A patient with an acute exacerbation of COPD is experiencing increased shortness of breath, productive cough, and decreased SpO2 levels. Which nursing intervention is the priority to improve the patient's respiratory status?

D) Administer prescribed bronchodilators and monitor effectiveness.

A) Encourage increased fluid intake to thin secretions.

B) Initiate high-flow oxygen therapy to maintain SpO2 above 90%.

C) Position the patient in high Fowler's to facilitate lung expansion.

D) Administer prescribed bronchodilators and monitor effectiveness.

A nurse is caring for a patient with an acute exacerbation of COPD, experiencing increased shortness of breath, productive cough, and a drop in SpO2 levels. What is the priority nursing intervention to address the patient's immediate respiratory needs?

C) Position the patient in high Fowler's position

A) Administer a bronchodilator via nebulizer

B) Increase the patient's supplemental oxygen flow rate

C) Position the patient in high Fowler's position

D) Prepare for endotracheal intubation

A patient with COPD exacerbation and suspected pneumonia presents with respiratory acidosis, hypoxemia, and signs of right ventricular hypertrophy. The healthcare team has decided to initiate noninvasive ventilation (NIV) and broad-spectrum antibiotics. Which of the following nursing interventions is the most critical to implement first to stabilize the patient's condition?

C) Initiate noninvasive ventilation to improve gas exchange

A) Administer bronchodilator therapy immediately

B) Begin broad-spectrum antibiotics as ordered

C) Initiate noninvasive ventilation to improve gas exchange

D) Position the patient in a semi-Fowler's position to enhance breathing

A patient with COPD exacerbation is experiencing acute respiratory failure, as evidenced by ABG results showing respiratory acidosis and hypoxemia. The patient also shows signs of pneumonia and possible cor pulmonale. What is the nurse's priority intervention to optimize the patient's respiratory status?

B) Initiate noninvasive ventilation to improve gas exchange and reduce work of breathing.

A) Encourage deep breathing and coughing exercises to improve lung expansion.

B) Initiate noninvasive ventilation to improve gas exchange and reduce work of breathing.

C) Increase the patient's oxygen flow rate to achieve an SpO2 of 100%.

D) Administer broad-spectrum antibiotics immediately to address potential infection.

A patient receiving high-dose diuretics for fluid management presents with fatigue and muscle weakness. Recent lab results show a serum potassium level of 3.2 mEq/L. What is the most appropriate nursing intervention to address the patient's electrolyte imbalance?

B) Administer potassium supplements as prescribed and monitor serum potassium levels.

A) Encourage increased fluid intake to dilute serum electrolyte levels.

B) Administer potassium supplements as prescribed and monitor serum potassium levels.

C) Restrict dietary sodium to prevent further electrolyte imbalances.

D) Increase the dosage of diuretics to enhance fluid elimination.

A patient receiving treatment for respiratory distress and infection has shown improvements in SpO2 and a decrease in white blood cell count but reports increased fatigue and difficulty mobilizing. Which intervention should the nurse prioritize based on the current clinical findings?

B) Administer potassium supplements to address hypokalemia.

A) Increase the dose of broad-spectrum antibiotics to enhance infection control.

B) Administer potassium supplements to address hypokalemia.

C) Increase the frequency of noninvasive ventilation to improve respiratory parameters.

D) Initiate physical therapy to improve muscle strength and mobility.

A patient with COPD exacerbation presents with new symptoms of a persistent cough, greenish-yellow sputum, mild confusion, disorientation, peripheral edema, tachycardia, and elevated blood pressure. After reviewing the patient's arterial blood gas results revealing a PaO2 of 58 mmHg and PaCO2 of 60 mmHg, what should be the nurse's priority intervention?

A) Administer supplemental oxygen to improve oxygenation.

B) Increase the dose of diuretics to reduce peripheral edema.

C) Obtain sputum cultures to identify the causative organism.

D) Consult with cardiology for further evaluation of cardiac function.

A patient with COPD exacerbation is showing signs of new complications, including increased sputum production, mental confusion, and peripheral edema. Which intervention should the nurse prioritize to address the patient's respiratory status?

B) Increase oxygen therapy to improve oxygenation

A) Administer a loop diuretic to reduce peripheral edema

B) Increase oxygen therapy to improve oxygenation

C) Obtain a sputum culture to guide antibiotic therapy

D) Perform chest physiotherapy to enhance sputum clearance

A patient with ongoing respiratory issues and recent changes in diuretic therapy is showing signs of fluctuating mental status and confirmed hypokalemia. What is the most appropriate nursing action to prioritize at this time?

C) Notify the physician about the low potassium level for further orders

A) Administer oxygen therapy to improve hypoxemia

B) Initiate fall precautions to prevent injury from confusion

C) Notify the physician about the low potassium level for further orders

D) Educate the patient and family about the prevention of delirium

A patient with a history of heart failure and recent respiratory infection is showing signs of fluctuating mental status and elevated heart rate. The laboratory results indicate hypokalemia. Which nursing intervention should be prioritized to address the current findings?

