Unit 3- Treatment of COPD. 1000w. 4 references. Due 23
Scenario: You are seeing an 89-year-old male who has a history of smoking 2 packs of cigarettes a day for 69 years.
· He quit smoking cold turkey when he was 78 years old.
· He is in your office for a general health evaluation. He reports ongoing challenges with ‘belching’ but other than that he conveys that he is feeling pretty good.
· He is on no routine medications.
· During your interview with the patient you note that he utilizes pursed lip breathing. At times you note a faint ‘whistling’ sound associated with his respiratory effort.
· In conducting your review of systems he reports a cough, particularly in the mornings, productive for thick clear to white sputum.
· When queried about shortness of breath he does indicate that he gets SOB more easily than he used to.
· His breath sounds are course and diminished in the lower lobes bilaterally.
Please develop a discussion that responds to each of the following prompts. Where appropriate your discussion needs to be supported by scholarly resources. Be sure to include in-text citations in the context of the discussion and provide a full reference citation at the end of the discussion.
Utilize the information provided in the scenario to create your discussion post.
1. Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan).
2. Structure your ‘P’ in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the ‘heading’ and after the ‘:’ input N/A]
3. Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional – any other therapies in lieu of pharmacologic intervention]
4. Educational: health information clients need in order to address their presenting problem(s); health information in support of any of the ‘therapeutics’ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit
5. Consultation/Collaboration: if appropriate – collaborative ‘Advanced Care Planning’ with the patient/patient’s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate – consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making.
Support the interventions outlined in your ‘P’ with scholarly resources.
Respond to the additional questions below.
6. What role does disease prevalence of COPD play among groups such as the patient in the study?
7. Summarize a scholarly article that pertains to the case study and provide feedback.
Please be sure to validate your opinions and ideas with citations and references in APA format.
Talking points that should be included.
Chronic obstructive pulmonary disease (COPD)
encompasses two diseases: emphysema and
chronic bronchitis. Most clients who have
emphysema also have chronic bronchitis. COPD
is irreversible.
Emphysema is characterized by the loss of
lung elasticity and hyperinflation of lung
tissue. Emphysema causes destruction of the
alveoli, leading to a decreased surface area for
gas exchange, carbon dioxide retention, and
respiratory acidosis.
Chronic bronchitis is an inflammation of
the bronchi and bronchioles due to chronic
exposure to irritants.
COPD typically affects middle‑age to
older adults.
HEALTH PROMOTION AND
DISEASE PREVENTION
●● Promote smoking cessation.
●● Avoid exposure to secondhand smoke.
●● Use protective equipment, such as a mask, and ensure
proper ventilation while working in environments that
contain carcinogens or particles in the air.
●● Influenza and pneumonia immunizations are
important for all clients who have COPD, but especially
for older adults.
ASSESSMENT
RISK FACTORS
●● Advanced age: Older adult clients have a decreased
pulmonary reserve due to age-related lung changes.
●● Cigarette smoking is the primary risk factor for the
development of COPD.
●● Alpha1‑antitrypsin (AAT) deficiency
●● Exposure to environmental factors (air pollution)
EXPECTED FINDINGS
Chronic dyspnea. The respiratory rate can reach
40 to 50/min during acute exacerbations.
PHYSICAL ASSESSMENT FINDINGS
●● Dyspnea upon exertion
●● Productive cough that is most severe upon rising in
the morning
●● Hypoxemia
●● Crackles and wheezes
●● Rapid and shallow respirations
●● Use of accessory muscles
●● Barrel chest or increased chest diameter
(with emphysema) (22.1)
●● Hyperresonance on percussion due to “trapped air”
(with emphysema)
●● Irregular breathing pattern
●● Thin extremities and enlarged neck muscles
●● Dependent edema secondary to right‑sided heart failure
●● Clubbing of fingers and toes (late stages of the disease)
●● Pallor and cyanosis of nail beds and mucous membranes
(late stages of the disease)
●● Decreased oxygen saturation levels (expected reference
range is 95% to 100%)
●● In older adults or clients who have dark‑colored skin,
oxygen saturation levels can be slightly lower.
LABORATORY TESTS
●● Increased hematocrit level is due to low oxygenation levels.
●● Use sputum cultures and WBC counts to diagnose acute
respiratory infections.
