2. JS is a 74 year old man who presents to your
family medicine office with his wife complaining
of shortness of breath and fever. They just
moved to the area and had been planning to
come to your office next week to establish care
as new patients.
Due to the onset of symptoms, JS called and
was given a walk-in slot today. His wife did
bring records from his last physician’s office.
3. Past Medical/Surgical History
Heart failure following myocardial infarction at age 68
years
COPD (on 2 L home oxygen)
Hypertension
Appendectomy
Family History
Father died of myocardial infarction at age 59 years
(diabetes, hypertension, smoker)
Mother alive (atrial fibrillation, heart failure)
Healthy siblings
4. Social History
Married, 3 children
30 pack year smoking history (quit after MI)
Worked on a farm
No alcohol or illicit drug use
Medications / Allergies
Lisinopril 20 mg twice daily
Metoprolol 50 mg twice daily
Spironolactone 25 mg daily
Furosemide 40 mg daily
Salmeterol/fluticasone 50/500 dry powdered inhaler (DPI) one puff
inhaled twice daily
Tiotropium DPI one cap inhaled daily
Albuterol/ipratropium metered dose inhaler (MDI) or solution for
nebulization every 6 hours as needed
Levalbuterol MDI two puffs every 4 to 6 hours as needed
Home oxygen
5. He is confused about what to use when,
so you are not sure which medications he
actually takes.
No known allergies
JS Past Record Review (brought by wife)
Echocardiogram with EF of 25%
Spirometry with FEV1 35% predicted that
does not change significantly after inhaled
bronchodilator
6. Records Review
Unable to determine when last
pneumoccal vaccine was given
Patient and wife don’t recall “a
pneumonia shot”
Does know he got his “flu shot” last
month at a grocery store
7. JS current symptoms include the following:
Unable to speak in full sentences for the past several hours per
wife
Cough productive but unknown color of sputum
Audible wheezing since last night per wife
Mild chest tightness
Dyspnea
His wife has noted no change in his alertness or mental status
When you inquire, the wife states that JS usually has a
cough, worse in the morning, productive of gray sputum, gets
short of breath if he walks more then 10 feet, and has
episodes of wheezing if he gets sick (e.g. with an upper
respiratory infection).
He usually is able to help around the house with light work
and fixing things.
8. Physical examination
Vital Signs: BP 128/74; P 68, reg; RR 32; Ht 5ft 6 in; Wt
122 lbs; T 101.5 °F oral
Unable to speak in full sentences, audible wheezing, alert
and oriented
Pertinent positives:
General: audible wheezing, no accessory muscle use
Nails: tar stains, clubbing
Chest: increased anteroposterior (AP) diameter; diffuse
wheezing to auscultation
Heart: regular, no murmurs
9. Study results
Pulse oximetry 86%
Chest x-ray shows hyperinflation and right
lower lobe pneumonia
You continue his heart failure medications as
per his home regimen
No need to discontinue the
cardioselective beta-blocker
10. ABG Normal Range Other bloods Normal Range
PH 7.236 7.35-7.45 Digoxin Level 0.5 1.0-2.0 nmol/L
PO2 4.7 11-15 kPa
PCO2 8 4.6-6 kPa
HCO3 30.0 22-26
BE +5 -2.4-+2.3
SaO2 70 95-98%
Glucose 10.0 3.7-5.2
11. Altered mental status
At least three exacerbations in the previous 12 months
Body mass index of 20 kg per m2 or less
Marked increase in symptoms or change in vital signs
Medical comorbidities (especially cardiac ischemia, heart
failure, pneumonia, diabetes mellitus, or renal or hepatic
failure)
Poor physical activity levels
Poor social support
Severe baseline COPD (FEV1/FVC ratio less than 0.70 and
FEV1 less than 50 percent of predicted)
Underutilization of home oxygen therapy
12. Based on this information, JS has the
following clinical factors that increase his
risk of a severe COPD exacerbation:
Marked increase in symptoms and change in
his vital signs including a low oxygen
saturation
a new medical co-morbidity of pneumonia
all combined with his severe baseline COPD
13. Indications for hospitalization
Risk of death from an exacerbation
increases with:
Development of respiratory acidosis
Presence of significant comorbidities,
Need for ventilatory support
14. Upon questioning his wife, you find out that he has had
5 exacerbations in the past year, three of which were
treated with antibiotics and oral steroids
Amoxicillin x2 courses, doxycycline x1 course
Most recent course 6 weeks ago
No hospitalizations within the last 6 months
Based on this information, and his chest x-ray findings,
you initiate treatment for community acquired pneumonia.
15. Over 3 days, JS has significantly improved
and has weaned back to his home oxygen
regimen.
He is taking the albuterol/ipratropium
nebulized treatments every 6 hours, and is
ready to switch back to bronchodilators via
inhaler device.
Along with antibiotics for a total of 7 days, you
need to determine the dose and duration of
treatment for oral corticosteroids.
