COPD Case Study

Write your own Case Study: Main Diagnosis Chronic Obstructive Pulmonary Disease Patients Name:  Henry Winston DOB:  12/1 4/1933             Gender: Male Allergies= :  Sulfonamides Height: 65 inches             Weight: 185 lbs Admitted with chronic obstructive pulmonary disease (COPD) and emphysema.  The patient presents with dyspnea on exertion, cough, and labored breathing. Past Medical History:  Previously diagnosed with emphysema.  Hx of MI, HTN, left sided HF, and a fractured ankle.  Paternal history of CAD.   HX of smoking 2 ppd for 35 years but has recently quit.  Drinks 2 beers per week.  Married with 1 child. Initial Vital Signs: T: 98.4 degrees F              P: 88      R: 20      BP: 126/84           SpO2:  93% RA on admit     Pain:4/10 with cough Physician Orders: Oxygen to maximum of 4L/min to keep pulse ox at or above 90% I/O Saline Lock VS q 4 hours and prn Up with assistance Low Sodium (4 gram) diet CXR CBC BMP ABGs UA   Medications: Prednisolone 80 mg po q day Aspirin 81 mg po daily Atrovent 2 puffs t.i.d Albuterol MDI 2 puffs q6 hr prn Lasix 40 mg po daily Lopressor 50 mg po bid Lanoxin 0.125 mg po daily Nurse Report Patient is a married male, admitted after midnight with acute exacerbation of CPOD.  Pt is anxious who is becoming more dyspneic with exertion.  The UAP just obtained a pulse ox of 88% on RA.  Pt does not use O2 at home.  Heart rate is regular, respirations are labored, with right lower lobe crackles and wheezing bilaterally.  He is up with assist but he is voiding per urinal as he does not tolerate getting up to go to the restroom.  Saline lock is in place and present. S: Increased SOB B:  70 pack-year hx of smoking, Complaints of increased dyspnea at home for the past 24 hours.  Exhibiting signs of increased SOB and his SpO2 is now 88% RA.  ABGs and labs drawn, results just arrived. A: Worsening resp. distress and hypoxia. R:  Assess respiratory status, evaluate ABG results, initiate O2 therapy as ordered and position patient as needed.   Nursing DX and Intervention Hints: Fall risk, Ambulates independently with fairly steady gait, Increasing SOB, weakness, Implement fall precautions and ambulate with assist.   What is COPD Chronic Obstructive Pulmonary Disease (COPD) is an umbrella term used to describe progressive lung diseases including emphysema, chronic bronchitis, and refractory (non-reversible) asthma. This disease is characterized by increasing breathlessness. What is the primary problem for this patient? Dyspnea, worsening respiratory distress and hypoxia What is your interpretation of the patient’s vital signs? Vitals are all within normal limits for someone with COPD What should you do first with this patient? Ensure the safety of the patient. What are your priorities as far as data collection for this patient? Assess respiratory status, ABG test was done so I would check those results and report to the doctor any abnormal results, initiate O2 therapy as ordered and position patient as needed. What questions would you ask this patient to gather information about breathing difficulties? Where is any pain felt? How does it feel? What makes it better? What makes it worse? What would you expect a patient to look like when they are SOB? I would expect to see the patient tenting if they are standing. Maybe some signs of anxiety. What types of nursing interventions do you see appropriate for this patient? They are a fall risk so I would assure the patient is safe. Ensure urinal is within easy reach of patient. What type of education would you provide this patient with? Continue to not smoke. Rest when you feel like you are getting over exhorted. What health promotion activities could you encourage for this patient? Continue to not smoke. Light activity as tolerated. Rest when needed. Monitor your O2 levels and apply oxygen as needed. What are your priority nursing actions for a patient with hypoxia? Administer up to 4L of O2 to patient What is each medication prescribed to the client? Prednisolone 80mg po q day Aspirin 81 mg po daily Atrovent 2 puffs t.i.d Albuterol MDI 2 puffs q6 hr prn Lasix 40 mg po daily Lopressor 50 mg po bid Lanoxin 0.125 mg po daily When administering these medications are there any special precautions you need to take or special teaching you should do with this patient? When administering the Atrovent rinse the mouth after using the inhaler to prevent dry mouth and throat irritation. Is each medication safe to administer to this patient? The Prednisolone can have a risk of hypokalemia when administered with a loop diuretic (Lasix). What are concerns the nurse has with administering oxygen at a high flow rate to this patient? Giving high concentrations of oxygen to hypoxemic patients with hypercapnia can result in individuals losing their hypoxic drive to breathe, with development of CO2 retention, respiratory acidosis, and even death. Concept Map Boxes Student name: Heather Peters Patient initials: Room #: Date: Include all abnormal data applicable to the nursing diagnosis from the Patient Profile and medication research forms ONLY. Include all medications and treatments applicable to the nursing diagnosis as data Use only NANDA diagnoses. Knowledge deficits should be written as separate problems, instead of having one all-encompassing “Knowledge Deficit” box. Key Problem # 2 I don’t know how this fits Key Problem # 1 Impaired gas exchange Ineffective airway clearance Pulse ox of 88% Labored breathing Crackles and wheezing bilaterally Pulse ox of 88% Respirations are labored Crackles and wheezing bilaterally Interventions Interventions Position patient with head of bed elevated, in a semi-Fowler’s position as tolerated. Apply oxygen as ordered. Practice breathing with patient. Have him match your breathing Reason for needing health care (Medical diagnosis/Surgical Procedure) Acute Exacerbation of COPD Priority Assessments: Ineffective airway clearance- O2 level Key Problem # 4 Key Problem # 3 Key Problem # Activity intolerance anxiety Dyspneic with exertion Does not tolerate getting up to go to the restroom Labored breathing Interventions Interventions Interventions Recommend frequent rest periods. Give actives to calm and take their mind off of what is going on.