UNIVERSITY OF PERPETUAL HELP SYSTEM Dr. Jose G. Tamayo Medical University Sto.

Nio, Bian, Laguna

COLLEGE OF NURSING
Since 1976

CASE STUDY

COPD in Acute Exacerbation, CAP MR ; CAD

Submitted to: Mr. Reuben C Peralta RN, MBA

Clinical Instructor

Submitted by: RICACHO, Ma. Norilyn BSN 4B Group 8

January 26, 2014

INTRODUCTION
Chronic obstructive pulmonary disease (COPD) is estimated to affect 32 million persons in the United States and is the fourth leading cause of death in this country. Patients typically have symptoms of chronic bronchitis and emphysema, but the classic triad also includes asthma. Chronic bronchitis is defined clinically as the presence of a chronic productive cough for 3 months during each of 2 consecutive years (other causes of cough being excluded). Emphysema is defined pathologically as an abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis. Signs and symptoms Patients typically present with a combination of signs and symptoms of chronic bronchitis, emphysema, and reactive airway disease. Symptoms include the following:

Cough, usually worse in the mornings and productive of a small amount of colorless sputum Acute chest illness Breathlessness: The most significant symptom, but usually does not occur until the sixth decade of life Wheezing: May occur in some patients, particularly during exertion and exacerbations The sensitivity of physical examination in detecting mild to moderate COPD is relatively poor, but physical signs are quite specific and sensitive for severe disease. Findings in severe disease include the following:
Tachypnea and respiratory distress with simple activities Use of accessory respiratory muscles and paradoxical indrawing of lower intercostal

spaces (Hoover sign)

Cyanosis Elevated jugular venous pulse (JVP) Peripheral edema

Thoracic examination reveals the following:

Hyperinflation (barrel chest) Wheezing Frequently heard on forced and unforced expiration Diffusely decreased breath sounds Hyperresonance on percussion Prolonged expiration Coarse crackles beginning with inspiration in some cases Certain characteristics allow differentiation between disease that is predominantly chronic bronchitis and that which is predominantly emphysema. Chronic bronchitis characteristics include the following:

Overall appearance is more like classic COPD exacerbation

PATIENTS PROFILE

Name: Address: Birth date: Age: Civil Status: Religion: Attending Physician: Admission date: Admitting Diagnosis: Chief Complain: Family History:

S.A., R. Sampaloc, Manila February 18, 1951 62 years old Married Roman Catholic Dr. F. January 20, 2014 COPD in Acute Exacerbation, CAP MR, CAD dyspnea (+) Hypertension

History of Present Illness: 1 week prior to confinement, patient had new onset of cough with whitish phlegm, (+) dyspnea at rest, (+) SOB, (-) fever. Patient self-medicated with Duavent + Ventolin & Co-Amoxiclav 625mg/tab BID (consumed 10 tablets) but without relief. 3 days PTC, patient had consult at hospital ng Manila. No meds given, sputum AFB was requested but not yet done. 9 hours PTC, patient had severe dyspnea with diaphoresis. Rushed to nearest hospital managed > labs were also taken, but referred to transferred at the institution.

PHYSICAL ASSESSMENT BODY PARTS

Skin

TECHNIQUE
Inspection Palpation

NORMAL FINDINGS
- Light to dark brown - No swelling - Good skin turgor

ACTUAL FINDINGS
-Pale - No swelling -Good skin turgor

ANALYSIS
May be related to low RBC level count.

-emaciated -may be sign of dehydration and weight loss Hair and scalp Head Inspection Inspection - No lesion - Color black - Face is symmetrical - No lesion - No swelling -No palpable nodes -Normal - Symmetrically align - No lesion - Black with Gray -face is symmetrical - No lesion - No swelling -Bilateral palpable nodes -may be a sign of infection

Neck

Inspection

Lymphnodes

Inspection/Palp ation Inspection Inspection

Shoulders Eyes

-Evenly distributed Eye brows - Eyelashes are short Eye lashes Eye lids Sclera Pupil - Eyelid margins are moist - White in color - Equally round and reactivated to light accommodation

- Symmetrically align -Sunken Eyeballs -Evenly distributed - Eyelashes are short - Eyelid margins are moist - anicteric sclera - Equally round and reactivated to light accommodation

-May be sign of dehydration

Ears

Palpation Inspection

Nose

Inspection

Mouth

Inspection Palpation

- Equal in size - Symmetrically align - No lesion - No swelling - Color is same as face - No lesion - No swelling - No lesion - No swelling - Red to pink in color - No lesion - Smooth with no lesion - Red to pink in color - No lesion - No swelling - Pink and moist

- Equal in size - Symmetrically align - No lesion - No swelling - Color is same as face - No lesion - No swelling - No lesion - No swelling - Pale - No lesion -Pale - Smooth with no lesion - Pale & dry color - No lesion - No swelling - Pale May be Sign of Dehydrati on May be related to low RBC level count.

Lips

Buccal mucosa

Tongue

Gums

May be related to low RBC level count. Nails Inspection -Capillary refill of <2-3 secondas - Symmetrically align - No lesion - No swelling - No mumps - Light to dark brown in color - Even and firm muscle tone -Capillary refill of more than 3 seconds - Symmetrically align - No lesion - No swelling - No mumps - Pale -May be related to low RBC level count

Upper Extremities

Inspection Palpation

May be related to low RBC level count. Possibly related to exhaustion she experienced when

Muscle tonicity

Palpation

- Weak muscle tone

coughing.and probably due to her decreased appetite causing inadequate nutrients to sustain muscle strength. Abdomen Inspection Palpation - Smooth to touch - No lesion - No swelling - No mumps - No redness - Warm to touch - Round and symmetrical - Abdomen rises with inspiration in synchrony with chest - Bilaterally symmetrical and equal - Right foot has complete fingers - Left foot has complete fingers - Skin color is as same as the other parts of the body - Smooth to touch - No lesion - No swelling - No mumps - No redness - Warm to touch - Round and symmetrical - Abdomen not in synchrony with inspiration - Bilaterally symmetrical and equal - Right foot has complete fingers - Left foot has complete fingers - Pale

_May be due to ineffective airway breathing

Lower Extremities

Inspection

May be related to low RBC level count.

