Introduction

The essay is focused over analyzing the 72 years old male elderly patient named as Jim who
has been diagnosed with Chronic obstructive pulmonary disease (COPD). He has been
admitted to the medical ward in the morning reporting an inefficacious exacerbation of
problem COPD. The essay is to explain two problems of this girl patient as respiration issue
and related cardiovascular changes due to COPD. Further, this essay will be demonstrating
the two defined and highly required nursing interventions for the two defined problems
above. For respiration issue, the essay is concentrating over implementing the nursing
intervention of (1) assessing the signs and symptoms of Jim’s impaired respiratory function
consistently under observation; and (2) positioning of Jim in medically appropriate level. For
the problem of cardiovascular changes due to COPD in extreme condition, the directed
nursing interventions include (1) documenting changes in heart functioning through
consistent assessment of Jim’s vital signs as dysrhythmia, and sensorium; and (2)
withholding digitalis preparation.

Priority Problem 1

Respiratory issue in COPD in Jim is quite expected and a major symptom to deal with.
Pathologic alterations in the chronic obstructive pulmonary disease (COPD) usually occur in
the patient’s large (central) airways, the lung parenchyma and the small (peripheral)
bronchioles (Maclay & MacNee, 2013). As Jim was a smoker, this smoking has been
responsible for developing COPD in Jim due to his exposure to noxious stimuli. His normal
inflammatory response has been amplified being prone to severity of COPD development
(Matsumura et al., 2015). The incremented numbers of the activated polymorphonuclear
leukocytes as well as macrophages have released the elastases in the true manner which is
not plausible to counteract efficaciously by the antiproteases (Roberts et al., 2015). This has
been responsible for causing lung destruction causing respiration issues and coughing
(Hodson & Sherrington, 2014). The primary offender as stated in the medical analysis is the
human leukocyte elastase along with the synergistic roles that are well suggested for the
defined range of proteinase-3 (Efraimsson et al., 2015) and the macrophage-derived and
induced matrix metalloproteinases (MMPs), a plasminogen activator and the cysteine
proteinases (Matsumura et al., 2015). On additional note, there is incremented level of
oxidative stress that is being caused by the free radicals that are present in cigarette smoke
which has been the major culprit in Jim’s COPD. The oxidants being released by
polymorphonuclear leukocytes and phagocytes, all can result in the necrosis or apoptosis of
the exposed cells (Lewis et al., 2014). Jim has quit smoking only 3 years before but this habit
of cigarette smoking has resulted in neutrophil influx that is quite required for the MMPs
aligned secretion. This truly defines that the neutrophils along with the macrophages have
been needed for the proper development of the problem of emphysema (Matsumura et al.,
2015).

First intervention is to essentially assess the signs and symptoms of the impaired respiratory
function certainly focusing over the rapid, slow, irregular or shallow respirations (Maclay &
MacNee, 2013); orthopnea, dyspnea; usage of the accessory muscles while breathing and
indulging in respiration process; and adventitious forms of breath sounds (such as crackles
[or rales] and wheezes) (Lewis et al., 2014). It is a collaborative nursing intervention to be
accomplished with other nursing colleagues on duty. In the case study it has been depicted
that Jim when assessed by the doctor with the stethoscope on his chest (Efraimsson et al.,
2015), it is quite audible that the internal coarse crackles are present that can worsen if
situation is not handled. Even there seems to be reduced air entry in his both lower level
lobes (Hodson & Sherrington, 2014).

Other symptoms to assess under nursing observation includes the diminished or absent
breath sounds; irritability, restlessness (Roberts et al., 2015); dry or hacking cough or the
cough coming up with product as blood tinged or frothy sputum (in Jim’s case the sputum
had turned a thick green colour already); and limited chest excursion (Dickens et al., 2014).
This is again somehow visible in the case study. Jim reported of having the experience of a
prolonged expiratory phase. He has been responding that he is not able to get his breath
and his mouth is also quite dry. He is not able to cough this stuff in upper way (Porakhonko
et al., 2014). Jim’s somnolence, confusion; abnormal blood gases; central cyanosis (a late
sign) (Efraimsson et al., 2015); abnormal chest X-ray results; and substantial reduction in
oximetry results must also be assessed timely. This nursing intervention can be wholly
acknowledged and observed by the nurse on duty (Strong et al., 2014).
The second intervention in nursing is to position the patient Jim accurately as medically
stated. This is an independent nursing intervention. It is a necessity to lay Jim as flat (and if
plausible to elevate his legs) that will surely improve the venous blood return of Jim to his
heart (Lewis et al., 2014). On contrasting note, Jim must not be placed in an upright position
as it can completely impair the blood that returns to the heart leading to the insufficient
blood circulation for heart and lowering of the blood pressure (Royals et al., 2016). The
nurse has to be strict and assured that Jim does not sit or stand suddenly as fatality can
occur in seconds due to these movements in extreme respiration issue (Zwakman et al.,
2015).

