Question

A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these? Group of answer choices

Anterior-to-posterior diameter ratio of 1:1 (Barrel chest)

Unequal chest expansion

Chest-tube insertion

Atrophied neck and trapezius muscles

Answer 1

Group of answer choices are:During assessment of a patient with long history of COPD,the nurse is most likely to observe the following findings:

anterior to posterior chest diameter ratio 1:1(barrel chest)

unequal chest expansion.

chest tube insertion

Explanation: The reasons for the above choices being the answer to the nursing assessment of chronic COPD patient are as follows

Pathophysiology of COPD

Chronic obstructive pulmonary disease is a group of conditions(includes chronic bronchitis,emphysema) where the expiration of the patient is delayed and efforted due to obstruction in the airways(spasm of muscles,mucus plugs,mucosal edema and inflammation) leading to hyperinflation of the lungs and difficulty in respiration especially expiration.

It is a chronic condition which is very disabling as the patient suffers from recurrent episodes of breathlessness chronic cough,excessive sputum production,fatigue and repeated chest (lung )infections sometimes severe pneumonia. There are episodes of exacerbations which require hospitalization. Long-standing COPD causes right heart failure,pulmonary hypertension and arrhythmias,acute or chronic respiratory failures.

anterior to posterior chest diameter 1:1.(barrel chest)

Barrel chest occurs in COPD patient due to the chronic overinflation of the lungs as a result of obstructed airways.

Normally the transverse diameter of the chest is greater than the anterior posterior diameter and the ratio of the anterioposterior diameter of the chest to the transverse diameter is less than one.In cases of COPD ,on account of airway obstruction, there is hyper inflation of the lungs and this causes the rib cage to be elevated and raised chronically thereby increasing the anteroposterior diameter of the chest wall .This causes the chest to be inflated in the anterior posterior direction. it increases the anteroposterior diameter of the Chest to the same as that of the transverse diameter causing the ratio to be 1:1 and this condition is called as barrel chest(chest ressembles a barrel). Barrel chest is an accompaniment of chronic COPD and hence this nursing assessment is the correct answer option.

Unequal chest expansion The common causes of unequal chest expansion are pneumothorax, pneumonia fracture of the rib (unilateral),large unilateral pleural effusion,lung collapse.

Complicated cases of COPD could be associated with the Pneumothorax as in cases of emphysema(secondary spontaneous pneumothorax) or pneumonia which is severe lung infection and these conditions will result in an unequal chest expansion.

Since the incidence of Pneumothorax and pneumonia are high in patients of COPD , Unequal chest expansion could be an assessment nursing finding in the COPD patients .However the most common finding in the COPD patient is bilateral decrease in the chest expansion due to chronic hyperinflation of lungs in absence of the above complications.

chest tube insertion

Pneumothorax occurs following breakdown of the bullae(commonly seen in emphysema) due to the hyperinflation of the lungs and bullae rupture in chronic COPD patients and this is treated by chest tube insertion.

Secondary spontaneous Pneumothorax occurs in long-standing COPD patients, most often those with emphysema and in age of 60 to 65 years group and has to be treated as an emergency with chest tube insertion.As the lung function in the patients of COPD  is already depressed,the patients with superimposed Pneumothorax present with severe dyspnea needing emergent chest tube insertion.

Hence the chest tube insertion could be a likely nursing assessment finding in the patient of chronic COPD .This is therefore a correct answer option.

The reasons why the last option given is not possible as the nursing assessment finding in the COPD patient are :

atrophied neck and trapezius muscles :The patient of COPD uses the accessory muscles of respiration as the diaphragm and the intercostal muscles are ineffective in helping the patient to exhale due to longstanding obstruction in the airways and the hyperinflation of the lungs which decreases the elasticity and recoil capacity of the diaphragm and the intercostal muscles. Hypertrophied and prominent muscles of neck and trapezius are seen in COPD patients. Atrophy of the neck and the trapezius muscles is not observed in COPD patients hence this option as the choice of nursing assessment in the COPD patients is not correct option.