james robin is a 67 year old male client who was brought to the emergency department or ed with a three-day history of exertional breathlessness wheezing fatigue and a worsening productive cough he states he's been having increased difficulty with normal day-to-day activities such as eating talking and going up the stairs he has a history of cigarette smoking two packs per day since he was 25 years old however he quit smoking a year ago after being diagnosed with chronic obstructive pulmonary disease or copd copd or chronic obstructive pulmonary disease is a type of lung disease where chronic inflammation causes damage to the lungs and obstructs air flow it's usually caused by inhalation of toxic substances like tobacco smoke or occupational pollutants like dust and silica in some people an autosomal dominant disorder called alpha alpha-1 anti-trypsin deficiency results in breakdown of the lung parenchyma by an enzyme called elastase copd is characterized by long-term inflammation of the bronchial tubes referred to as chronic bronchitis and alveolar destruction referred to as emphysema most people diagnosed with copd have elements of both chronic bronchitis and emphysema chronic inflammation of the bronchial tubes in copd causes a hyper secretion of mucus by the respiratory goblet cells the mucus then forms a plug that obstructs the airways causing air trapping and it also causes chronic productive cough obstruction of the bronchi can also cause exertional dyspnea which can progress to resting dyspnea fatigue wheezing and chest tightness destruction of the alveolar sacs impairs gas exchange resulting in hypoxemia and hypercapnia loss of elastic recoil causes collapse of the airways during exhalation trapping the air and dilating the air spaces to make breathing easier they often use the tripod position where they sit up and lean forward with their hands on their knees they may use pursed lip breathing to prolong expiration and produce positive and expiratory pressure or peep which allows them to breathe out as much air as possible because this breathing technique requires use of accessory breathing muscles they will expend a lot of energy just to breathe air trapping also leads to an increased anteroposterior diameter of the chest sometimes called a barrel chest chronic hypoxemia can result in cyanosis a bluish discoloration of the lips or fingertips it causes constriction of the pulmonary vessels and pulmonary hypertension this increases the workload on the right side of the heart leading to right-sided heart failure or core pulmonale diagnosis of copd is based on the client history physical examination and pulmonary function tests or pfts to evaluate the degree of airway limitation the forced expiratory volume in one second or fev1 and the vital capacity or fvc are measured after the client is given a bronchodilator such as albuterol a fev1 to fvc ratio less than 70 percent indicates airway obstruction since copd is an irreversible disease giving a bronchodilator does not change the person's pfts too much finally alpha-1 anti-trypsin deficiency screening may also be done long-term management for stable copd includes smoking cessation and the avoidance of other triggers such as pollution and allergens influenza and pneumococcal vaccines should be administered to decrease the risk of respiratory infections although copd is an irreversible disease bronchodilators can help ease symptoms and corticosteroids can decrease inflammation in the lungs supplemental oxygen may be needed to maintain an oxygen saturation between 88 to 92 percent for these clients the goal is not 100 saturation because hypoxemia is the main stimulus for their respiratory drive finally since these individuals expend much of their energy on simply breathing dietary adjustments may be needed to maintain weight and muscle mass an exacerbation or a sustained deterioration of their respiratory symptoms beyond their normal day-to-day variability may manifest with increased dyspnea cough sputum production and fatigue increased wheezing may be noted and increased hypoxia may result in confusion or decreased level of consciousness arterial blood gases or abg's may show decreased pao2 increased pa co2 increased hco3 minus and decreased ph okay let's get back to our client mr robin since presenting to the ed he has been admitted to the pulmonary ward for treatment of an acute exacerbation of copd you have been assigned to his care after entering his room you introduce yourself wash your hands and confirm his identity mr robin is sitting up on the side of the bed leading over his bedside table in a tripod position you begin your assessment of mr robin by asking how he's feeling today he states he's feeling short of breath and very tired you notice that he struggles to complete full sentences because he has to stop to breathe you notice nasal flaring and he's pursing his lips during expiration he states that he has had worsening respiratory symptoms for about a week including breathlessness when doing activities such as getting up to go to the bathroom talking and eating he states he has had a chronic productive cough for years he says he usually coughs up clear sputum however in the last few mornings it is increased in volume and is a thicker consistency upon visual inspection of mr robin you know he has a barrel chest and that he is using accessory muscles to aid with breathing demonstrated by his ribs pulling inwards during inspiration you auscultate his lungs which reveals expiratory wheezing and coarse crackles to the lower lobes capillary refill is less than three seconds throughout your assessment mr robin appears alert and oriented but continues to be short of breath his vital signs are as follows blood pressure 135 over 80 heart rate 