Chronic Obstructive Pulmonary Disease COPD Case Study PDF

Preview

Summary

Chronic Obstructive Pulmonary Disease COPD Case Study. Teaches possible effective nursing interventions for patients with chronic lung disease(s)....

Description

Pneumonia-COPD

Joan Walker, 84 years old

Primary Concept Gas Exchange Interrelated Concepts (In order of emphasis) 1. 2. 3. 4. 5.

© 2016 Keith Rischer/www.KeithRN.com

Infection Acid-Base Balance Thermoregulation Clinical Judgment Pain

RAPID Reasoning Case Study: STUDENT

Pneumonia-COPD History of Present Problem: Joan Walker is an 84-year-old female who has had a productive cough of green phlegm that started four days ago that continues to persist. She was started three days ago on prednisone 40 mg PO daily and azithromycin (Zithromax) 250 mg PO x5 days by her clinic physician. Though she has had intermittent chills, she had a fever last night of 102.0 F/38.9 C. She has had more difficulty breathing during the night and has been using her albuterol inhaler every 1-2 hours with no improvement so she called 9-1-1 and is brought to the emergency department (ED) where you are the nurse who will handle her care.

Personal/Social History: Joan was widowed six months ago after 64 years of marriage and resides in assisted living. She is a retired elementary school teacher. She called her pastor before coming to the ED and he has now arrived and came back with the patient. The nurse walked in the room when the pastor asked Joan if she would like to pray. The patient said to her pastor, “Yes please, I feel that this may the beginning of the end for me!” What data from the histories is RELEVANT and has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance:

Productive cough Green phlegm Condition is persistent Albuterol is not working effectively High fever

The indicate that the patient is presenting with an infection of the respiratory system. This needs to be addressed and treated quickly as it could result in respiratory failure.

RELEVANT Data from Social History:

Clinical Significance:

Lost her husband 6 months ago She finds comfort in her pastor and prayer She fears this is the end for her Resides in assisted living home

The patient likely feels depressed and lonely since losing her husband. Living in an assisted living home may create feelings of lack of autonomy. She may also lose her will to survive since she fears this is the end for her, which could lead to additional stress and health concerns.

Patient Care Begins: Current VS: T: 103.2 F/39.6 C (oral) P: 110 (regular) R: 30 (labored) BP: 178/96 O2 sat: 86% 6 liters n/c

P-Q-R-S-T Pain Assessment (5th VS): Provoking/Palliative: Deep breath/Shallow breathing Ache Quality: Generalized over right side of chest with no radiation Region/Radiation: 3/10 Severity: Intermittent, lasting a few seconds Timing:

What VS data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance:

T: 103.2 F/39.6 C (oral) P: 110 (regular) R: 30 (labored) BP: 178/96 O2 sat: 86% 6 liters n/c Pain: 3/10, ache, generalized over right side of chest with no radiation, intermittent, lasting a few seconds

Elevated r/t infection Elevated r/t stress Elevated r/t Pneumonia/COPD Elevated r/t anxiety and stress Elevated O2 is contraindicated in patients with COPD Pain level should be monitored.

What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: GENERAL APPEARANCE: Appears anxious and in distress, barrel chest present RESP: Dyspnea with use of accessory muscles, breath sounds very diminished bilaterally with scattered expiratory wheezing. CARDIAC: Pale, hot & dry GU: Voiding without difficulty, urine clear/yellow

Anxiety can occur due to SOB and hypoxia barrel chest is known to appear in later stages of COPD. In respiratory distress, skeletal muscles are used to improve ventilation. Wheezing indicates narrowed bronchioles that are creating a whistling noise. Inspiratory wheezing with expiratory wheezing can represent more severe narrowing and must be recognized. Patient is experiencing a fever. Pallor could be due to sympathetic nervous system stimulation and is expected in this context. This is a normal finding, but the possibility of a UTI should be considered since they are prevalent in her age group.

Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: SKIN:

12 Lead EKG

Appears anxious and in distress, barrel chest present Dyspnea with use of accessory muscles, breath sounds very diminished bilaterally ant/post with scattered expiratory wheezing Pale, hot & dry, no edema, heart sounds regular–S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks Alert & oriented to person, place, time, and situation (x4) Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants Voiding without difficulty, urine clear/yellow Skin integrity intact, skin turgor elastic, no tenting present

Interpretation: Sinus tachycardia

Clinical Significance:

Normal heart rhythm with tachycardia is most likely from anxiety due to hypoxia.

Chest x-ray: What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Results: Clinical Significance: Left lower lobe infiltrate. Hypoventilation present in both lung fields

Infiltrate reflects the consolidation and presence of exudates or secretions caused by the infection/inflammatory process. The hypoventilation is an expected finding in end-stage COPD.

