A nurse is caring for a patient with COPD exacerbation and notes peripheral edema in both ankles. Which of the following interventions should the nurse prioritize to address the underlying cause of the edema?

B) Administer prescribed diuretics

A) Increase the patient's fluid intake

B) Administer prescribed diuretics

C) Encourage the patient to perform leg exercises

D) Elevate the patient's legs above heart level

A patient with COPD exacerbation is receiving supplemental oxygen, antibiotics, diuretics, and bronchodilators. Which assessment finding would indicate a need to adjust the current treatment plan?

B) The patient reports increased shortness of breath and chest tightness

A) Oxygen saturation remains consistently above 92%

B) The patient reports increased shortness of breath and chest tightness

C) Peripheral edema has decreased in both ankles

D) The patient's sputum color changes from yellow-green to white

A nurse is caring for a patient with worsening respiratory distress, as evidenced by increased respiratory rate, use of accessory muscles, and changes in arterial blood gases. Which intervention should the nurse prioritize to address the patient's current respiratory status?

D) Initiate non-invasive positive pressure ventilation (NIPPV)

A) Administer a bronchodilator as prescribed

B) Increase oxygen flow rate to 6 liters per minute

C) Prepare the patient for intubation immediately

D) Initiate non-invasive positive pressure ventilation (NIPPV)

A patient with worsening respiratory distress and recent arterial blood gas results showing respiratory acidosis with a pH of 7.28 and PaCO2 of 60 mmHg is being evaluated. The patient is also tachycardic and hypertensive. What is the priority nursing intervention to address the patient's condition?

B) Initiate non-invasive positive pressure ventilation (NIPPV) to enhance ventilation

A) Increase the oxygen flow rate to improve oxygenation

B) Initiate non-invasive positive pressure ventilation (NIPPV) to enhance ventilation

C) Administer a bronchodilator to open the airways

D) Prepare the patient for intubation and mechanical ventilation

A patient on non-invasive positive pressure ventilation (NIPPV) for respiratory distress shows signs of potential right-sided heart strain. Which nursing intervention is most appropriate to address the current complications?

B) Reassess and ensure optimal fit of the NIPPV mask

A) Increase the oxygen flow rate to improve oxygenation

B) Reassess and ensure optimal fit of the NIPPV mask

C) Administer a diuretic to reduce fluid overload

D) Collaborate with the healthcare provider to consider invasive ventilation options

A patient receiving non-invasive positive pressure ventilation (NIPPV) for respiratory distress shows slight improvement in arterial blood gases but develops signs of right-sided heart strain. What is the nurse's priority action in managing this patient?

D) Monitor the patient closely for changes in vital signs and ensure effective NIPPV mask fit.

A) Increase the NIPPV pressure settings to improve oxygenation.

B) Collaborate with the healthcare provider to order diuretics to manage fluid overload.

C) Prepare the patient for possible intubation due to ongoing respiratory compromise.

D) Monitor the patient closely for changes in vital signs and ensure effective NIPPV mask fit.

A patient with COPD and early cor pulmonale is being monitored closely by the nursing team. The nurse notes a decrease in blood pressure to 150/88 mmHg and a heart rate of 102 beats per minute. Which nursing intervention should be prioritized to manage the patient's condition effectively?

C) Adjust the patient's position to semi-Fowler's to facilitate breathing.

A) Increase fluid intake to maintain hydration status.

B) Administer bronchodilators to improve airflow.

C) Adjust the patient's position to semi-Fowler's to facilitate breathing.

D) Initiate a sodium-restricted diet to prevent fluid overload.

A patient with COPD and early cor pulmonale is being monitored by the healthcare team. The nurse is reviewing the patient's medication regimen. Which intervention should the nurse prioritize to address both respiratory and cardiac concerns?

C) Start diuretics to manage fluid overload and reduce cardiac workload

A) Initiate oxygen therapy to maintain SaO2 above 92%

B) Administer bronchodilators to improve airflow and reduce respiratory effort

C) Start diuretics to manage fluid overload and reduce cardiac workload

D) Educate the patient on smoking cessation to prevent further lung damage

A patient with COPD and signs of fluid retention is experiencing increased respiratory distress. The nurse has noted an elevated respiratory rate and decreased oxygen saturation. Which nursing intervention should the nurse prioritize to address the patient's current status?

B) Position the patient in a semi-Fowler's position

A) Increase the patient's diuretic dosage as prescribed

B) Position the patient in a semi-Fowler's position

C) Administer a bronchodilator and reassess respiratory status

D) Encourage the patient to perform pursed-lip breathing exercises

A patient with COPD and suspected fluid overload is experiencing increased fatigue, peripheral edema, and labored breathing with an oxygen saturation of 88% on supplemental oxygen. Which nursing intervention is most appropriate to prioritize at this time to improve the patient's oxygenation status?

