CHRONIC OBSTRUCTIVE PULMONARY DISEASE final case study., Exams of Nursing

Download CHRONIC OBSTRUCTIVE PULMONARY DISEASE final case study. and more Exams Nursing in PDF only on Docsity! CHRONIC OBSTRUCTIVE PULMONARY DISEASE final case study. CHRONIC OBSTRUCTIVE PULMONARY DISEASE I. Disease state and definition Lungs • They are sacks of tissue located just below the rib cage and above the diaphragm. • They are important part of the respiratory system and waste management for the body. • The right lung is made up of three lobes. The left lung has only two lobes to make room for your heart. • One organ in which its condition with Chronic Obstructive Pulmonary Disease (COPD) progresses and becomes worse over time. • This is prevented by COPD from working efficiently, which can lead to a range of complications. Lungs function: • Pair of breathing organs located with the chest which remove carbon dioxide and bring oxygen to the blood. From there, it circulates to the rest of the body. • As they expand, air is sucked in for oxygen. As they compress, the exchanged carbon dioxide waste is pushed back out during exhalation. Chronic Obstructive Pulmonary Disease (COPD) • It is a progressive disease characterized by airflow limitation that is not fully reversible. • Its inflammation and proteolysis is an amplification of the normal inflammatory response to cigarette smoke. • The main symptoms include shortness of breath and cough with sputum production. Chronic = a disease that doesn't go away even when you’re feeling well and don’t have symptoms Obstructive = you have trouble getting air out of your lungs, making it difficult also, to get air into your lungs Pulmonary = a disease in COPD Disease = a medical condition with symptoms that affect structure or function CHRONIC OBSTRUCTIVE PULMONARY DISEASE final case study. Other names: • Chronic obstructive Lung Disease (COLD) • Chronic bronchitis • Emphysema • Pulmonary emphysema Emphysema and Chronic bronchitis are older terms used for different types of COPD. These are also the two main forms of COPD. Emphysema – This involves damage to lungs over time. Third picture shown above: A blackened lung that was removed from a chronic smoker. Chronic bronchitis – still used to define a productive cough with mucus that is present for at least three months each year for two years. Most people with COPD have a combination of both conditions. CAUSES • Cigarette Smoking (Major risk factor) - The more a person smokes, the more likely that person will develop COPD. But some people smoke for years and never get COPD. • In rare cases, nonsmokers who lack a protein called alpha-1 antitrypsin can develop emphysema. OTHER RISK FACTORS • Exposure to certain gases or fumes in the workplace • Exposure to heavy amounts of secondhand smoke and pollution • Frequent use of a cooking fire without proper ventilation COMPLICATIONS CHRONIC OBSTRUCTIVE PULMONARY DISEASE final case study. Diagnosis • A suspected diagnosis of COPD should be based on the patients symptoms or history of exposure to risk factors. • It is important to distinguish COPD from asthma because treatment and prognosis differ. Differentiating factors include age of onset, smoking history, triggers and occupational history. • In some patients clear distinction between asthma and COPD is not possible. • Bronchiectasis, cystic fibrosis, obliterative bronchiolitis, congestive heart failure and tuberculosis are other possible differential diagnoses that are usually easier to distinguish from COPD. • Spirometry is required to confirm the diagnosis. • The presence of FEV1/ FVC ratio less than 70% confirms the presence of airflow limitation that is not fully reversible. • Hematocrit test • Arterial blood gases tests should be obtained in patients with an FEV1 less than 40% predicted or signs or symptoms suggestive of cor pulmonale or respiratory failure. • The Medical Research Council (MRC) dyspnea scale can be used to monitor physical limitation due to breathlessness; the scale is simple to administer and correlates well with scores of health status. • The BODE index is a validated predictor of mortality and is a better predictor than FEV1 alone. It is a composite score derived from body mass index (B), FEV1 or degree of airflow obstruction (O), modified medical research council (MMRC) dyspnea scale (D), and 6 minute walking distance (E, exercise capacity). All of this variables predict important outcomes such as health-related quality of life, the rate of exacerbation and the risk of death. o The composite score is based on a 10-point scale in which higher scores indicate a higher risk of death. The BODE index can be used clinically to monitor disease progression. CHRONIC OBSTRUCTIVE PULMONARY DISEASE final case study. NON-PHARMACOLOGICAL TREATMENTS FOR COPD COPD is among the leading causes of death in industrialized countries, and new pharmacological treatments are being developed to help patients with this disease. But a spectrum of non-pharmacological ways of treating COPD are also available and important, ranging from actions a patient could take or oxygen use to a lung transplant. Here is a list of some of these options. Smoking cessation Quitting smoking is the most essential first step that COPD patients are advised to take. Smoking is among the leading risk factors for developing COPD, and it is known to worsen disease morbidity and accelerate airflow obstruction. Long-term oxygen therapy CHRONIC OBSTRUCTIVE PULMONARY DISEASE final case study. Long-term oxygen therapy is