LABORATORY AND DIAGNOSTICS

Clinical Chemistry Name: S.A., R. Room: 2124A Attending Physician: DR. M. A. TEST BUN CREATI NINE SODIUM POTASSIUM RESULT 4.5 122 142 3.5 Age: 62 Sex: M Date Released: January 20, 2014 REFERENCE RANGE 36.72 65-120 135-148 3.5-5.3

UNITS mmol/L umol/L mmol/L mmol/L

HEMATOLOGY TEST COMPLETE BLOOD COUNT Hemoglobin Hematocrit RBC WBC Differential Count Neutrophil Lymphocyte Monocyte Eosinophils Band Platelet count MCV MCH MCHC RDM MPV 120 0.36 3.96 13.4 0.70 0.20 0.05 0.04 0.01 443 90 30.30 0.34 13.00 8.50 g/L 10^12/L 10^9/L RESULT UNITS Analysis

10^9/L fL pg

fL

MEDICAL MANAGEMENT
Smoking cessation continues to be the most important therapeutic intervention for COPD. Risk factor reduction (eg, influenza vaccine) is appropriate for all stages of COPD. Approaches to management by stage include the following: Stage I (mild obstruction): Short-acting bronchodilator as needed Stage II (moderate obstruction): Short-acting bronchodilator as needed; long-acting bronchodilator(s); cardiopulmonary rehabilitation Stage III (severe obstruction): Short-acting bronchodilator as needed; long-acting bronchodilator(s); cardiopulmonary rehabilitation; inhaled glucocorticoids if repeated exacerbations Stage IV (very severe obstruction or moderate obstruction with evidence of chronic respiratory failure): Short-acting bronchodilator as needed; long-acting bronchodilator(s); cardiopulmonary rehabilitation; inhaled glucocorticoids if repeated exacerbation; long-term oxygen therapy (if criteria met); consider surgical options such as lung volume reduction surgery (LVRS) and lung transplantation Agents used include the following: Short-acting beta2 -agonist bronchodilators (eg, albuterol, metaproterenol, levalbuterol, pirbuterol) Long-acting beta2 -agonist bronchodilators (eg, salmeterol, formoterol, arformoterol, indacaterol, vilanterol) Respiratory anticholinergics (eg, ipratropium, tiotropium, aclidinium) Xanthine derivatives (ie, theophylline) Phosphodiesterase-4 Inhibitors (ie, roflumilast) Inhaled corticosteroids (eg, fluticasone, budesonide) Oral corticosteroids (eg, prednisone) Beta2 -agonist and anticholinergic combinations (eg, ipratropium and albuterol, umeclidinium bromide/vilanterol inhaled) Beta2 -agonist and corticosteroid combinations (eg, budesonide/formoterol, fluticasone and salmeterol, vilanterol/fluticasone inhaled) Pulmonary rehabilitation programs are typically multidisciplinary approaches that emphasize the following: Patient and family education Smoking cessation Medical management (including oxygen and immunization) Respiratory and chest physiotherapy Physical therapy with bronchopulmonary hygiene, exercise, and vocational rehabilitation Psychosocial support Indications for admission for acute exacerbations include the following:

Failure of outpatient treatment Marked increase in dyspnea Altered mental status Increase in hypoxemia or hypercapnia Inability to tolerate oral medications such as antibiotics or steroids

Medications:
Hydrocortisone 100mg q4 Losartan 50mg 1tab OD Simvastatin 20mg 1tab ODHS Doxophylline 400MG 1tab BID Azithromycin 500mg OD Combivent PRN

Nursing Management
1. Assessing the Patient - Assessment involves obtaining information about current symptoms as well as previous disease manifestations. 2. Achieving Airway Clearance - Bronchospasm, which occurs in many pulmonary diseases, reduces the caliber of the small bronchi and may cause dyspnea, static secretions, and infection. Bronchospasm can sometimes be detected on auscultation with a stethoscope when wheezing or diminished breath sounds are heard. 3. Improving Breathing Patterns - Ineffective breathing patterns and shortness of breath are due to the ineffective respiratory mechanics of the chest wall and lung resulting from air trapping, ineffective diaphragmatic movement, airway obstruction, the metabolic cost of breathing, and stress. Inspiratory muscle training and breathing retraining may help improve breathing patterns. 4. Improving Activity Tolerance - Patients with COPD experience progressive activity and exercise intolerance and disability. Education is focused on rehabilitative therapies to promote independence in executing activities of daily living. These may include pacing activities throughout the day or using supportive devices to decrease energy expenditure. 5. Monitoring and Managing Potential Complications - The nurse must assess for various complications of COPD, such as life-threatening respiratory insufficiency and failure, as well as respiratory infection and chronic atelectasis, which may increase the risk of respiratory failure. - The nurse monitors pulse oximetry values to assess the patients need for oxygen and administers supplemental oxygen as prescribed. 6. Promote Home and Community-Based Care - When providing instructions about self-management, it is important for the nurse to assess the knowledge of patients and family members about self- care and the therapeutic regimen.