It is quite plausible that Jim may prefer sitting and as it assists in supporting the breathing
process and improving the ventilation. But, the nurse has to be aware of the fact that it can
also trigger hypotension in Jim. It is must to monitor closely (Lewis et al., 2014). On
immediate note, Jim must be laid down flat again in case it is observed that there is certain
change in the conscious state or there is certain drop in the blood pressure (Efraimsson et
al., 2015). This must be focused over and observed severely as Jim in the case study is sitting
up on the side of the bed in leaned position over his bedside table and is continuously
coughing (Hodson & Sherrington, 2014). It is quite probable that Jim might vomit due to
extreme coughing and respiration issue. In this case, Jim must be laid on their side of
recovery position. The nurse with nursing staff support and physician support can
implement the measures for improving Jim’s respiratory status (Lewis et al., 2014). Actions
must be performed for improving the cardiac output for improving his pulmonary tissue
perfusion as well reducing the fluid accumulation in his lungs that is disturbed (Roberts et
al., 2015). The nurse must also perform actions for reducing the anxiety and fear that also
impact respiration. Jim must be instructed to breathe slowly when hyperventilating (Hodson
& Sherrington, 2014). Jim can be placed in a semi- to high Fowler's position until he is
involved in contraindicated and can be position over the bed table to make him lean down
forward if it is desirable. In extreme cases, the nurse might need to use incentive spirometer
after every 1-2 hours for better breathing control (Royals et al., 2016).

The nursing actions must be there to increment the activity and strength tolerance for
increasing the ability and willingness of Jim to make a move, deep breathe, cough and make
use of the incentive spirometer (Creed & Hargreaves, 2016). The actions that can promote
the removal of his pulmonary secretions includes instructing and assisting Jim for coughing
or huffing after every 1-2 hours and humidifying the inspired air for keeping secretions on
thin level (Strong et al., 2014). Along with this, the nurse must be efficient in maintaining
good oxygen therapy as defined by the doctor like assisting in the positive airway pressure
techniques such as IPPB, expiratory positive airway pressure (EPAP) (Dickens et al., 2014),
continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP). If
the respiration improves with reduction in cough level, this means the nursing interventions
are effective and are showing their ability (Porakhonko et al., 2014).

Priority Problem 2

The key cardiovascular changes that occur during the COPD problem are the vasolidation
and the fluid extravasation with the usage of the mixed distributive-hypovolaemic shock
based pattern (Creed & Hargreaves, 2016). The circulation of the blood volume can reduce
in COPD by as much as over 35% in the time span of 10 minutes because of extravasation
and the severe vasodilation resistant towards the adrenaline or epinephrine (Esquinas et al.,
2015). This also means to respond just towards the potent vasoconstrictors being well
described (Porakhonko et al., 2014). During the COPD attack of extreme coughing, severe
form of reversible cardiac dysfunction is linked with the non-specific electrocardiogram
alterations along with the normal coronary arteries (Weldam et al., 2015). Even the mast
cells are quite present all across the cardiac blood vessels and somewhere between the
myocardial fibres in the humans including Jim (Strong et al., 2014). Even if Jim experiences
no cardiovascular instability due to extreme coughing and breathing problem, it is quite
observable that he might have global ST segment alterations that suggest the direct
mediator effect over the heart of Jim (Efraimsson et al., 2015). The cardiac manifestations
because of chronic obstructive pulmonary disease (COPD) have been numerous (Creed &
Hargreaves, 2016). It has been stated in medical literature that the impairments of the right
ventricular dysfunction along with the pulmonary vascular disease have complicated the
clinical course of this disease COPD and also correlates with survival inversely (Strong et al.,
2014). The true pathogenesis of the pulmonary vascular disease in COPD is probably
multifactorial and is associated with alterations in the gas exchange along with the vascular
biology and structural alterations in the pulmonary vasculature and various bodily
mechanical factors (Esquinas et al., 2015). It has been defined that COPD and the coronary
artery disease coexistence generally occurs on frequent note (Fletcher & Dahl, 2013). This
form of association is probably associated with shared risk factors and same form of
pathogenic mechanisms like the systemic inflammation. Arrhythmias have been found to
occur quite frequently in the patients with COPD (Strong et al., 2014).

