Question

D.Z., a 65-year-old man, is admitted to a medical floor for exacerbation of his chronic obstructive pulmonary disease (COPD; emphysema). He has a past medical history (PMH) of hypertension (HTN), which has been well controlled by enalapril (Vasotec) for the past 6 years, and a diagnosis (Dx) of pneumonia yearly for the past 3 years. He appears as a cachectic man who is experiencing difficulty breathing at rest. He reports cough productive of thick yellow-green sputum. D.Z. seems irritable and anxious when he tells you that he has been a 2-pack-a-day smoker for 38 years. He complains of (C/O) sleeping poorly and lately feels tired most of the time. His vital signs (VS) are 162/84, 124, 36, 102°F, Sao2 88%. His admitting diagnosis is chronic emphysema with an acute exacerbation, etiology to be determined. His admitting orders are as follows: diet as tolerated; out of bed with assistance; oxygen (O2) to maintain Sao2 of 90%; maintenance IV of D5W at 50 ml/hr; intake and output (I&O); arterial blood gases (ABGs) in am; CBC with differential, basic metabolic panel (BMP), and theophylline (Theo-Dur) level on admission; chest x-ray (CXR) q24h; prednisone 60 mg/day PO; doxycycline 100 mg PO q12h × 10 days, azithromycin 500 mg IV piggyback (IVPB) q24h ×2 days then 500 mg PO × 7 days; theophylline 300 mg PO bid; heparin 5000 units SC q12h; albuterol 2.5 mg (0.5 ml) in 3 ml normal saline (NS) and ipratropium 500 mg by nebulizer q4-6h; enalapril 10 mg PO q am. Identify the expected findings in patients with COPD. Identify three measures you could try to improve oxygenation status. Explain the priority nursing care needed for patients with COPD. What are two of the most common side effects of bronchodilators? Identify the acid-base imbalance expected for patients with COPD. Identify the expected arterial blood gas value results commonly seen in patients with COPD. You deliver D.Z.'s dietary tray, and he comments how hungry he is. As you leave the room, he is rapidly consuming the mashed potatoes. When you pick up the tray, you notice that he hasn't touched anything else. When you question him, he states, “I don't understand it. I can be so hungry, but when I start to eat, I have trouble breathing and I have to stop.” One theory for the increased work of breathing is based on carbohydrate (CHO) loading. D.Z.'s wife approaches you in the hallway and says, “I don't know what to do. My husband used to be so active before he retired 6 months ago. Since then he's lost 35 pounds. He is afraid to take a bath, and it takes him hours to dress—that's if he gets dressed at all. He has gone downhill so fast that it scares me. He's afraid to do anything for himself. He wants me in the room with him all the time, but if I try to talk with him, he snarls and does things to irritate me. I have to keep working. His medical bills are draining all of our savings, and I have to be able to support myself when he's gone. You know, sometimes I go to work just to get away from the house and his constant demands. He calls me several times a day asking me to come home, but I can't go home. You may not think I'm much of a wife, but quite honestly, I don't want to come home anymore. I just don't know what to do.” How would you respond to her statement? What education will you provide for this patient and his wife? Answer all components of this discussion.

Answer 1

1.COPD is characterized by three primary symptoms chronic cough,sputum production,and dyspnea on exertion.These symptoms worsen over time..Chronic cough and and sputum production often precede the development of airflow limitation by many years.Dyspnea may be so severe that it hinders the activities of daily living.Weight loss is common and as time progress they are at risk for resiratory insufficiency and respiratory infections..in patients with COPD that has a primary emphysematous content ,chronic hyperinflation leads to barrel chest thorax configuration..This results from fixation of ribs in the inspiratory system and from loss of lung elasticity.Retraction of supraclavicular fossae occurs in inspiration ,causing the shoulders to heave upward.

2

• Practice pursed lip breathing.
• Breathe more slowly and deeply.
• Controlled coughing to clear the secretions.

3 Major patient goals include smoking cessation,improved gas exchange ,airway clearance ,improved breathing pattern,improved activity tolerance,improved coping ability,adherence to the therapeutic program and home care,and absence of complications.

Nursing interventions

Promoting smoking cessation-

Because smoking has such a detrimental effect on the lungs,the nurse must discuss smoking cessation strategies with the patient.The nurse should inform the patient that continuing to smoke impairs the mechanisms used to clear the airways and keep them free of irritants.

Improving gas exchange

Bronchospasm can be detected on auscultation with a stethoscope when wheezing or diminished breathing sounds are heard.The nurse monitor the patient for dyspnea and hypoxaemia.The relief of bronchospasm is confirmed by measuring improvement in expiratory flow rates and volumes as well as by assessing the dyspnea and making sure that it has lessened.

Achieving airway clearance

The nurse instructs the patient in directed or controlled coughing .Huff coughing may also be effective.Chest physiotherapy with postural drainage ,intermittent positive-pressure breathing ,increased fluid intake,and bland aerosol mists maybe useful for some patients with COPD

Improving breathing patterns

Inspiratory muscle training and breathing retraining may help improve breathing patterns.Training in diapphragmatic breathing reduces the respiratory rate,increases alveolar ventillation .Pursed lip breathing helps slow expiration ,prevent collapse of small airways and control the rate and depth of respiration.

Monitoring and managing potential complications

The nurse must assess for various complications of COPD such as life threatening respiratory insufficiency and failure as well as infection and atlectasis,which may increase the risk of respiratory failure.The nurse monitors for cognitive changes,increasing dyspnea,tachypnea and tachycardia which may indicate increasing hypoxaemia and impending respiratory failure.

4 The main sideeffects are nausea and vomiting ,palpitations,headaches,insomnia,tachycardia and arrythmias.

5 One of the major compliance in COPD patients is the development of stable hypercapnia.The consequence of hypercapnia due to alteration of gas exchange in COPD patients result in hypercapnic acidosis.Both metabolic acidosis and metabolic alkalosis can occur with respiratory acidosis for COP patients who have heart failure and treated with diuretics and extracellular volume .

6 "Firstly COPD and its progression promote a cycle of physical,social,and psychological consequences all of which are inter-related.The patient may at times experience depression ,altered mood states,social isolation and altered functional status.There are community resources such as pulmonary rehabilitation programs to help improve the patients ability to cope with his or her chronic condition and the therapeutic regimen and to give the patient a sense of worth ,hope and well-being.It is beneficial to participate in general health promotion activities and health screening."