B) Administer prescribed potassium supplements and monitor cardiac rhythm.

A) Increase the patient's fluid intake to promote kidney function.

B) Administer prescribed potassium supplements and monitor cardiac rhythm.

C) Restrict the patient's mobility to prevent falls due to confusion.

D) Implement a high-sodium diet to manage hypertension.

COPD - Nursing Case Study

Pathophysiology

• Primary mechanism: Chronic inflammation in the airways causes narrowing and obstruction, primarily due to long-term exposure to irritants like cigarette smoke. This inflammation leads to increased mucus production and airway remodeling, resulting in airflow limitation.

• Secondary mechanism: Destruction of alveolar walls due to protease-antiprotease imbalance, often seen in emphysema, reduces the surface area for gas exchange. The loss of elastic recoil in the lungs further contributes to airflow obstruction and air trapping.

• Key complication: Reduced gas exchange efficiency leads to hypoxemia and hypercapnia, which can cause respiratory acidosis and put strain on the heart, potentially leading to cor pulmonale (right-sided heart failure).

Patient Profile

Demographics:

62-year-old male, retired factory worker

History:

• Key past medical history: Diagnosed with COPD 5 years ago, history of smoking (30 pack-years), hypertension, and hyperlipidemia

• Current medications: Tiotropium, Salbutamol, Lisinopril, Atorvastatin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing shortness of breath and persistent cough

• Key symptoms: Wheezing, frequent exacerbations, productive cough with sputum, mild chest tightness, and fatigue

• Vital signs: Blood pressure 148/92 mmHg, heart rate 96 bpm, respiratory rate 24 breaths per minute, SpO2 89% on room air, temperature 37.8°C

Section 1

Change in Patient Status:

The patient's condition has recently changed, manifesting as an acute exacerbation of COPD. Despite adhering to his medication regimen, he has experienced a marked increase in the frequency and severity of his symptoms. His shortness of breath has worsened, now occurring even with minimal exertion, such as walking short distances or performing routine activities like dressing. Furthermore, his cough has become more productive, with thick, yellowish sputum, indicating a possible bacterial infection. In the past 24 hours, his SpO2 levels have dropped to 85% on room air, prompting the need for supplemental oxygen therapy.

During a recent assessment, auscultation revealed bilateral coarse crackles and wheezing, particularly in the lower lung fields, suggesting airway obstruction and fluid accumulation. The patient's heart rate has increased to 110 beats per minute, and his blood pressure has risen to 152/94 mmHg, indicating increased cardiovascular strain. His respiratory rate has also climbed to 28 breaths per minute, as he struggles to maintain adequate ventilation. Additionally, the patient reports worsening fatigue and confusion, possibly linked to hypoxemia and hypercapnia. Given these findings, the clinical team is concerned about the development of acute respiratory failure and the potential onset of cor pulmonale.

In response to these changes, a thorough analysis of arterial blood gases (ABGs) is necessary to evaluate the patient's acid-base balance and guide treatment decisions. The healthcare team should consider implementing noninvasive ventilation to improve oxygenation and reduce carbon dioxide retention. Additionally, they must reassess the patient's medication regimen, particularly the use of bronchodilators and corticosteroids, to manage the exacerbation effectively. A sputum culture may be needed to identify any infectious pathogens, allowing for targeted antibiotic therapy. This evolving situation demands careful monitoring and prompt intervention to prevent further deterioration and stabilize the patient's respiratory status.

Section 2

New Diagnostic Results:

Following the concerning changes in the patient's condition, the healthcare team proceeded with a series of diagnostic tests to gain a clearer understanding of the underlying issues. The arterial blood gas (ABG) analysis revealed a pH of 7.32, indicating respiratory acidosis, with a partial pressure of carbon dioxide (PaCO2) elevated to 58 mmHg and a decreased partial pressure of oxygen (PaO2) at 55 mmHg. These results confirm significant hypoxemia and hypercapnia, corroborating the clinical suspicion of acute respiratory failure. Additionally, a complete blood count (CBC) showed leukocytosis, with a white blood cell count of 14,000/mm³, suggesting a possible bacterial infection. The sputum culture is pending, but the presence of yellowish sputum aligns with this preliminary finding.

The chest X-ray demonstrated increased interstitial markings and areas of consolidation, particularly in the lower lobes, indicating possible pneumonia complicating the COPD exacerbation. This radiological evidence, combined with the ABG results, suggests a multi-faceted approach is necessary to address both the infectious process and the respiratory insufficiency. Furthermore, the echocardiogram showed signs of right ventricular hypertrophy, reinforcing the potential development of cor pulmonale due to chronic lung disease.

Given these diagnostic findings, the clinical team must prioritize interventions that address the identified complications. Immediate considerations include adjusting the patient's oxygen therapy to maintain SpO2 above 90% and initiating noninvasive ventilation to support better gas exchange. The empirical use of broad-spectrum antibiotics should be considered while awaiting definitive culture results. These measures, alongside optimizing the patient's bronchodilator and corticosteroid regimen, are critical in stabilizing the patient's condition and preventing further deterioration. This comprehensive approach underscores the importance of timely and targeted interventions in managing complex COPD exacerbations with concurrent complications.