16. In completing the medication
reconciliation forms, you see that JS had
a complex medication regimen upon
admission
It is clear, during discussions with him,
that he is unable to comply with this
expensive, complex and potentially
unnecessary regimen.
17. Lisinopril 20 mg twice daily
Metoprolol 50 mg twice daily
Spironolactone 25 mg daily
Furosemide 40 mg daily
Salmeterol/fluticasone 50/500 dry powdered inhaler
(DPI) one puff inhaled twice daily
Tiotropium DPI one cap inhaled daily
Albuterol/ipratropium metered dose inhaler (MDI) or
solution for nebulization every 6 hours as needed
Levalbuterol MDI two puffs every 4 to 6 hours as
needed
18. Streamline regimen
No need for levalbuterol
Continue salmeterol/fluticasone 50/500 DPI
and/or tiotropium DPI
Short-acting bronchodilator MDI as needed
Patient given pneumococcal vaccine
prior to discharge
21. In COPD, the airflow limitation is both progressive
and associated with an abnormal inflammatory
response of the lungs to noxious particles or gases.
The inflammatory response occurs throughout
the airways, parenchyma, and pulmonary vasculature
Because of the chronic inflammation and the body’s
attempts
to repair it, narrowing occurs in the small peripheral
airways.
Over time, this injury-and-repair process causes scar
tissue formation and narrowing of the airway lumen.
Airflow obstruction may also be due to parenchymal
destruction as seen
22. IN THE PATIENTIN THE BOOK
THICKENENG OF AIRWAY WALLTHICKENENG OF AIRWAY WALL
PERIBRONCHIAL FIBROSISPERIBRONCHIAL FIBROSIS
EXUDATE IN THE AIRWAYEXUDATE IN THE AIRWAY
SMOKINGOVERAL AIRWAY
NARROWING(OBSTRUCTIVE
BRONCHIOLITIS)
AMBIENT AIR POLLUTIOTHINCKENING OF THE LINING OF
THE VESSEL AND HYPERTOPHY OF
SMOOTH MUSCLE
SMOKING
AMBIENT AIR POLLUTIO
23. Pathophysiology
the airflow limitation is both progressive and associated
with an abnormal inflammatory response of the lungs to
noxious particles or gases.
The inflammatory response occurs throughout
the airways, parenchyma, and pulmonary vasculature
Because of the chronic inflammation and the body’s
attempts to repair it, narrowing occurs in the small
peripheral airways.
Over time, this injury-and-repair process causes scar tissue
formation and narrowing of the airway lumen.
Airflow obstruction may also be due to parenchymal
destruction as seen
24. In book and in patient:
1. chronic cough
2. sputum production
3. dyspnea on exertion
4. Weight loss is common
25. Complications:
respiratory failure
Respiratory insufficiency and failure may be chronic
(with severe COPD) or acute (with severe
bronchospasm or pneumonia in the patient with severe
COPD.
Acute respiratory
insufficiency and failure may necessitate ventilatory
support until
other acute complications, such as infection, can be
treated.
26. Promoting Home- and Community-Based Care
Teaching Patients Self-Care
Provide instructions about self-management; assess
the knowledge of patients and family members about
self-care and the therapeutic regimen.
Teach patients and family members early signs and
symptoms of infection and other complications so that
they seek appropriate health care promptly.
Instruct patient to avoid extremes of heat and cold and
air pollutants (eg, fumes, smoke, dust, talcum, lint, and
aerosol sprays). High altitudes aggravate hypoxemia.
27. pollutants (eg, fumes, smoke, dust, talcum, lint,
and aerosol sprays). High altitudes aggravate
hypoxemia.
Encourage patient to adopt a lifestyle of
moderate activity
ideally in a climate with minimal shifts in
temperature and humidity; patient should avoid
emotional disturbances and stressful
situations; patient should be encouraged to
stop smoking.
28. Review educational information and have
patient demonstrate correct metered-dose
inhaler (MDI) use before discharge, during
follow-up visits, and during home visits.
29. Continuing Care
Refer patient for home care if necessary.
Direct the patient to community
resources (eg, pulmonary rehabilitation
programs and smoking cessation
programs); remind the patient and family
about the importance of participating
in general health promotion activities and
health screening.
30. Nursing Management
The nurse plays a key role in identifying potential
candidates for pulmonary rehabilitation and in
facilitating and reinforcing the material learned in the
rehabilitation program.
PATIENT EDUCATION
Breathing Exercises.
Inspiratory Muscle Training.
Activity Pacing.
Self-Care Activities.
Physical Conditioning.
Oxygen Therapy.
Nutritional Therapy.
Coping Measures.
31. CONT…
Achieving Airway Clearance
Monitor the patient for dyspnea and hypoxemia.
If bronchodilators or corticosteroids are prescribed, administer
the medications properly and be alert for potential side
effects.
