RUA Case Study: Chronic Obstructive Pulmonary Disease

Health History

Pamela Carothers is a 71-year-old Caucasian female who was diagnosed with COPD last year is being admitted for shortness of breath and chest pain that she has had for the last 2 days. She is sitting up in the bed gripping tightly the bed rails, breathing through her mouth with rapid, shallow breaths and the use of accessory muscles. Pamela’s daughter Karen is present and answering questions for her mother. Karen tells the nurse that Pamela has a past medical history of emphysema and hypertension and that Pamela smokes 2 packs of cigarettes a day as she has for the past 35 years. Since her last follow up with her cardiologists, she has lost 15 pounds. Today in the ER Pamela’s vitals are, blood pressure of 152/90, heart rate at 82, temperature of 98.9F, O2 saturation at 92% at 2L on nasal cannula, respirations of 12, and wheezing noted for breathes sound. The nurse is aware that amongst COPD patients diagnosed within the past year, they have a higher prevalence of acquiring a case of severe pneumonia compared to patients without COPD (Restrepo, Sibila, & Anzueto, 2018).

When asked about exercise Pamela states she cannot exercise because she gets “winded” immediately and even getting in and out of her favorite chair at home leaves her out of breath. She exclaims that she is always extremely tired as it is difficult for her to sleep in her bed at night so she sleeps in her favorite chair which is now causing swelling in her legs and feet. Pamela has also expressed that she is extremely tired and frustrated with feeling like she is dying. She states that she is a burden to her daughter and that her daughter would be better off if she didn’t have to take care of her. Pamela states “a mother is supposed to take care of her child not the other way around”. Pamela states that she has not been taking her prescribed medications as she is on a fixed income and cannot afford them. Pamela stated, “I have to choose between food on my table or medications that I don’t need”. She stated she has opted to buy and take herbal supplements because one of her good friends recommended, she take a tablespoon of apple cider vinegar a day for her “pressure” and turmeric capsules because she read online that it was good for inflammation.

Laboratory/Diagnostic Testing

Arterial blood gas is the best way to determine the severity of a COPD exacerbation. The pH is closer to normal in those with COPD, anything less than 7.3 is considered to be an acute episode. Pamela’s result was pH 7.39 PCO2 28.6 PO2 55 HCO3 20.6.

Spirometry was used to measure the expiratory forced vital capacity which is how much air she could forcefully exhale after breathing in as deeply as possible. Normal value is eighty percent or greater and abnormal is considered lower than eighty percent. The second measurement is forced expiratory volume which is how much air you can force out of the lungs within one second. The FEV1 is the grade on how severe an abnormality is. Pamela’s results were FCV/FEV1 40%. A chest x-ray was done to help support a diagnosis of COPD by showing images of enlarged lungs, a flat diaphragm, or air pockets. Pamela’s results were hyperinflation of the lung.

Collaborative Management

Pamela has states that she is non-compliant in taking her prescribed medication due to the cost of the medication. She is currently prescribed albuterol and fluticasone to treat her COPD and emphysema. With compliance of medications the patient should see an improvement in her COPD. There are many resources that can assist Pamela with the costs of her medications. Many drug companies offer discounts to people who may not be able to afford those medications. Due to the cost of the albuterol inhaler the patient could try the Albuterol Sulfate tablet, which is a twelve-hour extended release. The Albuterol sulfate tablet is offered at many pharmacies ranging from four to nine dollars (RxVantage, 2019). This may also assist with compliance because it is a once a day dose. A social worker will follow up with Pamela to see if she may qualify for government assistance to aid in the purchase of her medications and to possible have a CNA assist her a few days a week in her home. The social worker can also arrange to have modifications made to Pamela’s bed to make it easier for her to breath while sleeping.

Pamela was scheduled for a chest x-ray to rule out any other lung problems other than her emphysema and COPD and to rule out heart failure. Next a referral for a pulmonary function test will be place so that a new baseline can be established for her COPD. The pulmonary function test will allow us to adjust her treatment and medications appropriately. Since Pamela is still currently smoking the recommendation for smoking cessation will be made as well as education on the importance of quitting smoking. We would also recommend that Pamela participate in a pulmonary rehabilitation program in the future. She would greatly benefit from their services. This program includes education, nutrition advice, counseling, and exercise training. This program includes a specialist from different fields, who can build a plan based on her specific needs. Pulmonary rehabilitation will allow Pamela to gradually increase her ability to participate in daily activities and improve her quality of life (Lee & Kim, 2019).

Pamela’s weight has decreased by fifteen pounds since her last visit. As a result, a consult with nutrition will be placed to help her pick foods that are easier for her to eat so that she will not be fatigued as easily with eating. The recommendation for a soft food, low sodium, high protein diet has been explained at length with the patient. She understands but realizes she needs assistance with food choices (Hodson, 2016). “Stopping smoking may also help with improving the senses of taste and smell making food more pleasurable” (Hodson, 2016).

Nursing Management

Nursing Diagnosis: Priority physiological

Ineffective breathing pattern related to hyperventilation as evidenced by the use of accessory muscles to breathe.

Short term goal: Pamela will exhibit no use of accessory muscles by end of shift

Long term goal: Pamela will take her medications as prescribed with the help of case

management to find assistance with paying for medications by discharge.

