct sunlight
Place the oxygen tank on the floor behind the front seat when traveling in the car.
Define, compare and contrast these two types of advanced directives and how they contribute to the end-of-life decisions in this situation. Check the Connecticut statutes that guide patients in executing these documents- what is required for valid advanced directives?
An “advance directive” is a legal document to provide your directions or preferences concerning your health care and appoint someone to act on your behalf when you are unable to.
A “living will” is a document that may state your wishes regarding any health care you may receive.
A “health care representative” is a person you authorize in writing to make any and all health care decisions on your behalf, including whether to withhold or withdraw life support systems.
A “conservator of the person” is appointed by the Probate Court when the Court finds that a person is incapable of caring for themself, including the inability to make decisions about their medical care.
People who can be your representative or conservator include: your physician administrators and employees of the facility
For completion of the forms, a person must have a notary and witness; they do not always need a lawyer
What if the family disagrees with the patient? Discuss how you would advocate for the patient.
Nurses can articulate the benefits of advance directives; however, nurses generally lack the knowledge and training to conduct such discussions
Providing EOL care that is appropriate, compassionate, and per the patient’s wishes is an essential component of the nurse’s role
Inform an administrator or risk manager of the conflict. It is also helpful to bring in a social worker to explore the conflict
The ethics committee might meet with the family and key members of the healthcare team
COPD risk factors
Smoking
Environmental toxins – fumes, smoke, gas, etc
Age
Poor nutrition – obesity, malnutrition
Childhood respiratory infections
Pneumonia
COPD Signs and Symptoms
Blue-tinged lips
Chronic cough
Increased WOB
Barrel chest
Finger clubbing
Pursed breathing
Accessory muscle used to breathe
SOB
Fatigue
COPD Pathophysiology
Peripheral airway inflammation
Narrowing of the airways
Chronic Bronchitis Pathophysiology
Inflammation in bronchi = permanently narrowed airways
Increased oedema, mucous
Decreased cilia action
Increased WOB, airway resistance
Decreased air volume
Emphysema Pathophysiology
Inflammation in alveoli = permanent damage to lung tissue and lung elasticity
Decrease in gas exchange
Elastin breakdown decreased expiratory airflow = hyperinflation
Smoking consequences
Chronic inflammation
Increased mucous
Fibrosis
Protein breakdown
Carbon deposits in airspaces
Hyperinflation consequences
Increased residual volume
Flattened diaphragm
Increased WOB, dyspnoea, hyperventilation
Barrell’s chest
Prolonged expiration
COPD Tests – Physical Observations
Pallor – cyanosis?
Overall condition – malnutrition
Breathing – sounds, chest movements, RR, WOB
COPD Tests – Laboratory
Sputum – bacteria? Cancer cells?
Blood – infection, oxygen, and carbon dioxide (acid balance)
COPD Tests – Investigations
Chest x-ray – lung size, position, hyperinflation signs
ECG – check if SOB is caused by heart
Pulmonary Function Test (Spirometry) Features
Forced Vital Capacity – exhaled air volume
Peak Flow – max. speed of exhalation
Forced Expiratory Volume – % forced vital capacity in the first second
Management – Beta Agonists Action and Effect
Action – binds to beta2 receptors on bronchiole smooth muscle
Effect – bronchodilation
Management – Anticholinergics Action and Effect
Action – block acetylcholine receptors on bronchiole smooth muscle
Effect – bronchodilation
Management – Corticosteroids Action and Effect
Action/Effect – decrease inflammation
Management – Oxygen Therapy Effect
Increases oxygen saturation
Medication – Salbutamol Features
Beta agonist
Short-acting
Inhaled
Medication – Seretide Features
Beta agonist and corticosteroid
Long-acting
Inhaled
Medication – Spiriva Features
Anticholinergic
Inhaled
Medication – Morphine Features
Opioid
Decreases respiratory effort
Decreases anxiety
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