copd - Nursing Case Study

Pathophysiology

• Primary mechanism: Chronic inflammation - In COPD, exposure to irritants like tobacco smoke and pollution causes persistent inflammation in the lungs. This leads to damage of the airways (bronchitis) and destruction of air sacs (emphysema), making it harder to breathe.

• Secondary mechanism: Airflow limitation - The inflammation and damage cause the airways to narrow and lose elasticity, resulting in less air being able to flow in and out of the lungs. This is further exacerbated by the production of excess mucus which can block the airways.

• Key complication: Hypoxemia and Hypercapnia - Continued disease progression can lead to inadequate oxygen supply (hypoxemia) and buildup of carbon dioxide (hypercapnia) in the blood. This can cause fatigue, confusion, and can potentially lead to organ damage.

Patient Profile

Demographics:

67-year-old male retired construction worker

History:

• Key past medical history: Diagnosed with early stage COPD last year, mild hypertension

• Current medications: Salbutamol inhaler as needed, Lisinopril for hypertension

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Mild shortness of breath on exertion, no changes in symptoms since last visit

• Key symptoms: Occasional cough, breathlessness during physical activities

• Vital signs: Blood pressure 130/85, heart rate 75 beats per minute, respiratory rate 16 breaths per minute, oxygen saturation 97% on room air.

Section 1

Initial Assessment Findings:

Upon further assessment, the nurse notes that the patient demonstrates pursed-lip breathing, a common coping mechanism in COPD patients to improve exhalation. The patient also reports occasional wheezing, especially after physical exertion. Physical examination reveals decreased breath sounds in the lower lobes of the lungs and a prolonged expiratory phase, both suggestive of obstructive airway disease. The patient's weight and BMI are within normal range, and he has no signs of peripheral edema, reducing the likelihood of heart failure. The nurse also assesses the patient's inhaler technique and finds that he is using his salbutamol inhaler correctly.

New Diagnostic Results:

The patient undergoes a spirometry test, a key diagnostic tool for COPD. The results show a forced expiratory volume in one second (FEV1) of 70% predicted, and a FEV1/FVC (forced vital capacity) ratio of 0.6, confirming the presence of airflow obstruction, characteristic of COPD. Results of the patient's complete blood count (CBC), electrolyte panel, and cardiac markers are all within normal limits. The chest X-ray reveals hyperinflation of the lungs but no signs of pneumonia or other acute conditions. The echocardiogram shows normal heart structure and function, further ruling out heart failure as a cause of his symptoms.

Section 2

Response to Interventions:

In response to the patient's COPD diagnosis, the nurse initiates COPD management interventions. The patient is encouraged to engage in moderate physical activity to strengthen his respiratory muscles and improve overall lung function. He is also educated about the importance of avoiding lung irritants like smoke and dust. The nurse provides further instruction on proper inhaler technique, ensuring the patient understands the salbutamol should be used as a reliever medication for sudden breathlessness, not as a regular treatment.

Over the next few weeks, the nurse monitors the patient's condition closely. His breath sounds improve marginally, and he reports less frequent wheezing after exertion. He adheres to the advised physical activity and has noticed a slight improvement in his stamina. The patient's oxygen saturation remains stable at 94-96% on room air, and he has no new complaints. While the patient's FEV1 remains at 70%, he is managing his symptoms more effectively, demonstrating a positive response to the interventions. The nurse continues to educate the patient about the progressive nature of COPD and the importance of regular follow-ups and symptom management.

Section 3

Change in Patient Status:

Over the next week, the patient reports that he is feeling increasingly tired and has difficulty performing his usual activities. He also mentions that he has been having a dry cough more frequently, especially at night, making it difficult for him to sleep. On assessment, the nurse notes that his respiratory rate has increased to 22 breaths per minute from his usual 18, and his oxygen saturation has dropped slightly to 92%. His heart rate is slightly elevated at 90 beats per minute, and his blood pressure remains within normal range.

The nurse recognizes these changes as possible signs of exacerbation and takes immediate action. She instructs the patient to increase the use of his salbutamol inhaler to help relieve his symptoms and arranges for a same-day appointment with the healthcare provider. She also advises the patient to rest and drink more fluids. These changes in the patient's status highlight the need for ongoing assessment and vigilance in monitoring the patient's condition, as well as the importance of prompt action in response to signs of COPD exacerbation.

Section 4

New Diagnostic Results:

After the healthcare provider's visit, the patient underwent a spirometry test which showed a decreased forced expiratory volume in one second (FEV1) of 70% predicted, correlating with mild to moderate COPD. His arterial blood gas (ABG) analysis showed a partial pressure of oxygen (PaO2) of 75 mm Hg and a partial pressure of carbon dioxide (PaCO2) of 45 mm Hg, indicating a slight hypoxemia and hypercapnia. The blood test also revealed a slightly increased white blood cell count of 11,000 cells/mm3, suggesting a possible infection.

These results confirmed the nurse's suspicion of a COPD exacerbation, potentially triggered by an underlying infection. The healthcare provider decided to prescribe a short course of corticosteroids and antibiotics to manage the exacerbation and potential infection. The patient was advised to continue using his salbutamol inhaler and was scheduled for a follow-up appointment in a week to monitor his progress. This scenario emphasizes the significance of diagnostic tests in confirming clinical suspicions and guiding patient management.

Section 5

Change in Patient Status:

A week later, during the follow-up visit, the patient reported reduced shortness of breath and improved exercise tolerance. However, he mentioned experiencing a dry mouth and mild tremors, potentially side effects of the salbutamol inhaler. His vital signs were stable with a blood pressure of 120/80 mmHg, heart rate of 78 beats per minute, respiratory rate of 18 breaths per minute, and oxygen saturation of 95% on room air.

The nurse, keeping in mind these observations and the patient's feedback, decided to assess the patient's inhaler technique. The assessment revealed that the patient was not using the inhaler properly, which could contribute to the side effects and potentially limit the medication's effectiveness. The nurse took this opportunity to educate the patient about the correct inhaler technique and stress the importance of adherence to medication for managing his COPD. This case emphasizes the importance of ongoing patient assessment and education in managing chronic diseases. Following this, the nurse scheduled another appointment for the following week to re-evaluate the patient's status and inhaler technique.