The first nursing intervention is the documentation of the changes in heart functioning
through consistent assessment of Jim’s vital signs as dysrhythmia, and sensorium. The nurse
needs to auscultate the apical pulse along with the assessment of the heart rate and rhythm
both. The documentation of the dysrhythmia is also essential if the telemetry is easily
available (Dickens et al., 2014). This is an essential nursing intervention as Tachycardia is
generally the present form (even at rest) making good compensation for the reduction of
the ventricular contractility (Weldam et al., 2015). It has been found that the premature
atrial contractions (PACs), PVCs, paroxysmal atrial tachycardia (PAT), atrial fibrillation (AF)
and multifocal atrial tachycardia (MAT) have been quite common form of dysrhythmias
linked with HF (Porakhonko et al., 2014). Though the other forms of the dysrhythmias can
also be present. It is a must for the nurse to understand that the intractable ventricular
dysrhythmias have been unresponsive towards the medication suggesting the ventricular
aneurysm. It also includes noting down the heart sounds of Jim (Dickens et al., 2014). This is
evident because the S1 and S2 can be quite weak due to the diminished pumping action.
Even the gallop rhythms have been found to be common (S3 and S4) which gets produced
when the blood flows in the chambers being non-compliant. The murmurs can reflect over
the valvular incompetence (Porakhonko et al., 2014).

When the impact is found on heart assessment, simultaneously the nurse must monitor
Jim’s urine output certainly when there is decreasing output and the concentrated urine
(Dickens et al., 2014). This is because the kidneys make response towards the decreased
cardiac output by the retainment of the sodium and water. The urine output is generally
reduced during the day due to the fluid shifts occurring into tissues but can get incremented
at the night as the fluid returns towards the circulation if the patient is recumbent
(Zwakman et al., 2015). In the case study, Jim’s urine bottle over the side of his bed is
consisting of the small amount of urine in dark amber color (Esquinas et al., 2015). The
nurse must note down the alterations in sensorium such as his lethargy, depression,
confusion, anxiety and disorientation in true form. This can indicate inappropriate cerebral
perfusion that is being secondary towards the reduced cardiac output (Dickens et al., 2014).

The second nursing intervention includes the aspect of withholding the digitalis preparation
as defined and indicated which is a collaborative approach (Weldam et al., 2015). And the
nurse must make notification to the physician if there are marked alterations occurring in
the cardiac rate or the rhythm or the defined signs for the occurrence of the digitalis toxicity
(Fletcher & Dahl, 2013).

This intervention is reliable and valid with the rationale that there incidence of toxicity is
quite high that is 20% as the narrow margin present between the therapeutic and the toxic
ranges are present (Zwakman et al., 2015). Even digoxin may hold being discontinued in the
wider presence of the toxic drug levels, lower potassium level or the slower heart rate
(Esquinas et al., 2015). This has to be associated with the checking of the calf tenderness,
swelling, pallor of extremity, local redness or diminished pedal pulses (Fletcher & Dahl,
2013). This part of nursing intervention is useful as the reduced cardiac output during COPD,
enforced bed rest and venous pooling as seen in Jim’s case can increment the risk of
thrombophlebitis. It is good to encourage rest, chair or semi recumbent in bed for Jim as it
helps with the patient’s physical care as defined medically (Zwakman et al., 2015).

The Physical rest must be well maintained during the refractory or acute HF for improving
the efficacy of the cardiac contraction and for decreasing the myocardial oxygen demand as
well as consumption along with the workload (Weldam et al., 2015). The rhythmic rate must
lower to normal range gradually with ease on his pulse rate and blood pressure to define
that these nursing interventions are giving positive effects and evaluation (Fletcher & Dahl,
2013).

Conclusion

Jim is in an age which is quite critical to care and manage health issues and he was also a
smoke till 3 years back from the teenage period and now he is suffering from COPD problem
that is quite deteriorating for his lungs. Cigarette smoking has already impacted Jim’s health
and caused respiration problem and lung infection to the core. He is now coughing more
often with thick green color and feeling unwell with the reporting of respiration problem
(breathing trouble). He has been suffering from the prolonged expiratory phase. This
defines that priority basis for his nursing interventions include focus on treating and
managing his respiration and cardiac output that might get affected.

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