Confirm relief of bronchospasm by measuring improvement
in expiratory flow rates and volumes (the force of expiration,
how long it takes to exhale, and the amount of air
exhaled) as well as by assessing the dyspnea and making sure
that it has lessened.
Encourage patient to eliminate or reduce all pulmonary irritants,
particularly cigarette smoking.
Instruct the patient in directed or controlled coughing.
Chest physiotherapy with postural drainage, intermittent
positive-pressure breathing, increased fluid intake, and bland
aerosol mists (with normal saline solution or water) may be
useful for some patients with COPD.
32. CONT…
Improving Breathing Patterns
Inspiratory muscle training and breathing retraining may
help improve breathing patterns.
Training in diaphragmatic breathing reduces the respiratory
rate, increases alveolar ventilation, and sometimes helps
expel as much air as possible during expiration.
Pursed-lip breathing helps slow expiration, prevent collapse
of small airways, and control the rate and depth of
respiration; it also promotes relaxation.
33. CONT…
Improving Activity Tolerance
Evaluate the patient’s activity tolerance and limitations and
use teaching strategies to promote independent activities of
daily living.
Determine if patient is a candidate for exercise training to
strengthen the muscles of the upper and lower extremities
and to improve exercise tolerance and endurance.
Recommend use of walking aids, if appropriate, to improve
activity levels and ambulation.
Consult with other health care professionals (rehabilitation
therapist, occupational therapist, physical therapist) as
needed.
34. Monitoring and Managing Complications
Assess patient for complications (respiratory insufficiency
and failure, respiratory infection, and atelectasis).
Monitor for cognitive changes, increasing dyspnea, tachypnea,
and tachycardia.
Monitor pulse oximetry values and administer oxygen as
prescribed.
Instruct patient and family about signs and symptoms of
infection or other complications and to report changes in
physical or cognitive status.
Encourage patient to be immunized against influenza and
Streptococcus pneumonia.
35. CONT…
Caution patient to avoid going outdoors if
the pollen count is high or if there is
significant air pollution and to avoid
exposure to high outdoor temperatures
with high humidity.
If a rapid onset of shortness of breath
occurs, quickly evaluate the patient for
potential pneumothorax by assessing the
symmetry of chest movement, differences
in breath sounds, and pulse oximetry.
36. Promoting Rest:
Position bed for maximal respiratory
efficiency; provide oxygen if needed.
Initiate efforts to prevent respiratory,
circulatory, and vascular disturbances.
Encourage patient to increase activity
gradually and plan rest with activity
and mild exercise.
37. Improving Nutritional Status:
Provide a nutritious, high-protein diet
supplemented by Bcomplex vitamins and
others, including A, C, and K.
Encourage patient to eat: Provide small,
frequent meals, consider patient
preferences, and provide protein
supplements, if indicated.
Provide nutrients by feeding tube or total
PN if needed.
38. Cont…
Provide patients who have fatty stools
(steatorrhea) with water-soluble forms of fat-
soluble vitamins A, D, and E, and give folic
acid and iron to prevent anemia.
Provide a low-protein diet temporarily if
patient shows signs of impending or
advancing coma; restrict sodium if needed.
39. Providing Skin Care:
Change patient’s position frequently.
Avoid using irritating soaps and adhesive
tape. Provide lotion to soothe irritated skin;
take measures to prevent patient from
scratching the skin.
40. Reducing Risk of Injury:
Use padded side rails if patient
becomes agitated or restless.
Orient to time, place, and procedures
to minimize agitation.
Instruct patient to ask for assistance
to get out of bed.
Carefully evaluate any injury because
of the possibility of internal bleeding.
41. Cont…
Provide safety measures to prevent
injury or cuts (electricrazor, soft
toothbrush).
Apply pressure to venipuncture sites
to minimize bleeding.
42. Cont…
Administer oxygen if oxygen desaturation
occurs; monitor for fever or abdominal pain,
which may signal the onset of bacterial peritonitis
or other infection.
Assess cardiovascular and respiratory status;
administer diuretics, implement fluid restrictions,
and enhance patient positioning, if needed.
43. Monitoring and Managing
Complications:
Monitor for bleeding and hemorrhage.
Monitor the patient’s mental status
closely and report changes so that
treatment of encephalopathy can be
initiated promptly.
Carefully monitor serum electrolyte levels
are and correct if abnormal.
44. Cont…
Administer oxygen if oxygen desaturation
occurs; monitor for fever or abdominal
pain, which may signal the onset of
bacterial peritonitis or other infection.
Assess cardiovascular and respiratory
status; administer diuretics, implement
fluid restrictions, and enhance patient
positioning, if needed.
45. Cont…
Monitor intake and output, daily weight
changes, changes in abdominal girth, and
edema formation.
Monitor for nocturia and, later, for oliguria,
because these states indicate increasing
severity of liver dysfunction.