often defined as oxygen use for at least 15 hours a day. It is commonly given to COPD patients with low-blood oxygen levels to improve breathing difficulties, exercise tolerance, and survival. Noninvasive Ventilation Treatment of COPD with noninvasive ventilation (NIV) is effective in acute flares, in helping in pulmonary rehabilitation, and in managing high levels of carbon dioxide. According to the GOLD Guidelines, the use of NIV is preferred over intubation and positive pressure ventilation as a first ventilation treatment of respiratory failure in acute flares of COPD. Studies show a success rate of 80–85%, with NIV improving oxygenation and decreasing carbon dioxide levels, as well s slowing the respiratory rate and easing severity of breathlessness. It also helps to avoid such complications such as pneumonia, related to ventilator use and length of hospital stay. Interventional bronchoscopy and surgery A common COPD condition is emphysema, which destroys the bronchi walls, creating less and larger bronchi instead of many tiny ones, reducing the amount of gas exchanged in the lungs and leaving large spaces filled with air even upon exhalation. The GOLD Guidelines recommend that lung volume reduction surgery be considered in patients with severe breathlessness and enlarged lungs, where emphysema has diminished the ability of non-affected lung areas to work well. The goal of lung volume reduction surgery is to remove the least functional parts of the lungs to improve airflow, gas exchange (oxygen and carbon dioxide) and create more room for lung mechanics in its remaining portions. Intra bronchial valves placement may be a less invasive and more cost-effective option for some people with severe COPD, leading to an improved quality of life and better lung function. These valves are designed to limit airflow to more damaged and hyper-inflated portions of the lung, gradually collapsing these portions, so as to make space for the healthy parts of the lung to “breathe.” CASE STUDY Chronic obstructive pulmonary disease (COPD) is an epidemic in many parts of the world. Most patients with COPD demonstrate mild disease. The cornerstone of management of mild disease is smoking cessation, which is the only proven intervention to relieve symptoms, modify its natural history and reduce mortality. General Information: • Patient’s Initial: A.M. • Age: 74 years old CHRONIC OBSTRUCTIVE PULMONARY DISEASE final case study. • height – 5’6’’ • weght- 122 lbs • Body Mass index= 19.7kg per m2 Pertinent Positives: General: audible wheezing, no accessory muscle use Nails: tar stains, clubbing Chest: increased anteroposterior diameter; diffuse wheezing to auscultation. Heart: regular no murmurs. Laboratory and Study Results ABG and others Patient’s Normal range PH 7.236 7.35-7.45 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 • Pulse oximetry 86%, normal range of 95-100 mmHg • Ejection Fraction of 25% (indicative of heart failure) normal range is 50%-70% • spirometry with FEV1 35% predicted • Chest x-ray shows hyperinflation and right lower lobe pneumonia • continue heart failure medications as per home regimen • no need to discontinue beta-blocker Problem List 1. Drug related Problem 2. COPD complication and characteristics 3. COPD exacerbation risk factors CHRONIC OBSTRUCTIVE PULMONARY DISEASE final case study. 4. Others Drug contraindication Side effect Levalbuterol- for Diabetes, ketoacidosis, -may raise blood wheezing and shortness of excess body acid, low pressure, chest pain, rapid breath amount of potassium in breathing the blood, high blood pressure • A.M had a complex medication regimen upon admission. He was unable to comply with this expensive, complex and potentially unnecessary regimen. COPD complications and characteristics • pneumonia • Acute respiratory distress syndrome (ARDS) o ARDS is a life-threatening condition in which severe inflammation of the lungs causes fluid to leak into the blood vessels in the airways. The small air sacs, or alveoli, collapse as a result. ARDS usually develops in response to a severe chest injury or an infection, such as pneumonia. • Depression • Heart Failure • Frailty o Frailty is a term that refers to physical weakness and fragile health. Factors that increase risk of severe COPD exacerbation • Altered mental status • at least three exacerbation in the previous 12 months • body mass index of 20kg per m2 or less • marked increase symptoms or change in vital signs • medical comorbidities (especially cardiac ischemia, heart failure, pneumonia, diabetes mellitus, or renal or heaptic failure) • poor physical activity levels CHRONIC OBSTRUCTIVE PULMONARY DISEASE final case study. Others: • poor social support • severe baseline COPD (FEV/FVC ratio less than 0.70 and FEV1 less than 50% of predicted • Underutilization of home oxygen therapy 1. Air Pollution 2. Smoking 3. Pneumonia HPI: FINDINGS A.M. is a 74 year old man complains of shortness of breath and fever. history of five COPD exacerbation this year. Heart failure following myocardial infarction at 68. Hypertension. Chief Complaint: • Shortness of breath and fever • audible wheezing since last night per wife • mild chest tightness • Gets short of breath if he walks more than 10 feet. Tests Done: • ABG tests Assessment 1. Drug related Problem 2. COPD complication and characteristics 3. COPD exacerbation risk factors o has a severe baseline COPD with FEV1 of 35% predicted o patient has developed respiratory acidosis o has a presence of significant comorbidities i.e. pneumonia