Case Study 29 COPD Exacerbation

Case Study 29 COPD Exacerbation Difficulty: Advanced Setting: Hospital Index Words: chronic obstructive pulmonary disease (COPD), medications, nutrition, patient education, assessment, coping Giddens Concepts: Clinical Judgment, Collaboration, Gas Exchange, Nutrition, Oxygenation, Safety HESI Concepts: Assessment, Clinical Decision Making—Clinical Judgment, Collaboration/Managing Care, Gas Exchange, Nursing Interventions, Nutrition, Oxygenation, Safety u Scenario D.Z., a 68-year-old man, is admitted at 1600 to a medical floor with a diagnosis of acute exacerbation of chronic obstructive pulmonary disease (COPD). His other past medical history includes hypertension and type 2 diabetes. He has had pneumonia yearly for the past 3years and has been a two-pack-a-day smoker for 38years. His current medications include enalapril (Vasotec), hydrochlorothiazide (HCTZ), metformin (Glucophage), and fluticasone/salmeterol (Advair). He appears a cachectic man who is experiencing difficulty breathing at rest. D.Z. seems irritable and anxious; he complains of sleeping poorly and states that lately he feels tired most of the time. He reports cough productive of thick yellow-green sputum. You auscultate decreased breath sounds, expiratory wheezes, and coarse crackles in both lower lobes anteriorly and posteriorly. His vital signs (VS) are 162/84, 124, 36, 102° F (38.9° C), and SpO2 88%. Chart View Physician's Orders Diet as tolerated Out of bed with assistance Oxygen (O ) to maintain SpO 2 of 90% 2 IV of D5W at 50 mL/hr ECG monitoring Arterial blood gases (ABGs) in AM CBC with differential now Basic metabolic panel (BMP) now Chest x-ray (CXR) daily Sputum culture Albuterol 2.5 mg plus ipratropium 250 mcg nebulizer treatment STAT 1. Are D.Z.'s VS and Spo2 acceptable? If not, explain why. D.Z vitals are not appropriate, he is hypertensive at 162/84 mmHg ,tachycardic at 124 bpm, and tachypneic at RR of 36, SpO2 88% is low, the pt has orders for O2 to maintain SpO2 of 90%> and has a fever of 102 F. Most concerning for me are D.Z. RR of 36, pt's SpO2 needs to be closely monitored. A RR of 36 is very close to needing assisted ventilation for efficient gas exchange (Ex. BiPAP) An infection process may be thhe underlying cause of D.Z. symptomatology. 2. Describe a plan for implementing these physician's orders. After administering the albuterol treatment, provide the patient with 3L-5L oxygen through nasal cannula for improve his oxygen saturation. Once the patients O2 sat is stable then I would place the 5 leads EKG electrodes (telemetry monitor), collect the sputum culture, and hang the D5W. Then I would draw blood for the CBC and BMP, and ABG as ordered in the AM Lastly, I would make sure the chest xray is ordered daily for the patient. What is the primary nursing goal at this time? 3. Patient maintains optimal gas exchange as evidenced by usual mental status, unlabored respirations at 12-20 per minute, oximetry results within normal range SpO290%>, blood gases within normal range, and baseline HR for pt. Patient will maintain clear lung fields and remains free of signs of respiratory distress. 4. Based on this priority, identify three independent nursing actions you would implement. 1. Initiate the Albuterol nebulizer treatment 2. Continue administering O2 to the patient vis nasal cannula after the treatment 3. Recheck vitals and reassess the patient. 5. Identify three expected outcomes for D.Z. as a result of your interventions. 1. DZÕs Spo2 level will be 90% or higher 2. The patientÕs respirations will slow down and become unlabored 3. When the patient has a decrease in their anxiety level, the vital signs will return to normal limits Chart View Medication Administration Record Methylprednisolone (Solu-Medrol) 125 mg IVP every 8 hours Azithromycin (Zithromax) 500 mg IVPB q24h × 2 days then 500 mg PO × 7 days Fluticasone/salmeterol (Advair) 100/50 mcg 2 puffs twice daily Heparin 4000 units subcut every 12 hours Enalapril (Vasotec) 10 mg PO daily Albuterol 2.5 mg/ipratropium 250 mcg nebulizer treatment every 6 hours Metformin (Glucophage) 500 mg PO twice daily 6. Indicate the expected outcome for D.Z. that is associated with each medication he is receiving. Methylprednisolone (Solu-Medrol) Ð stress of inflammatory and immune responses inautoimmune disorders, allergic reactions and neoplasms Azithromycin Azithromycin (Zithromax) Ð resolution of the signs and symptoms of infection Fluticasone/salmeterol (Advair) Ð treat air flow blockage and reduce the worsening of COPD Heparin Ð prolonged PTT without signs of hemorrhage, prevent DVTs Enalapril (Vasotec) Ð decrease BP and decrease development of heart failure. Albuterol / ipratropium Ð prevention or relief of bronchospasm Metformin (Glucophage) Ð control blood glucose levels • 7. Because D.Z. is on azithromycin (Zithromax), what interventions need to be included in his plan of care? Select all that apply. a. Monitor intravenous (IV) site for inflammation or extravasation. b. Assess liver function study results and bilirubin levels. c. Request a hearing test before initiating therapy. d. Carefully dilute the medication in the proper amount of solution. e. Place D.Z. on intake and output. f. Administer the medication over 30 minutes. 