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.