A patient with chronic COPD presents with acute respiratory failure and worsening symptoms despite supplemental oxygen therapy. Arterial blood gas analysis reveals a pH of 7.32, PaCO2 of 58 mmHg, and PaO2 of 55 mmHg. Which intervention should the nurse prioritize to improve the patient's respiratory status?

C) Prepare the patient for non-invasive positive pressure ventilation (NIPPV).

A) Increase the flow rate of supplemental oxygen via nasal cannula to 4 liters per minute.

B) Administer a dose of intravenous corticosteroids as prescribed.

C) Prepare the patient for non-invasive positive pressure ventilation (NIPPV).

D) Encourage the patient to perform incentive spirometry every hour.

A patient with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute respiratory failure. Which intervention should the nurse prioritize to improve the patient's breathing and gas exchange?

A) Increase the oxygen flow rate via nasal cannula to 5 liters per minute.

B) Administer prescribed inhaled bronchodilators and corticosteroids.

D) Position the patient supine to facilitate better lung expansion.

A patient with acute respiratory failure secondary to a confirmed Streptococcus pneumoniae infection is being treated with non-invasive positive pressure ventilation (NIPPV) and antibiotics. The patient develops mild tachycardia and peripheral edema. What is the most appropriate nursing intervention to address these new symptoms?

B) Reassess fluid management and consider diuretics if indicated.

A) Increase the frequency of nebulized bronchodilators.

B) Reassess fluid management and consider diuretics if indicated.

C) Discontinue NIPPV to reduce cardiac workload.

D) Increase corticosteroid dosage to manage inflammation.

A patient with acute respiratory failure due to Streptococcus pneumoniae infection is being managed with oral corticosteroids, nebulized bronchodilators, and non-invasive positive pressure ventilation (NIPPV). The patient now exhibits mild tachycardia and peripheral edema. What is the nurse's priority intervention?

D) Monitor intake and output closely and prepare for a cardiology consult.

A) Increase the frequency of nebulized bronchodilators to address respiratory distress.

B) Administer diuretics as prescribed to address potential fluid overload.

C) Discontinue NIPPV and initiate invasive mechanical ventilation.

D) Monitor intake and output closely and prepare for a cardiology consult.

A patient with acute decompensated heart failure is being monitored after initiating diuretic therapy. Which assessment finding would best indicate that the treatment is effective?

B) Heart rate of 130 beats per minute

C) Blood pressure reading of 150/90 mmHg

D) Increased respiratory rate to 30 breaths per minute

A patient with acute decompensated heart failure is experiencing worsening peripheral edema and dyspnea. Following the initiation of diuretic therapy, which of the following nursing assessments is most critical to evaluate the effectiveness of the treatment?

C) Evaluating the patient's lung sounds for reduction in crackles

A) Monitoring the patient's blood pressure for hypotension

B) Assessing the patient's urine output for increased diuresis

C) Evaluating the patient's lung sounds for reduction in crackles

D) Checking the patient's heart rate for normalization

A patient receiving diuretic therapy has developed hypokalemia and hypomagnesemia. What is the most appropriate nursing intervention to prioritize in this situation?

B) Monitor the patient for signs of cardiac arrhythmias.

A) Encourage the patient to increase fluid intake.

B) Monitor the patient for signs of cardiac arrhythmias.

C) Restrict the patient’s dietary intake of sodium.

D) Advise the patient to avoid foods high in potassium.

A patient receiving diuretic therapy has developed hypokalemia and hypomagnesemia. Which nursing intervention is the priority to address these electrolyte imbalances and prevent further complications?

A) Administer prescribed potassium and magnesium supplements and monitor the patient's cardiac rhythm.

B) Increase the patient's fluid intake to promote renal excretion of excess diuretics.

C) Provide the patient with a low-sodium diet to prevent fluid retention.

D) Encourage the patient to perform daily exercise to improve circulation.

A patient receiving potassium and magnesium supplementation reports mild muscle weakness, cramps, and exhibits labored breathing with a low-grade fever. The magnesium level remains suboptimal, and arterial blood gas analysis shows respiratory acidosis. What is the priority nursing intervention to address the patient's current symptoms while ensuring respiratory stability?

C) Initiate non-invasive positive pressure ventilation to improve respiratory effort.

A) Increase the rate of potassium infusion to correct muscle weakness.

B) Administer additional magnesium supplementation to correct the low magnesium level.

C) Initiate non-invasive positive pressure ventilation to improve respiratory effort.

D) Discontinue diuretic therapy to prevent further electrolyte imbalances.

A patient receiving potassium and magnesium supplementation presents with mild muscle weakness, cramps, and labored breathing. The latest lab results show a serum magnesium level of 1.7 mg/dL and ABG results indicating respiratory acidosis. Which nursing intervention should be prioritized to address the patient's current condition?

