Question

D.Z., a 65-year-old man, is admitted to a medical floor for exacerbation of his chronic obstructive pulmonary disease (COPD; emphysema). He has a past medical history (PMH) of hypertension (HTN), which has been well controlled by enalapril (Vasotec) for the past 6 years, and a diagnosis (Dx) of pneumonia yearly for the past 3 years. He appears as a cachectic man who is experiencing difficulty breathing at rest. He reports cough productive of thick yellow-green sputum. D.Z. seems irritable and anxious when he tells you that he has been a 2-pack-a-day smoker for 38 years. He complains of (C/O) sleeping poorly and lately feels tired most of the time.

His vital signs (VS) are 162/84, 124, 36, 102°F, Sao2 88%. His admitting diagnosis is chronic emphysema with an acute exacerbation, etiology to be determined.

His admitting orders are as follows: diet as tolerated; out of bed with assistance; oxygen (O2) to maintain Sao2 of 90%; maintenance IV of D5W at 50 ml/hr; intake and output (I&O); arterial blood gases (ABGs) in am; CBC with differential, basic metabolic panel (BMP), and theophylline (Theo-Dur) level on admission; chest x-ray (CXR) q24h; prednisone 60 mg/day PO; doxycycline 100 mg PO q12h × 10 days, azithromycin 500 mg IV piggyback (IVPB) q24h ×2 days then 500 mg PO × 7 days; theophylline 300 mg PO bid; heparin 5000 units SC q12h; albuterol 2.5 mg (0.5 ml) in 3 ml normal saline (NS) and ipratropium 500 mg by nebulizer q4-6h; enalapril 10 mg PO q am.

Identify the expected findings in patients with COPD.

Identify three measures you could try to improve oxygenation status.

Explain the priority nursing care needed for patients with COPD.

What are two of the most common side effects of bronchodilators?

Identify the acid-base imbalance expected for patients with COPD.

Identify the expected arterial blood gas value results commonly seen in patients with COPD.

You deliver D.Z.'s dietary tray, and he comments how hungry he is. As you leave the room, he is rapidly consuming the mashed potatoes. When you pick up the tray, you notice that he hasn't touched anything else. When you question him, he states, “I don't understand it. I can be so hungry, but when I start to eat, I have trouble breathing and I have to stop.”

One theory for the increased work of breathing is based on carbohydrate (CHO) loading. D.Z.'s wife approaches you in the hallway and says, “I don't know what to do. My husband used to be so active before he retired 6 months ago. Since then he's lost 35 pounds. He is afraid to take a bath, and it takes him hours to dress—that's if he gets dressed at all. He has gone downhill so fast that it scares me. He's afraid to do anything for himself. He wants me in the room with him all the time, but if I try to talk with him, he snarls and does things to irritate me. I have to keep working. His medical bills are draining all of our savings, and I have to be able to support myself when he's gone. You know, sometimes I go to work just to get away from the house and his constant demands. He calls me several times a day asking me to come home, but I can't go home. You may not think I'm much of a wife, but quite honestly, I don't want to come home anymore. I just don't know what to do.”

How would you respond to her statement?

What education will you provide for this patient and his wife?

Answer 1

1. Expected findings in COPD in this patient are difficulty in breathing at rest, productive cough with thick yellow green sputum, less saturation 88%, poor sleep.

2. Measures to increase oxygenation are educate the patient to do deep breathing and coughing exercise, administer iron rich diet, make the patient to breathe fresh air, etc.

3. Nursing care for patients with COPD : Educate the patient to avoid irritants such as smoking, exposure to cold weather or any allergic substances, Administer fowlers position to ease breathing, educate about deep breathing and coughing exercises, provide protein rich and iron rich foods, increase the hydration level of the patient to liquify the secretions, provide steam inhalation to improve the respiration etc.

4. Side effects of bronchodilators : rapid heart rate, nausea, restlessness, irritability, nervousness,, vomiting . headache, trembling.