C) Encourage the patient to perform pursed-lip breathing exercises.

A) Increase the patient's supplemental oxygen to 4 liters per minute.

B) Position the patient in a high Fowler's position to promote better lung expansion.

C) Encourage the patient to perform pursed-lip breathing exercises.

D) Restrict the patient's fluid intake to manage peripheral edema.

COPD - Nursing Case Study

Pathophysiology

• Primary mechanism: Chronic inflammation leads to structural changes and narrowing of the airways, primarily affecting the bronchioles. This inflammation is exacerbated by exposure to irritants like cigarette smoke, triggering an immune response that damages lung tissue and impairs airflow.

• Secondary mechanism: Destruction of alveolar walls, or emphysema, results from an imbalance between proteases and antiproteases. This damage reduces the surface area for gas exchange, leading to decreased oxygen intake and carbon dioxide elimination, contributing to respiratory distress.

• Key complication: Air trapping occurs due to loss of lung elasticity and airway collapse during exhalation, causing hyperinflation. This increases the work of breathing and results in symptoms like dyspnea and exercise intolerance, significantly impacting the patient's quality of life.

Patient Profile

Demographics:

62-year-old male, retired construction worker

History:

• Key past medical history: Chronic obstructive pulmonary disease (COPD) diagnosed 5 years ago, hypertension, and type 2 diabetes

• Current medications: Tiotropium, Salbutamol (as needed), Metformin, Lisinopril

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increased shortness of breath and productive cough over the past week

• Key symptoms: Wheezing, fatigue, and mild chest tightness, occasional ankle swelling

• Vital signs: Blood pressure 148/92 mmHg, heart rate 102 bpm, respiratory rate 24 breaths per minute, oxygen saturation 91% on room air, temperature 37.4°C

Section 1

The nurse begins an initial assessment to gather further information about the patient's current status. Upon examination, the patient appears mildly distressed, with increased use of accessory muscles during respiration. Auscultation reveals bilateral wheezing and diminished breath sounds in the lower lobes, consistent with obstructive lung disease. The productive cough has yielded thick, yellow-green sputum, suggesting a possible infection exacerbating the COPD symptoms. Peripheral edema is noted in both ankles, indicating potential fluid retention, which may be linked to the patient's hypertension and right-sided heart strain due to chronic lung disease.

Laboratory results provide additional insights into the patient's condition. A complete blood count shows leukocytosis, with an elevated white blood cell count of 14,000/mm³, indicating an inflammatory or infectious process. Arterial blood gas analysis reveals respiratory acidosis, with a pH of 7.32, PaCO2 of 55 mmHg, and PaO2 of 65 mmHg, indicative of CO2 retention and impaired gas exchange. These findings align with the clinical picture of COPD exacerbation, potentially complicated by an infectious process like pneumonia or bronchitis.

The healthcare team decides to initiate treatment with supplemental oxygen to maintain an oxygen saturation above 90%, alongside a course of antibiotics to address the suspected infection. The patient is also started on diuretics to manage peripheral edema, while bronchodilators are adjusted to optimize airway patency. The nurse monitors the patient's response to these interventions closely, watching for any signs of further respiratory compromise or improvement in symptoms. This comprehensive approach aims to stabilize the patient's condition and prevent the progression of complications, while ongoing assessment and clinical reasoning will guide further management decisions.

Section 2

As the nurse continues to monitor the patient over the next 24 hours, a change in the patient's status becomes evident. Despite the initial interventions, the patient exhibits increased respiratory distress, characterized by a further increase in the use of accessory muscles and a more pronounced effort to breathe. The patient's respiratory rate has escalated to 30 breaths per minute, and auscultation now reveals louder wheezing with the addition of crackles in the right lower lung field. The patient also reports feeling more fatigued and is having difficulty completing sentences due to shortness of breath.

During a repeat arterial blood gas analysis, the results show a worsening of the respiratory acidosis with a pH of 7.28 and a PaCO2 level rising to 60 mmHg, while the PaO2 has decreased to 60 mmHg. These findings suggest that the patient's condition is deteriorating, potentially due to inadequate ventilation and gas exchange. Additionally, the patient's blood pressure has risen to 160/95 mmHg, and the heart rate is now tachycardic at 110 beats per minute, possibly indicating increased cardiac workload and strain.

The healthcare team is prompted to reevaluate the current management plan. Given the potential for an unresolved or worsening infection, consideration is given to modifying the antibiotic regimen based on culture results. Furthermore, the need for non-invasive positive pressure ventilation (NIPPV) is discussed to improve ventilation and decrease CO2 retention. The nurse's role in this critical period involves closely monitoring the patient's vital signs and respiratory status, ensuring the timely administration of medications, and providing reassurance to the patient and family, while anticipating the next steps in management to stabilize the patient and prevent further complications.