B) Elevate the head of the bed and administer oxygen to improve respiratory effort.

A) Increase the rate of potassium infusion to quickly correct electrolyte imbalance.

B) Elevate the head of the bed and administer oxygen to improve respiratory effort.

C) Discontinue diuretic therapy to prevent further electrolyte disturbances.

D) Initiate intravenous calcium gluconate to counteract potential cardiac effects.

copd - Nursing Case Study

Pathophysiology

• Primary mechanism: Chronic inflammation in the airways leads to narrowing and obstruction. This results from the body’s response to irritants like cigarette smoke, causing structural changes and mucus hypersecretion, which obstruct airflow and reduce lung capacity.

• Secondary mechanism: Destruction of alveolar walls (emphysema) caused by an imbalance between proteases and antiproteases, leading to loss of elastic recoil. This impairs gas exchange and causes air trapping, further reducing lung efficiency.

• Key complication: Hypoxemia and hypercapnia can develop as the disease progresses, due to the combined effects of airway obstruction and impaired gas exchange, leading to respiratory distress and potential right-sided heart failure (cor pulmonale).

Patient Profile

Demographics:

67-year-old male, retired coal miner

History:

• Key past medical history: Chronic bronchitis, hypertension, history of smoking (40 pack-years), and hyperlipidemia

• Current medications: Tiotropium, Albuterol as needed, Lisinopril, Atorvastatin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing shortness of breath over the past week

• Key symptoms: Persistent cough with sputum production, wheezing, fatigue, occasional chest tightness

• Vital signs: Blood pressure 145/90 mmHg, heart rate 102 bpm, respiratory rate 24 breaths per minute, oxygen saturation 88% on room air, temperature 98.6°F (37°C)

Section 1

As the healthcare team continues to assess the patient, they note a change in his status that warrants further investigation. Over the next 24 hours, the patient experiences increasing difficulty maintaining adequate oxygen saturation despite supplemental oxygen therapy. His oxygen saturation drops to 84% with 2 liters per minute of oxygen via nasal cannula. Auscultation reveals diminished breath sounds bilaterally with increased wheezing and crackles at the lung bases. The patient also reports worsening fatigue and a sensation of increased chest tightness, which raises concern about potential exacerbation of his underlying COPD and possible development of acute respiratory failure.

Lab results show an arterial blood gas (ABG) analysis indicating a pH of 7.32, PaCO2 of 58 mmHg, and PaO2 of 55 mmHg, confirming respiratory acidosis and hypoxemia. These findings suggest that the patient is experiencing a chronic COPD exacerbation with acute respiratory failure. Blood tests reveal elevated white blood cell count, suggesting a possible infection contributing to the exacerbation. Given the patient’s history of chronic bronchitis and his current presentation, there is also a suspicion of a bacterial lung infection, prompting the initiation of empirical antibiotic therapy while awaiting sputum culture results.

The patient's condition highlights the importance of close monitoring and the need for a comprehensive management plan. This situation requires the healthcare team to utilize clinical reasoning to adjust medications, including inhaled bronchodilators and corticosteroids, to reduce airway inflammation and improve airflow. Additionally, consideration of non-invasive positive pressure ventilation (NIPPV) may be necessary to support breathing and improve gas exchange. The development of these complications underscores the need for vigilant assessment and timely intervention to prevent further deterioration and guide the next steps in the patient’s care.

Section 2

As the healthcare team implements the management plan, they closely monitor the patient's response to the interventions. The patient is started on a course of oral corticosteroids and is administered nebulized bronchodilators every 4 hours to address the bronchospasm and inflammation. Despite these efforts, his respiratory status remains precarious. The nursing team notes that the patient's respiratory rate has increased to 28 breaths per minute, and he exhibits accessory muscle use, indicating increased work of breathing. His vital signs show a heart rate of 110 beats per minute, blood pressure of 150/90 mmHg, and a temperature of 38.2°C, suggesting a febrile response potentially linked to the suspected infection.

The decision is made to initiate non-invasive positive pressure ventilation (NIPPV) to improve his oxygenation and reduce carbon dioxide retention. After several hours on NIPPV, there is a moderate improvement in his oxygen saturation, which increases to 90%, although his PaCO2 remains elevated at 55 mmHg. Repeat ABG analysis shows a slight improvement in pH to 7.34, indicating partial compensation, but the patient continues to feel fatigued and reports persistent chest tightness.

Sputum culture results return, confirming the presence of Streptococcus pneumoniae, aligning with the clinical suspicion of a bacterial infection. This leads to an adjustment in the antibiotic regimen to target the specific pathogen more effectively. However, the team begins to notice new complications; the patient develops mild tachycardia and some peripheral edema, raising concerns about potential fluid overload or cardiac strain. This prompts the healthcare team to reassess fluid management and consider a cardiology consult to evaluate the patient's cardiac status, particularly given the stress of acute respiratory failure on his cardiovascular system. Through careful clinical reasoning and ongoing assessment, the team aims to stabilize the patient's condition and prevent further deterioration.

