copd - Nursing Case Study

Pathophysiology

• Primary mechanism: Chronic inflammation - Long-term exposure to irritants like tobacco smoke and air pollutants causes inflammation in the airways and lung tissue, leading to structural changes. These changes restrict airflow and impair the lungs' ability to exchange oxygen and carbon dioxide efficiently.

• Secondary mechanism: Air-trapping - Over time, the inflammation causes airways to narrow and lose elasticity. The damaged airways can't fully expel air, causing it to become trapped in the lungs. This results in hyperinflation of the lungs, leading to breathlessness and decreased lung function.

• Key complication: Chronic bronchitis - This is a common complication in COPD patients. Inflammation and mucus production in the bronchial tubes lead to a persistent cough and increased difficulty in breathing. Frequent respiratory infections can further exacerbate these symptoms. This cycle of chronic inflammation and infection can accelerate the progression of the disease.

Patient Profile

Demographics:

58, male, office clerk

History:

• Hypertension, early-stage COPD diagnosed 2 years ago

• Metoprolol for hypertension, Salbutamol as required for COPD

• No known allergies

Current Presentation:

• Occasional cough and shortness of breath

• Mild persistent cough, occasional breathlessness especially on exertion, no chest pain, no weight loss

• Blood pressure: 130/85 mmHg, Pulse: 75 bpm, Respiratory rate: 16 breaths per minute, Oxygen saturation: 96% on room air, Temperature: 98.6 F

Section 1

Response to Interventions:

The patient was instructed to use his Salbutamol inhaler when he feels short of breath, especially before exertion. On follow-up, he reports that he is using the inhaler approximately twice a week, typically before partaking in activities like walking his dog or gardening. He reports that the inhaler does help to alleviate his symptoms of breathlessness. The patient was also advised to quit smoking, a habit he had for the past 30 years. He has managed to reduce his daily cigarette intake from 20 to 10 cigarettes per day, a significant achievement for him.

New Complications:

However, the patient has noted a gradual increase in the frequency of his cough over the past month, even though he has been using his inhaler as instructed. He also mentions that he wakes up at night due to coughing fits, which was not the case before. Although no fever or weight loss is reported, he has noticed an increased production of mucus, which is sometimes yellowish in color. These changes may suggest the onset of an acute exacerbation of his chronic bronchitis, a complication of COPD.

Section 2

Change in Patient Status:

On his latest visit, the patient appears visibly tired and states that his sleep has been disturbed due to the persistent cough. He also mentions that he feels more fatigued after performing routine tasks, which was not the case previously. On physical examination, his respiratory rate is slightly elevated at 22 breaths per minute, with a regular pulse of 88 beats per minute. Auscultation of the chest reveals the presence of scattered wheezes and crackles, more prominent than before.

New Diagnostic Results:

To evaluate the recent changes in his condition, a chest X-ray was ordered. The radiograph revealed hyperinflation of the lungs and an increase in the bronchovascular markings, both signs of COPD progression. His pulmonary function tests (PFTs) also showed a decreased forced expiratory volume in one second (FEV1) compared to his last visit, indicating a decline in lung function. Additionally, the sputum culture test showed the presence of Haemophilus influenzae, a common bacteria associated with exacerbations in COPD patients. These findings concur with the worsening of his symptoms and suggest the need for a change in his management plan.

Section 3

Change in Patient Status:

During the following visit, the patient reports experiencing shortness of breath even with minimal exertion, such as walking short distances or climbing stairs. He also mentions that he has been feeling more lethargic lately and has lost some weight unintentionally. On physical examination, his respiratory rate is noted to have increased further to 26 breaths per minute, and his pulse is now slightly tachycardic at 92 beats per minute. On auscultation, the wheezes and crackles in his chest are more widely spread and louder than before, suggesting further progression of his COPD.

New Diagnostic Results:

Considering the worsening of his condition, further tests were ordered. The patient's arterial blood gas (ABG) results showed a PaO2 of 70 mmHg, PaCO2 of 38 mmHg, and an oxygen saturation (SpO2) of 94% on room air, indicating mild hypoxemia. His complete blood count revealed an elevated white blood cell count of 12,000 per microliter, hinting at an ongoing infectious process, likely due to the previously identified Haemophilus influenzae. These new findings, combined with his worsening symptoms, suggest that the patient is experiencing an exacerbation of his COPD, which necessitates an adjustment in his treatment plan.

Section 4

Response to Interventions:

The patient was put on a short-term regimen of oral corticosteroids to manage the exacerbation of his COPD symptoms. His smoking cessation plan was reinforced, with a focus on behavioral strategies to help him quit. To address his hypoxemia, supplemental oxygen therapy was initiated at 2 liters per minute via a nasal cannula, which improved his oxygen saturation to 98%. His respiratory rate also reduced to 20 breaths per minute after the oxygen therapy.

However, despite these measures, his lethargy persisted. He reported feeling tired most of the day and his unintentional weight loss continued. An assessment of his nutritional status revealed that he had poor appetite and was not eating adequately. Considering these findings, a consultation with a dietitian was requested to address his nutritional needs and a complete metabolic panel was ordered to rule out metabolic causes for his weight loss and lethargy.

Section 5

Change in Patient Status:

During the subsequent few days, the patient's overall condition seemed to improve marginally with the interventions. He reported a slight increase in energy levels and was managing to eat better with the dietary plan provided by the dietitian. His weight was monitored daily and there was no further loss, indicating that the nutritional interventions were starting to have some effect.

However, the patient continued to report some degree of breathlessness, particularly during activities such as walking to the restroom or moving around his room. His oxygen saturation levels remained stable at 98% on the supplemental oxygen, but dropped to 92% during these periods of activity. The patient's heart rate also showed an intermittent increase up to 100 beats per minute, correlating with the dyspnea. These symptoms indicated that while his COPD was managed at rest, it was not fully under control during activity. This led to a decision to increase physical therapy to strengthen his respiratory muscles and improve his exercise tolerance. A reevaluation of his COPD management plan was also scheduled to better control his symptoms.