Lab Results: What lab results are RELEVANT that must be recognized as clinically significant to the nurse? Complete Blood Count (CBC) WBC (4.5–11.0 mm 3) Hgb (12–16 g/dL) Platelets (150–450x 103/µl) Neutrophil % (42–72) Band forms (3–5%)

Current 14.5 13.3 217 92 5

High/Low/WNL? High WNL WNL High WNL

Prior: 8.2 12.8 298 75 1

What lab results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Worsening WBC Sign of infection Neutrophils

Sign of the body fighting infection

Worsening

Band forms

Sign of the body fighting infection

Worsening

Basic Metabolic Panel (BMP:) Sodium (135–145 mEq/L) Potassium (3.5–5.0 mEq/L) CO2 (Bicarb) (21–31 mmol/L) Glucose (70–110 mg/dL) BUN (7–25 mg/dl) Creatinine (0.6–1.2 mg/dL) Misc. Labs: Lactate (0.5–2.2 mmol/L)

Current: 138 3.9 35 112 32 1.2 Current: 3.2

High/Low/WNL? WNL WNL High High High WNL

High/Low/WNL? High

Prior: 142 3.8 31 102 28 1.0 Most Recent: n/a

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: CO2: 35 All are worsening Significant due to COPD Significant due to taking a steroid, which can Glucose: 112 increase glucose. BUN: 32 Significant due to renal function Creatinine: 1.2 Monitor due to being on the higher side of Lactate: 3.2 normal. Confirm that sepsis may be present, and acidosis may be occurring or develop.

Arterial Blood Gas:

pH (7.35–7.45) pCO2 (35–45) pO2 (80–100) HCO3 (18–26) O2 sat (>92%)

Current:

7.25 68 52 36 84%

High/Low/WNL?

Low High WNL High Low

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: Acidosis pH: 7.25 pCO2: 68 Respiratory acidosis pO2: 52 Hypoxia HCO3: 36 Caused by elevated PO2 O2 sat: 84% Impaired ventilation Urine Analysis (UA): Color (yellow) Clarity (clear)

Current: Yellow Clear

High/Low/WNL? WNL WNL

Specific Gravity (1.015–1.030)

1.015

WNL

Protein (neg)

Neg

WNL

Glucose (neg)

Neg

WNL

Ketones (neg)

Neg

WNL

Bilirubin (neg)

Neg

WNL

Blood (neg)

Neg

WNL

Nitrite (neg)

Neg

WNL

LET (Leukocyte Esterase) (neg)

Neg

WNL

MICRO RBCs (90% No pattern of distress Oxygenation improved No changes in LOC or mental status

Place in high Semi-Fowlers position Monitor for behavior or mental status changes

Easier to ventilate and oxygenate sitting up. Change in mentation/decreased level of consciousness is early sign of deterioration with a gas exchange problem

5. What body system(s) will you most thoroughly assess based on the primary/priority concern?

Respiratory - Th relationship of impaired ventilation and neurologic status. As CO2 levels increase, mental status goes from increased confusion/agitation to decreased level of consciousness. 6. What is the worst possible/most likely complication to anticipate?

Respiratory failure from decreased oxygenation and sepsis. 7. What nursing assessments will identify this complication EARLY if it develops?

Lab value assessments indicating sepsis. Increased heart rate, and blood pressure that decreases over time. Assessing vitals with a focus on O2 saturation and ABGs. 8. What nursing interventions will you initiate if this complication develops?

Oxygen through nasal canula, us of an incentive spirometer, fluids to stay hydrated (watch for fluid volume excess). 9. What psychosocial needs will this patient and/or family likely have that will need to be addressed?

The patient’s fear that this is the end for her and that she will be dying, fear of her current health situation in general, feelings of loneliness, and possible depression related to losing her husband. 10. How can the nurse address these psychosocial needs?

Schedule for a chaplain/pastor to come talk to her, listen to her needs, and allow family to provide her company.

Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation?

Fear of not being able to breath, fear of the unknown, fear of death, and still grieving the loss of her spouse.

2. What can you do to engage yourself with this patient’s experience and show that she matters to you as a person?

Let her know the details of procedures and why they are done. Making sure to inform her that she is a priority, and I will do anything in my power to meet her needs. Spend quality time listening to her and engage in positive, uplifting talks.

Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment. 1. What did I learn from this scenario?

The importance of immediate treatment of respiratory symptoms for the best possible outcomes. The effect of psychosocial factors on physical health.

2.

How can I use what has been learned from this scenario to improve patient care in the future?

Treating patients’ physical health needs and psychosocial needs can improve the patients’ outcomes and boost their morale....