Interventions:

1. Demonstrate to Pamela how to perform pursed lip breathing (PLB). Rationale: This type of breathing prolongs exhalation and prevents the bronchioles from collapsing and trapping air. PLB is also gives the patient more control over breathing and is very beneficial during exercise and periods of dyspnea (Lewis, Bucher, Heitkemper, Harding, Kwong, & Roberts, 2017).
2. Assist Pamela with maintaining a diet high in protein and calories consisting of mechanical soft foods. Rationale: Diet is a main concern as Pamela is losing weight due in part to the fact that she breathes out of her mouth, so it is more difficult for her to eat. Pamela will need to eat mechanical soft foods which will be easier for her to consume.
3. Educate Pamela on the importance of regular exercise as physical activity. Rationale: Patients with COPD is consistently associated with mortality and increased exacerbations (Gimeno-Santos, Frei, Steurer-Stey, De Batlle, Rabinovich, Raste, Garcia-Aymerich, 2014).

Evaluations:

1. Pamela has demonstrated effective pursed lip breathing.
2. Pamela has identified appropriate foods included in her mechanical soft, high protein and calorie diet.
3. Pamela has begun exercising as tolerated by walking from her room to the end of the hall and back while using pursed lip breathing and resting when needed.

Education:

1. Educate Pamela on the Huff coughing technique to expel mucus from her airway.
2. Educate Pamela on the importance of smoking cessation.
3. Educate Pamela on the importance of taking her medications as prescribed.

Nursing Diagnosis: Priority Psychosocial

Stress overload related to coping with chronic illness (COPD) as evidence by patient expressed that she is feeling extremely tired and frustrated with feeling like she is dying and burden to her daughter and that her daughter would be better off if she didn’t have to take care of her.

 Short term goal: Pamela will identify at least three stressors that can be controlled and

those that cannot by the end of the shift.  

Long term goal: Pamela will identify three behavioral modifications to reduce or

eliminate that will increase successful stress management.

Intervention:

1. Assist Pamela to recognize her thoughts, feelings, actions, and physiological responses to feeling of tiredness or frustration. Rationale: Self-awareness can help Pamela reframe and reinterpret her feelings and experiences of what she can control and what she cannot control (Carpenito-Moyet, L.2016).
2. Teach Pamela how to break the stress cycle and how to decrease heart rate, respirations, and strong feelings of anger or feeling of powerlessness or hopelessness. Rationale: Pamela faced with overwhelming multiple stressors (health condition, dependence on her daughter, medication/financial), this will assist Pamela to differentiate which stressors and behavior can be modified to reduce or eliminate the stress overload.
3. Initiate health teaching and referrals. Rationale: Pamela expressed that she is feeling extremely tired and frustrated with feeling like she is dying and burden to her daughter and that her daughter would be better off if she didn’t have to take care of her. Consulting professional counseling would be very beneficial for Pamela.

Evaluations:

1. Pamela able to identify and recognize three of her thoughts, feelings, and actions that she took reduce of her feeling tired or frustrated.
2. Pamela able to use breathing technique correctly to reduce her heart rate and respiration.
3. Pamela scheduled or meeting with counseling to talk about her feelings.

Education:

1. Teach Pamela to purposefully distract herself when she is feeling overwhelmed by thinking of something pleasant and positive.
2. Teach Pamela to use mini-relaxation (breathing) techniques while also thinking of something pleasant and positive and this will help reduce her heart rate, respiration, and also can help reduce her COPD exacerbation as well. This will help Pamela to recognize which modification she can change.
3. Encourage Pamela meet with counseling to talk about her feelings.

Conclusion

In conclusion caring for a patient with COPD takes continuous monitoring and care. The patient must be willing to be compliant with care and medications to successfully manage their disease. It is important to treat the patient as a whole. By taking care of the patient’s psychosocial, socioeconomical and physiological needs then the patient is more likely to be successful. It is also important to be knowledgeable about their disease so that proper diagnosis and care can be given to the patient.

References

• Bodescu, M.-M., Turcanu, A. M., Gavrilescu, M.-C., & Mihăescu, T. (2015). Respiratory rehabilitation in healing depression and anxiety in COPD patients. Pneumologia (Bucharest, Romania), 64(4), 14–18. Retrieved from https://search-ebscohost-com.chamberlainuniversity.idm.oclc.org/login.aspx?direct=true&db=mdc&AN=27451589&site=eds-live&scope=site
• Carpenito-Moyet, L. (2016). Handbook of nursing diagnosis (15th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.
• COPD. (2017, August 11). Retrieved from https://www.mayoclinic.org/diseases-conditions/copd/diagnosis-treatment/drc-20353685
• Eun Nam Lee, & Moon Ja Kim. (2019). Meta-analysis of the Effect of a Pulmonary Rehabilitation Program on Respiratory Muscle Strength in Patients with Chronic Obstructive Pulmonary Disease. Asian Nursing Research, (1), 1. https://doi-org.chamberlainuniversity.idm.oclc.org/10.1016/j.anr.2018.11.005
• Gimeno-Santos, E., Frei, A., Steurer-Stey, C., De Batlle, J., Rabinovich, R., Raste, Y.,
• Garcia-Aymerich, J. (2014). Determinants and outcomes of physical activity in patients with copd: A systematic review. Thorax, 69(8), 731-731. doi:10.1136/thoraxjnl-2013-204763
• Hodson, M. (2016). Integrating nutrition into pathways for patients with COPD. British Journal of Community Nursing, 21(11), 548–552. https://doi-org.chamberlainuniversity.idm.oclc.org/10.12968/bjcn.2016.21.11.548
• Lewis, S. L., Bucher, L., Heitkemper, M., Harding, M., Kwong, J., & Roberts, D. (2017). Medical surgical nursing: Assessment and management of clinical problems (10^th ed.). St Louis, MO: Elsevier.
• Restrepo, M., Sibila, O., & Anzueto, A. (2018). Pneumonia in patients with chronic obstructive pulmonary disease. Tuberculosis and Respiratory Diseases, 81(3), 187-197. doi:10.4046/trd.2018.0030
• RxVantage. (2019). Patient Assistance Programs. Retrieved from https://www.rxassist.org/