●● Arterial blood gases (ABGs)
◯◯ Hypoxemia (decreased PaO2 less than 80 mm Hg)
◯◯ Hypercarbia (increased PaCO2 greater than 45 mm Hg)
●● Blood electrolytes
DIAGNOST IC PROCEDURES
Pulmonary function tests
These tests are used for diagnosis, as well as determining
the effectiveness of therapy.
●● Comparisons of forced expiratory volume (FEV) to
forced vital capacity (FVC) are used to classify COPD as
mild to very severe.
●● As COPD advances, the FEV‑to‑FVC ratio decreases. The
expected reference range is 100%. For mild COPD, the
FEV/FVC ratio is decreased to less than 70%. As the
disease progresses to moderate and severe, the ratio
decreases to less than 50%.
Chest x‑ray
●● Reveals hyperinflation of alveoli and flattened
diaphragm in the late stages of emphysema. (22.2)
●● It is often not useful for the diagnosis of early or
moderate disease.
Alpha1 antitrypsin levels
Used to assess for deficiency in AAT, an enzyme produced
by the liver that helps regulate other enzymes (which help
break down pollutants) from attacking lung tissue.
PATIENT‑CENTERED CARE
NURSING CARE
●● Position the client to maximize ventilation
(high‑Fowler’s).
●● Encourage effective coughing, or suction to
remove secretions.
●● Encourage deep breathing and use of an
incentive spirometer.
●● Administer breathing treatments and medications.
●● Administer oxygen as prescribed. In COPD, low
arterial levels of oxygen serve as the primary drive for
breathing. However, in most cases, oxygen levels should
be maintained between 88% and 92%.
●● Clients who have COPD can need 2 to 4 L/min of oxygen
via nasal cannula or up to 40% via Venturi mask. Clients
who have chronically increased PaCO2 levels usually
require 1 to 2 L/min of oxygen via nasal cannula.
●● Monitor for skin breakdown around the nose and mouth
from the oxygen device.
●● Promote adequate nutrition.
◯◯ Increased work of breathing increases caloric demands.
◯◯ Proper nutrition aids in the prevention of infection.
◯◯ Encourage fluids to promote adequate hydration.
◯◯ Dyspnea decreases energy available for eating, so soft,
high‑calorie foods should be encouraged.
●● Monitor weight and note any changes.
●● Instruct the client to practice breathing techniques to
control dyspneic episodes.
◯◯ For diaphragmatic (abdominal) breathing, instruct the
client to:
■■ Take breaths deep from the diaphragm.
■■ Lie on back with knees bent.
■■ Rest a hand over the abdomen to create resistance.
■■ If the client’s hand rises and lowers upon
inhalation and exhalation, the breathing is being
performed correctly.
◯◯ For pursed‑lip breathing, instruct the client to:
■■ Form the mouth as if preparing to whistle.
■■ Take a breath in through the nose and out through
the lips/mouth.
■■ Not puff the cheeks.
■■ Take breaths deep and slow.
●● Positive expiratory pressure device
◯◯ Assists client to remove airway secretions.
◯◯ Client inhales deeply and exhales through device.
◯◯ While exhaling, a ball inside the device moves, causing
a vibration that results in loosening secretions.
●● Exercise conditioning
◯◯ Includes improving pulmonary status by
strengthening the condition of the lungs by exercise.
◯◯ The client walks daily at a self‑paced rate until
dyspnea occurs, then stops to rest. Once dyspnea
resolves, the client resumes.
◯◯ The client walks 20 min daily 2 to 3 times weekly.
◯◯ Determine the client’s physical limitations, and
structure activity to include periods of rest.
◯◯ Provide rest periods for older adult clients who have
dyspnea. Design the room and walkways with
opportunities for relaxation.
●● Provide support to the client and family. Talk about
disease and lifestyle changes, including home care
services such as portable oxygen.
●● Increase fluid intake. Encourage the client to drink 2 to
3 L/day to liquefy mucus.
Incentive spirometry
Incentive spirometry is used to monitor optimal
lung expansion.
NURSING ACTIONS: Show the client how to use the
incentive spirometry machine.
CLIENT EDUCATION: Keep a tight mouth seal around the
mouthpiece and inhale and hold breath for 3 to 5 seconds.