80 beats per minute temperature 98.6 degrees fahrenheit or 37 degrees celsius oxygen saturation 87 on room air respiratory rate 26 per minute 0 out of 10 pain you review his latest lab values which include complete blood count basic metabolic panel and arterial blood gases you make a note of his abg values ph is 7.34 pao2 is 62 millimeters of mercury paco2 is 65 millimeters of mercury hco3 is 32 milli equivalents per liter you document your assessment findings before leaving the room based on the assessment data you've collected the nursing diagnoses include ineffective breathing pattern related to increased work of breathing ineffective airway clearance related to increased production of secretions impaired gas exchange related to airway destruction activity intolerance related to imbalance between oxygen supply and demand and deficient knowledge related to chronic disease management now that you've gathered all the assessment data relevant diagnostic information lab values and created some nursing diagnoses you outlined several important goals to achieve by the end of your shift mr robin will have an effective breathing pattern as evidenced by breathing at a normal rate and depth the absence of dyspnea and no use of accessory muscles and he will maintain clear open airways as evidenced by clear breath sounds and ability to effectively cough up secretions optimal gas exchange will be demonstrated by unlabored respirations at 12 to 20 per minute pulse oximetry at therapeutic levels during rest and exertion and blood gases closer to normal range increased activity tolerance will be evidenced by enhanced capacity and energy to ambulate 25 feet without feeling breathless finally prior to discharge mr robin will verbalize an understanding of copd demonstrate how to use his inhaler avoid triggers for exacerbations and understand the long-term management of copd after collaborating with mr robin's healthcare team and receiving orders you review the plan of care while completing mr robin's vital signs which are ordered every two hours you continue to monitor his respiratory status by listening to his lungs and observing his breathing rate depth and use of accessory muscles mr robin's other orders include supplemental oxygen therapy at 2 liters via nasal cannula with continuous monitoring of the saturations through pulse oximetry his target oxygen saturation is ordered to be between 88 and 92 percent several medications have been ordered including albuterol a bronchodilator administered via inhaler with a spacer and prednisone an oral corticosteroid while administering these medications you review with mr robin the proper technique for using the inhaler and remind him that he will need to adhere to his medication regimen after discharge you stress the importance of continued smoking cessation and measures to decrease the risk of infections including hand washing and vaccinations you collaborate with the physical therapist or pt who is helping mr robin with techniques and exercises to help ease his work of breathing and conserve energy while completing adls the respiratory therapist or rt helps him learn breathing and airway clearance techniques and draws blood for blood gas analysis throughout your shift you'll closely monitor for signs of deteriorating respiratory status any increased dyspnea cyanosis and decreased level of consciousness will be reported to the ordering physician immediately by now it's near the end of your shift and it's time to evaluate and see how mr robin is doing his breathing appears less labored he's no longer using accessory muscles and he's been effectively coughing up his secretions he has remained on two liters of oxygen via nasal cannula throughout your shift his oxygen saturation remains at 91 percent while resting but decreases to 87 when standing up or ambulating a few steps he remains alert and oriented throughout the shift but he tires quite easily his vital signs are blood pressure 125 over 79 heart rate 90 temperature 98.6 fahrenheit or 37 celsius respiratory rate 22 per minute and pain 0 out of 10.
his abg's are ph 7.4 pao2 72 millimeters of mercury pa co2 48 millimeters of mercury hco3 28 milli equivalents per liter so it's pretty clear mr robin is improving you continue to reassess re-evaluate and document mr robin's response to interventions to determine if his goals are being met and if his plan of care should be revised alright as a quick recap your assigned client james robin presented to the ed with an exacerbation of copd which is characterized by inflammation hypersecretion of mucous airway obstruction and alveolar destruction inhalation of toxic substances like tobacco smoke or environmental pollutants are common causes an acute exacerbation of copd is usually the result of an infection but can also be caused by seasonal allergies or inhalation of irritants signs and symptoms of an acute exacerbation include increased dyspnea cough and sputum production along with wheezing fatigue confusion and disorientation your assessment revealed that mr robin had dyspnia while completing adls he was using accessory muscles while breathing he had an increase in amount and consistency of secretion he was tachypnea and had wheezing and crackles in his lungs your nursing diagnoses were ineffective breathing pattern ineffective airway clearance impaired gas exchange activity intolerance and deficient knowledge the goals you identified when planning care for mr robin included establishing an effective breathing pattern maintaining clear airways increased activity tolerance and understanding his medication regiment effective breathing techniques and risk factors for exacerbations interventions will continue to be implemented and evaluated to determine if his goals are being met you