1 mL 0.8 0.6 0.4 0.2 8. D.Z is ordered heparin 4000 units subcutaneous q12h. The following vial is available. How many milliliters will D.Z. receive? Shade in the dose on the tuberculin syringe. 9. What are two common side effects of bronchodilators that you need to assess for? Nervous or shaky feeling. Increased heart rate or palpitations. Upset stomach. Trouble sleeping. Muscle aches or cramps. 10. You deliver D.Z.'s dietary tray, and he comments on 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 has not 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. Explain this phenomenon. Difficulty swallowing or chewing due to dyspnea, chronic mouth breathing, which can alter the taste of food; depression and side effect of medications. 11. Identify four interventions that might improve his caloric intake. - Eat meals when energy levels are at their highest, which is usually in the morning. - Eat several small, nutrient-rich meals to avoid becoming breathless while eating. - Eat slowly and chew foods thoroughly to avoid swallowing air while eating. - Choose foods that are easy to chew. Modify food consistency if mastication seems to increase fatigue while eating. 12. You notice a box of dark chocolate on D.Z.'s overbed table. He tells you that his wife brought him those because he always wakes at night and eats four or five pieces. What is thought to be the basis for this craving for chocolate? The pt has COPD. The pt potentially has a loss of calories in the body because energy is spent in persistent coughing and using accessory muscles. The patient will crave chocolate to meet his caloric and energy demands. 13. After speaking with D.Z. about his diet and reviewing his medications, you are now concerned about his glycemic control. Hospital policy allows you to obtain as-needed blood glucose levels for diabetic patients, so you direct the nursing assistive personnel (NAP) to obtain D.Z.'s blood glucose level at 2100. What is your responsibility in delegating this task to the NAP? RN responsibility when delegating this task to the NAP is to obtain the glucose result at the scheduled time and to review and interpret the results to plan interventions appropriately or communicate the results to the provider. 14. The NAP reports that D.Z.'s blood glucose level is 366 mg/dL. What action do you need to take and why? Indicate that this is an expected outcome for D.Z. that is associated with each medication he is receiving. Methylprednisolone: corticosteroid. However, I will prepare to administer insulin as ordered by the provider and/or contact the provider. 15. What other health care professional would probably be involved in D.Z.'s treatments and how? Pulmonologist, Endocrinologist, respiratory therapist, physical therapist, occupational therapist CaSE StuDy ProGrESS The next morning, D.Z. is sitting in the bedside chair and appears to be experiencing less difficulty breathing. He states his cough remains productive of yellow-green sputum, although it is “easier to cough up” than it was the previous day. You auscultate decreased breath sounds and a few coarse crackles in both lower lobes posteriorly. His VS are 150/78, 94, 24, 99.7° F (37.6° C). His SpO 2 is 92% with oxygen on at 2 L per nasal cannula. Chart View Arterial Blood Gases (ABGs) pH 7.34 PaCO 58 mm Hg 2 HCO 32 mmol/L 3 PaO 65 mm Hg 2 SaO 92% 2 16. Interpret D.Z.'s ABG values. pH: 7.34: Acidemia PaCo2 58mmHg: severe hypoxemia HCO3: high (likely compensation) PaO2 65 mmHg: low oxygen saturation in Hgb SaO2 92%: low total oxygen 17. Has D.Z.'s status improved or not? Defend your response. According to his symptomatology and vitals signs, his condition is improving. However, unable to determine based on ABGs as there is no baseline to compare. D.Z. is in partially compensating respiratory acidosis. 18. What interventions would you include in your plan of care for D.Z. today? All interventions ordered by the provided above. Reposition the patient for comfort and to improve breathing CaSE StuDy ProGrESS 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. 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." 19. How would you respond to her statement? Talk to teh provider to suggest a referral for respite care, OT, PT, and Home Health Services Provide education about community resources.