During inhalation, the needle of the spirometry machine
will rise. This promotes lung expansion.
MEDICATIONS
Bronchodilators (inhalers)
Short‑acting beta2 agonists , such as albuterol, provide
rapid relief.
Cholinergic antagonists (anticholinergic medications) ,
such as ipratropium, block the parasympathetic nervous
system. This allows for the sympathetic nervous system
effects of increased bronchodilation and decreased
pulmonary secretions. These medications are long‑acting
and are used to prevent bronchospasms.
Methylxanthines , such as theophylline, relax smooth
muscles of the bronchi. These medications require close
monitoring of blood medication levels due to narrow
therapeutic ranges. Use only when other treatments are
ineffective.
NURSING ACTIONS
●● Monitor for toxicity when taking theophylline. Adverse
effects include tachycardia, nausea, and diarrhea.
●● Watch for tremors and tachycardia when taking albuterol.
●● Observe for dry mouth when taking ipratropium.
CLIENT EDUCATION
●● Suck on hard candies to help moisten dry mouth while
taking ipratropium.
●● Increase fluid intake, report headaches, or blurred vision.
●● Monitor heart rate. Palpitations can occur, which can
indicate toxicity of ipratropium.
Anti‑inflammatory agents
These medications decrease airway inflammation.
●● If corticosteroids, such as fluticasone and prednisone,
are given systemically, monitor for serious adverse
effects (immunosuppression, fluid retention,
hyperglycemia, hypokalemia, poor wound healing).
●● Leukotriene antagonists, such as montelukast; mast
cell stabilizers, such as cromolyn; and monoclonal
antibodies, such as omalizumab, can be used.
NURSING ACTIONS
●● Watch for a decrease in immunity function.
●● Monitor for delayed wound healing.
●● Monitor for hyperglycemia.
●● Observe for fluid retention and weight gain. This
is common.
●● Check the throat and mouth for aphthous lesions
(canker sores).
●● Omalizumab can cause anaphylaxis.
CLIENT EDUCATION
●● Drink plenty of fluids to promote hydration.
●● Report black, tarry stools.
●● Take glucocorticoids with food.
●● Use medication to prevent and control bronchospasms.
●● Avoid people who have respiratory infections.
●● Use good mouth care.
●● Use medication as a prophylactic prevention of
COPD manifestations.
●● Do not discontinue medication suddenly.
Mucolytic agents
These agents help thin secretions, making them easier for
the client to expel.
●● Nebulizer treatments include acetylcysteine and
dornase alfa.
●● Guaifenesin is an oral agent that can be taken.
●● A combination of guaifenesin and dextromethorphan
also can be taken orally to loosen secretions.
TH ERAPEUTIC PROCEDURES
●● Chest physiotherapy uses percussion and vibration to
mobilize secretions.
●● Raising the foot of the bed slightly higher than the
head can facilitate optimal drainage and removal of
secretions by gravity.
●● Humidifiers can be useful for who live in a dry climate
or who use dry heat during the winter.
INTERPROFESS IONAL CARE
●● Consult respiratory services for inhalers, breathing
treatments, and suctioning for airway management.
●● Contact nutritional services for weight loss or gain
related to medications or diagnosis.
●● Consult rehabilitative care if the client has prolonged
weakness and needs assistance with increasing
activity level.
●● COPD is debilitating for older adult clients. Management of
the disease is continuous. Referrals to assistance programs,
such as food delivery services, can be indicated.
●● Set up referral services, including home care services
such as portable oxygen.
●● Provide support to the client and family.
CLIENT EDUCATION
●● Eat high‑calorie foods to promote energy.
●● Rest as needed.
●● Practice hand hygiene to prevent infection.
●● Take medications (inhalers, oral medications) as prescribed.
●● Stop smoking if needed.
●● Obtain immunizations, such as influenza and
pneumonia, to decrease the risk of infection.
●● Use oxygen as prescribed. Inform other caregivers not to
smoke around the oxygen due to flammability.
●● Acute infections and other complications often require
hospital stays. Report unusual findings or concerns to
the provider.
●● Ensure fluid intake of at least 2 L (68 oz) daily to thin
secretions, unless the provider recommends otherwise.