Section 3

Response to Interventions:

Following the initiation of noninvasive ventilation and adjustments to the patient's oxygen therapy, a noticeable improvement in respiratory parameters was observed. The patient's SpO2 levels increased to 92%, indicating a more adequate oxygenation status. Despite this positive change, the patient's respiratory rate remained elevated at 28 breaths per minute, pointing to ongoing respiratory distress. The healthcare team continued to closely monitor arterial blood gases, which showed a slight improvement in the pH level to 7.34, and a decrease in PaCO2 to 54 mmHg, suggesting partial compensation of the respiratory acidosis.

Concurrent with respiratory management, the empirical administration of broad-spectrum antibiotics was initiated to target the suspected bacterial infection. Within 48 hours, the patient's white blood cell count began to normalize, decreasing to 12,000/mm³, reflecting a potential response to the antibiotic therapy. However, despite these interventions, the patient reported increased fatigue and difficulty in mobilizing, raising concerns about possible muscle weakness or further complications such as electrolyte imbalances.

As the clinical team assessed these developments, a repeat set of laboratory tests revealed a drop in serum potassium to 3.2 mEq/L, likely secondary to the use of high-dose diuretics in managing fluid retention associated with right ventricular hypertrophy. This hypokalemia could be contributing to the patient's muscle weakness and necessitates prompt correction to prevent further cardiac or muscular complications. The team decided to administer potassium supplements and reassess the patient's electrolyte status, aiming to restore balance while continuing to address the underlying respiratory and infectious processes. This evolving situation requires vigilant monitoring and adjustment of the therapeutic approach to ensure comprehensive management of the patient's complex needs.

Section 4

New Complications

Despite initial improvements and interventions, the patient's condition began to show signs of new complications. Over the next 24 hours, the patient developed a persistent cough with increased sputum production, now tinged with greenish-yellow color, suggesting a possible superimposed or resistant bacterial infection. Concurrently, the patient began to exhibit mild confusion and disorientation, raising concerns for hypoxemia or carbon dioxide retention, a common issue in COPD exacerbations. These changes prompted the healthcare team to perform a repeat arterial blood gas analysis, revealing a PaO2 of 58 mmHg and a PaCO2 of 60 mmHg, indicating worsening gas exchange and likely hypercapnia.

In addition to respiratory concerns, the patient experienced a notable increase in peripheral edema, particularly in the lower extremities, with pitting edema observed up to the mid-calf. This could indicate worsening heart failure or fluid overload, necessitating a careful re-evaluation of fluid management and diuretic therapy. Vital signs also showed a mild tachycardia with a heart rate of 105 beats per minute and blood pressure at 145/90 mmHg. Given these developments, the healthcare team decided to adjust the diuretic regimen, considering the potential need for a different class of diuretics to optimize fluid balance while avoiding further electrolyte disturbances.

These new complications require an integrated approach to management, balancing the need for effective respiratory support, infection control, and cardiovascular stability. The team plans to obtain sputum cultures to refine antibiotic therapy and consult cardiology for further evaluation of cardiac function. Ongoing monitoring will focus on assessing changes in mental status, fluid balance, and metabolic parameters to guide further interventions. The evolving clinical picture underscores the need for careful reassessment and adaptation of the treatment plan to address the patient's complex and interrelated health issues.

Section 5

Change in Patient Status

Following the adjustments in the diuretic regimen and initiation of targeted antibiotic therapy, the healthcare team closely monitored the patient for any signs of improvement or further deterioration. Over the next 12 hours, the patient's respiratory status showed slight improvement; oxygen saturation levels increased to 92% on a 2-liter nasal cannula, and the patient's cough became less frequent, though the purulent sputum persisted. Despite these respiratory improvements, the patient's mental status fluctuated. Although there were periods of alertness, the patient experienced intermittent episodes of confusion, occasionally unable to recall the day or recognize familiar faces, suggestive of ongoing hypoxemic episodes or possibly beginning stages of acute delirium.

In terms of cardiovascular status, the peripheral edema showed minimal reduction, indicating that the revised diuretic therapy might require further optimization. The patient's heart rate remained elevated, fluctuating between 100 to 110 beats per minute, and blood pressure readings were consistently around 150/95 mmHg. These findings raised concerns about underlying cardiac strain, possibly exacerbated by fluid shifts and electrolyte imbalances, such as hypokalemia, which were confirmed by laboratory results showing a potassium level of 3.2 mEq/L.

The healthcare team recognized that the patient's evolving condition required an immediate re-evaluation of the treatment strategy. A multidisciplinary approach was initiated, involving consultations with a pulmonologist to consider non-invasive ventilation support to address potential hypercapnia and with nephrology to fine-tune diuretic use while correcting electrolyte imbalances. The team also planned to implement a delirium prevention protocol, including reorientation strategies and minimizing nighttime disturbances, to address the patient's cognitive fluctuations. This integrated approach aimed to stabilize the patient's condition, reduce the risk of further complications, and improve overall outcomes.