Section 3

As the healthcare team continues to monitor the patient, a new complication arises that requires immediate attention. The patient's peripheral edema worsens, and he reports an increase in dyspnea and discomfort when lying flat. A follow-up assessment reveals that his heart rate has escalated to 120 beats per minute, and his blood pressure has decreased slightly to 140/88 mmHg. Auscultation of the lungs indicates crackles at the bases, suggesting fluid accumulation. These findings raise concerns about potential heart failure exacerbated by the stress of his acute respiratory condition and the fluid administration he has received.

In response to these changes, a chest X-ray is ordered, revealing bilateral pulmonary congestion and cardiomegaly, confirming suspicions of acute decompensated heart failure. Laboratory tests show an elevated B-type natriuretic peptide (BNP) level, further supporting this diagnosis. The healthcare team revisits the patient's fluid management plan, reducing fluid intake and initiating diuretic therapy to alleviate the fluid overload and cardiac strain. The cardiology team is consulted to provide expertise on optimizing the patient's cardiovascular function, considering the interplay between his respiratory and cardiac issues.

The patient is closely monitored for any signs of improvement or further deterioration. Over the next 24 hours, there is a slight reduction in peripheral edema, and his respiratory status shows modest improvement with a decrease in respiratory rate to 24 breaths per minute. Oxygen saturation stabilizes around 92% with the continued use of NIPPV. Despite these positive trends, the patient remains at risk for further complications, necessitating vigilant monitoring and ongoing adjustments to his management plan. The clinical team focuses on a holistic approach, ensuring both respiratory and cardiac stabilization to pave the way for eventual recovery.

Section 4

As the patient continues to receive diuretic therapy and supportive care, the healthcare team remains vigilant for any further complications. Over the next 48 hours, while there is improvement in peripheral edema and slight stabilization of respiratory status, a new concern arises. The patient begins to exhibit signs of electrolyte imbalance, a potential side effect of aggressive diuresis. Laboratory results indicate a serum potassium level of 3.1 mEq/L, below the normal range, raising the risk for cardiac arrhythmias. Concurrently, his magnesium level is also found to be low at 1.5 mg/dL.

Recognizing the potential complications associated with these electrolyte disturbances, the clinical team swiftly adjusts the patient's management plan. Potassium and magnesium supplements are initiated to correct these deficiencies, and the patient's cardiac rhythm is closely monitored for signs of arrhythmia. The healthcare team revisits the patient's medication regimen, ensuring that diuretics are not contributing excessively to the electrolyte imbalances. Additionally, the patient's diet is evaluated to identify opportunities for dietary adjustments that could support electrolyte balance.

Throughout this period, the patient's clinical status is meticulously assessed. His heart rate remains elevated at around 115 beats per minute, but there is no evidence of arrhythmias on continuous cardiac monitoring. Blood pressure stabilizes slightly at 135/86 mmHg. The nursing team educates the patient and family on the importance of adherence to the revised treatment plan and the signs of worsening electrolyte imbalance. This comprehensive approach aims to address the patient's immediate needs while preventing further complications, setting the stage for continued recovery and stabilization.

Section 5

As the patient continues to receive potassium and magnesium supplementation, the healthcare team remains vigilant for the emergence of any new complications. Within 24 hours of initiating the electrolyte replacement therapy, a change in the patient's status is noted. The patient reports experiencing mild muscle weakness and cramps, symptoms that could indicate ongoing electrolyte disturbances despite the recent interventions. Additionally, the patient begins to exhibit a low-grade fever of 100.2°F, and his respiratory effort appears slightly labored compared to the previous day.

New diagnostic results reveal that while the serum potassium level has improved to 3.5 mEq/L, the magnesium level remains suboptimal at 1.7 mg/dL. Arterial blood gas analysis shows a pH of 7.34, PaCO2 of 48 mmHg, and HCO3- of 22 mEq/L, suggesting a mixed acid-base disturbance with a component of respiratory acidosis. The patient's heart rate remains elevated at 112 beats per minute, and although continuous cardiac monitoring shows no arrhythmias, the slight labored breathing and changes in blood gas values prompt concerns about the potential for respiratory compromise.

In response to these findings, the clinical team prioritizes optimizing the patient's ventilation and further supports electrolyte correction. Additional magnesium supplementation is administered, and the patient is placed on non-invasive positive pressure ventilation to alleviate respiratory strain and improve gas exchange. The nursing team intensifies monitoring and reassesses the patient's fluid and electrolyte management plan, considering adjustments to diuretic therapy to prevent further imbalances. This proactive strategy aims to stabilize the patient's condition, mitigate the risk of respiratory failure, and ensure that his clinical trajectory remains on a path toward recovery.