Section 3

As the healthcare team implements non-invasive positive pressure ventilation (NIPPV) to improve the patient's ventilation and reduce CO2 retention, the nurse continues to monitor the patient closely for any response to this intervention. Within a few hours, there is a noticeable change in the patient's status. The respiratory rate gradually decreases to 24 breaths per minute, and the use of accessory muscles becomes less pronounced, indicating that the NIPPV is helping to alleviate some of the respiratory distress. However, the patient still struggles with fatigue and has difficulty completing sentences, suggesting that while there is some improvement, significant respiratory compromise remains.

A repeat arterial blood gas analysis shows a slight improvement in the pH, now at 7.32, and a decrease in PaCO2 to 55 mmHg, while the PaO2 has risen to 65 mmHg. These values reflect a partial correction of the respiratory acidosis, but the persistent hypoxemia prompts further investigation. The nurse collaborates with the respiratory therapist to ensure the NIPPV settings are optimized and assesses for any potential barriers to effective ventilation, such as mask fit or patient cooperation.

Despite these interventions, new complications arise as the patient develops signs of potential right-sided heart strain, likely due to the ongoing hypoxemia and increased pulmonary vascular resistance. The blood pressure remains elevated at 158/92 mmHg, and the heart rate remains tachycardic at 108 beats per minute. An echocardiogram is ordered to assess the cardiac function and evaluate for signs of cor pulmonale. The nurse remains vigilant, educating the patient and family about these developments and preparing them for potential adjustments in treatment, including the possibility of escalating to more invasive respiratory support if the patient's condition does not continue to improve.

Section 4

As the healthcare team continues to monitor the patient, new diagnostic results from the echocardiogram reveal mild right ventricular hypertrophy, consistent with early cor pulmonale. This finding suggests that the chronic hypoxemia and increased pulmonary vascular resistance have begun to impact cardiac function. The nurse, recognizing the significance of this development, collaborates with the physician to adjust the treatment plan to address both the respiratory and cardiac concerns. Diuretics are considered to manage any fluid overload that might exacerbate the heart strain, and discussions begin regarding the potential introduction of pulmonary vasodilators to reduce pulmonary artery pressures.

In conjunction with these cardiac-focused interventions, the nurse carefully reviews the patient's current medication regimen to ensure optimal management of COPD while minimizing cardiac workload. Bronchodilators and corticosteroids are evaluated for their efficacy in reducing airway inflammation and improving airflow, with attention to any side effects that could further stress the cardiac system. The nurse also reinforces the importance of maintaining adequate hydration and nutrition to support overall health and recovery, providing education to the patient and family about lifestyle modifications that could alleviate symptoms.

The patient’s current status remains a delicate balance, with vital signs showing some stability but not yet reaching desired targets. The blood pressure has decreased slightly to 150/88 mmHg, and the heart rate has reduced to 102 beats per minute, indicating a modest response to the interventions. The nurse remains vigilant, monitoring for any signs of deteriorating respiratory or cardiac function and preparing the team for possible escalation of care. Continuous assessment and timely interventions become critical as the team strives to stabilize the patient's condition and prevent further complications. This ongoing vigilance ensures the patient receives comprehensive care tailored to both their respiratory and cardiac needs, laying the groundwork for potential improvement in their overall condition.

Section 5

As the healthcare team continues to monitor the patient, a change in patient status becomes evident. The patient begins to exhibit increased fatigue and mild peripheral edema, particularly in the lower extremities, which raises concerns of potential fluid retention despite the introduction of diuretics. The nurse conducts a thorough assessment and notes that the patient’s respiratory rate has increased to 26 breaths per minute, accompanied by slightly labored breathing. Oxygen saturation levels have decreased to 88% on 2 liters of supplemental oxygen, indicating a potential exacerbation of hypoxemia.

The nurse promptly communicates these findings to the physician, and together they decide to reevaluate the diuretic regimen, considering the possibility of adjusting the dosage to better manage fluid overload. Additionally, they discuss the need for further pulmonary function tests to assess the progression of COPD and determine if modifications in bronchodilator therapy are warranted. A repeat echocardiogram is also ordered to assess for any further changes in cardiac function, particularly given the signs of fluid retention and increased respiratory effort.

In the interim, the nurse implements non-pharmacological interventions to enhance the patient's comfort and breathing efficiency. This includes positioning the patient in a semi-Fowler’s position to facilitate better lung expansion and providing supplemental oxygen titration to maintain target saturation levels. The nurse also engages the patient and family in a discussion about recognizing early signs of exacerbation and the importance of adhering to the prescribed treatment plan. These proactive measures aim to stabilize the patient's condition while awaiting further diagnostic results and potential adjustments to the care plan. This dynamic situation underscores the need for ongoing clinical reasoning and adaptability in managing complex cases of COPD with cardiac involvement.