COMPLICATIONS
Respiratory infection
Respiratory infections result from increased mucus
production and poor oxygenation levels.
NURSING ACTIONS
●● Administer oxygen therapy.
●● Monitor oxygenation levels.
●● Monitor for indications of infection (increased WBC, CRP,
decreased SaO2, change in temperature).
●● Administer antibiotics and other medications.
CLIENT EDUCATION
●● Avoid crowds and people who have respiratory infections.
●● Obtain pneumonia and influenza immunizations.
Right‑sided heart failure (cor pulmonale)
●● Air trapping, airway collapse, and stiff alveoli lead to
increased pulmonary pressures.
●● Blood flow through the lung tissue is difficult. This
increased workload leads to enlargement and thickening
of the right atrium and ventricle.
MANIFESTATIONS
●● Low oxygenation levels
●● Cyanosis
●● Enlarged and tender liver
●● Distended neck veins
●● Dependent edema
NURSING ACTIONS
●● Monitor respiratory status and administer oxygen therapy.
●● Monitor for GI disturbances (nausea, anorexia).
●● Monitor heart rate and rhythm.
●● Administer medications as prescribed.
●● Administer IV fluids and diuretics to maintain fluid balance.
Sample
Unit 3 Discussion 1 – Treatment of COPD
From the presented symptoms and objective data, the primary diagnosis is Chronic
Obstructive Pulmonary Disease (COPD). In the course of this paper, a discussion of the
framework to assist in structuring the documentation and the assessment of the patient in a
consistent and clear way is provided.
Subjective
This section will detail how the patient is feeling now. The patient reports to have quit
smoking cold turkey when he was 78 years old. The elderly patient also reports to be
experiencing challenges with belching. Apart from that, the 89-year-old man states that he has
been feeling better. The patient is on no daily medications. However, when asked if he
experiences shortness of breath, the patient reports that he gets SOB more frequently compared
to the past. Upon conducting a review of systems, the patient tells of a cough he experiences
mostly in the morning, that has a thick clear to white sputum.
Objective
The section includes all the things that are observed about the patient. It is observed that
the patient uses pursed-lip breathing. Similarly, there is a faint whistling sound linked to
respiratory constraint. The patient’s breath sounds are coarse and less in the lower lobes
bilaterally. Therefore, the basic observations include respiratory rate and breathing difficulties.
Assessment
On this section, the diagnosis and the salient thoughts about the condition of the patient
will be included as conclusions from the subjective and objective sections. The patient has a
number of presenting health concerns including cough in the morning, which has clear to white
sputum, issues with belching, and gets SOB more often compared to the past. This could be an issue with the respiratory tract. The primary diagnosis for the patient is Chronic Obstructive
Pulmonary Disease (COPD). The disease is due to long-term exposure to particulate matter from
the cigarette smoke (Gregoriano et al., 2017). The patient feels that they have to clear their throat
in the morning, which is a triggered by the excessive mucus present in the lungs. The differential
diagnosis for this patient is Asthma. Asthma is a chronic infection that results in inflammation in
the airways. The symptoms of Asthma are a cough that worsens in the morning and tightness of
the chest. However, the diagnosis is rejected since the patient does not state that the cough gets
worse at any other time of the day.
Plan
The plan will consider further investigations to determine and confirm the diagnosis. The
plan will also detail the treatments, referrals to other specialists, review time and date, as well as
the frequency of the observations. Chest X-rays will be conducted on the patient to give a
detailed look at the blood vessels, heart and the lungs. A physical examination will also be
conducted and followed up at every two months. The attending healthcare professional will carry
out an exam that with focus on imaging of the chest spirometry for COPD. The spirometry is a
noninvasive test that is intended to test the utility of the lungs.
Since the patient is not on any medications, he should start bronchodilators, which will
help with the relaxation of the muscle airways. According to Goss (2017), the medication is
taken through a nebulizer or an inhaler. Glucocorticosteroids can also be added to the treatment
to assist in the reduction of the inflammation of the airways. For the belching, the patient will be
given methylprednisolone infusion for five days to ensure that the belching symptoms are
resolved significantly (Barnes, 2016). The patient will be provided with additional education that will aid in detecting signs of pulmonary embolism, which is critical as patients who are suffering
from COPD have high chances of developing COPD.
