Question

COPD WK is a 60-year-old white female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago with an acute, chronic obstructive pulmonary disease (COPD) exacerbation requiring hospitalization. She uses BiPAP ventilatory support at night when sleeping and has requested to use this in the emergency department due to shortness of breath and wanting to sleep. She denies fever, chills, cough, wheezing, sputum production, chest pain, palpitations, pressure, abdominal pain, abdominal distension, nausea, vomiting, and diarrhea. She does report difficulty breathing at rest, forgetfulness, mild fatigue, feeling chilled requiring blankets, increased urinary frequency, incontinence, and swelling in her bilateral lower extremities that is new onset and worsening. Subsequently, she has not ambulated from bed for several days except to use the restroom due to feeling weak, fatigued, and short of breath. There are no known ill contacts at home. Her family history includes significant heart disease and prostate malignancy in her father. Social history is positive for smoking tobacco use at 30 pack years. She quit smoking 2 years ago due to increasing shortness of breath. She denies all alcohol and illegal drug use. There are no known foods, drugs, or environmental allergies. Past medical history is significant for coronary artery disease, myocardial infarction, COPD, hypertension, hyperlipidemia, hypothyroidism, diabetes mellitus, peripheral vascular disease, tobacco usage, and obesity. Past surgical history is significant for an appendectomy, cardiac catheterization with stent placement, hysterectomy, and nephrectomy.

1.What short term and long term goal is expected for WK?

2.What diagnostic test do you expect the physician to order for WK?

3.What medications do you expect the physician to order for WK?

Answer 1

1.Short term goals,

• Monitor vital signs.
• Administer a low concentration of oxygen (1to 2L/min) as prescribed, the stimulus to breath is a low arterial Po2 instead of an increased pco2.
• Monitor pulse Oxymetry.
• Provide respiratory treatment and CPT.
• Instructor the client in diaphragmatic or abdominal breathind techniques and pursed lip breathing techniques which increase airway pressure andkeep air passages open.
• Record the colour, amount and consistency of sputum.
• Suction the client if necessary.
• Monitor weight.
• Encourage small frequent diet with high calory and high protein diet.
• Place the client in Fowler's position and leaning forward to aid in breathing.
• Allow activities as tolerated.
• Administer Bronchodilators, corticosteroids, mucolytics and antibiotics as ordered.

Long term goals

Client education such as

• Adhere to activity limitations, alternating rest periods with activity.
• Avoid eating gas producing foods, spicy foods, and extremely hot foods.
• Avoid exposure to individuals with infectious and avoid crowds.
• Avoid extreme in temperature.
• Avoid fore places, pets, pets, feather pillows, and other environmental allergens.
• Avoid powerful odors
• Meet nutritional requirements.
• Receive immunization as recommended
• Recognized the signs and symptoms of respiratory and hypoxia.
• Stop smoking.
• Use medications and inhalers as prescribed.
• Use oxygen therapy as prescribed.
• Use pursed lip and diaphragmatic or abdominal breathing when using dusting, use wet clothes.

2.Diagnostic meassure which the physical may order are,

• Arterial blood gas analysis (ABG) :usually assessed in the severe stages and monitered in hospitalised patients with acute exacerbations.
• Chest X ray:congestion and hyperinflation seen on chest x rayray
• Complete bloot count : for evaluating infectous rate.
• Sputum specimen for Gram stain and culture.
• Continues monitoring of ECG and pulse Oxymetry.

3.medications are

For symptomatic management of COPD brochodialator medications are central. Beta agonists(salmeterol) , anticolinergics(tiotropium) , theophylline and a combination of these drugs.

Inhaled corticosteroids is appropriate for symptomatic COPD.

Long term administration of oxygen more than (15 hrs/ day) has been shown to increase survival.

Frequent nebulisations. Eg:albuterol or ipratropium os single agents. Compininong Bronchodilators improve their risk of adverse effects compares with single agent. Two agents can be nebulised together (Duoneb) or delivered by one MDI(combivent) .

Along with these cardiac medicinesmedicines to be continued.