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University of New Hampshire
Nursing Department, DEMN Cohort 13
Chronic Obstructive Pulmonary Disease : A Look at Emphysema
Matthew C. Bennet
SITUATION
Background
 Stable, 95 year-old female, DNR/DNI, former smoker
(quite 40 years ago). Finished a steroid taper 1 day
ago. Awoke this morning with shortness of breath,
weakness, and a junky, non-productive cough.
 Patient initiated on protocol for immediate relief of
SOB.
 Solumedrol and PRN nebulizer treatment started.
 Chest X-Ray: Bilateral lung fields clear via
anterior/posterior and lateral views. No evidence of
respiratory infection.
 Post treatment, patient’s walking ambulation in ER is
84% on room air.
 Admitted to hospitalist services to have oxygen
monitored, overnight observation, and continued
steroid and bronchodilator treatment.
 Admitting Diagnosis :: COPD Exacerbation
PMH & CO-MORBITITIES
 Osteoporosis
 Glaucoma
 Asthma
 COPD
 Atrial Fibrillation
 Psoriasis
 Gout
 Atherosclerosis
Allergies
 No Known Allergies
SURGICAL HISTORY






Hysterectomy
Appendectomy
Varicose Vein Stripping
Hip Pinning
Right and Left Knee
Replacement
Cystoscopy with biopsy
MEDICATION
Medication
Brimonidine
Tartrate
Fentanyl Citrate
IMPLICATIONS OF CNL
A key implementation in promoting health in
admitted patient’s that have underlying chronic lung
disease is the use and education of an incentive
spirometer. Simulate the normal pattern of pulmonary
hyperinflation and increases transpulmonary pressure
and inspiratory volumes.
A study was performed by the Department of Chest
Diseases, Ege University Faculty of Medicine, Izmir,
Turkey about the efficiency of incentive spirometry
(IS) use in patient’s with COPD. 27 patients
participated in a study pertaining to IS use.
Medical Treatment
• Provide each patient with up-to-date information
regarding the benefits of incentive spirometry
• Establish IS encouragement as part of hourly
rounds, as well as, setting a standard for strict
documentation of usage
• Inexpensive tool, encourage use upon discharge for
patients with lung disease
Medical Treatment and
IS use
51.5 ± 14.3
42.9 ± 7.5 mmHg
PaCO2
decreased
No significant change in
pulmonary function of blood
gas
Guaifenesin
56.4 ± 15.0
68.7 ± 16.3 mmHg
PaO2 had
increased
85.3 ± 17.9
96.1 ± 9.4 mmHg
MISCELLANEOUS
Dyspneic while exerting
Chest tightness during inspiration
Desaturation while ambulating
7a-1p
1280ml and 75% of
Breakfast
After 1 day of treatment:
Lung sounds diminished, expiratory wheezes in upper lobes
Dyspnea with ambulating from bed to chair
Patient still c/o weakness
Appetite remains adequate on heart healthy diet.
Patient tolerating all medications with no adverse effects.
Assess
Care Teach
lowering intraocular
pressure
Anti-glaucoma
medication used
to treat openangle glaucoma
or ocular
hypertension
(high pressure
inside the eye).
Assess patient’s
ability to hold
ophthalmic
solution, during
administration
Openly
discuss
possibility of
independent
living staff
helping with
administration
Teach patient
to not allow
the dropper
tip to touch
any surface,
including the
eyes or hands
Opiate
analgesic
management of
persistent, moderate
to severe chronic
pain.
Acts upon
specific receptors
in your brain and
spinal cord to
decrease the
feeling of pain
and to reduce
your emotional
response to pain.
Assess patients
pain scale and
perception, q4h
Offer heat/ice
and position
changes to
help relieve
any
intermittent
pain
Educate
patient to
convey any
worsening
pain that is
not controlled
with
transdermal
patch
Stool softener
Relieving
constipation, by
preventing hard dry
stools
Increasing the
amount of water
the stool absorbs
in the gut,
making the stool
softer and easier
to pass.
Assess patient’s
diet to determine
adequate fiber and
fluid intake, qshift
Monitor signs
of diarrhea
and abdominal
cramping
Instruct
patient to
drink
sufficient
fluids with
each dose
and to
increase
fluid intake
during the
day.
Expectorant
thin bronchial
secretions. Ridding
the bronchial
passageways of
bothersome mucus
Loosen
congestion in
your chest and
throat, caused by
the common cold,
infections, or
allergies
Assess and
document patient’s
PO intake
with meals/PRN
Allows staff
to monitor
hydration
status
Educate the
patient on
recommended
daily water
intake to
promote
thinning of
secretions
Anticholinergic
selective
beta2adrenergic
bronchodilator
Bronchospasm shortacting rescue
Inhaler used to
treat and prevent
symptoms caused
by ongoing lung
disease
Assess lung
sounds and
respirations when
complaining of
SOB, q4h/PRN
Place patient
in position of
comfort
during
episodes of
difficulty
breathing
Educate that
while
receiving
medication,
do not talk
during
treatment
is a longacting, 24hour,
anticholinergic
bronchodilator
indicated for the longterm, once-daily,
maintenance
treatment of
bronchospasm
Inhalation to
prevent
bronchospasm in
people with
COPD including
emphysema.
Assess upper and
lower
extremities for
any signs of
edema, qshift
Monitor lab
values for
any changes
pertaining to
hydration
Teach
patient
information
regarding
diet and
sodium
intake
before
discharge
potent
glucocorticoid
steroid.
maintenance
treatment of asthma as
prophylactic therapy
Used in the
prevention of
asthma attacks
Assess oral cavity
for any signs of
fungal infection,
q8h
Provide
patient
opportunities
to rinse their
mouth with
water and
brush their
teeth after
dosage
Educate
patient to not
stop taking
this
medication
abruptly
Dose: 100mg
Frequency: QD
Route: PO
Dose: 600mg
Frequency: BID
Route: PO
Ipratropium
Bromide–Albuterol
PO Intake
The inability to absorb enough O2 and release enough CO2 means the patient may
not finish breathing out before they feel the need to breathe in. This leads to
breathlessness, which becomes especially apparent with increased activity or
exercise.
Docusate Sodium
Action
2 months after hospitalization the patients pulmonary function
and blood gases were redrawn to measure any changes
O2 had
improved
Patient was a smoker for 40 years.
Patient has underlying asthma.
Shortness of breath at baseline
Junky non-productive cough
Expiratory wheezing while auscultating
Indication
Selective
alpha2receptor
Dose: 50mcg
Frequency: q3d
Route: Transdermal Patch
Emphysema is defined by permanent enlargement of airspaces distal to the
terminal bronchioles. This leads to a dramatic decline in the alveolar surface area
available for gas exchange.
Second, loss of the alveolar supporting structure leads to airway narrowing, which
further limits airflow. The surface area for the exchange of oxygen and carbon
dioxide in the lungs makes it more difficult to occur. The elasticity of the alveolar
septa is compromised and the inspired air becomes trapped during exhalation.
Thus, the tidal volume of the lungs is decreased.
Class
Dose: 0.2 % per 1 drop
Frequency: Bilateral BID
Route: Ophthalmic
PATHOPHYSIOLOGY
Loss of the alveolar walls results in a decrease in elastic recoil, which
consequently, leads to airflow limitation. The destruction of elastic tissue from the
walls of the compromised alveoli cause the lungs to expand within the chest. The
expanded lungs compress the small bronchi and thus increase resistance to airflow.
UPON ADMISSION
Output
7a-1p
960ml
Sputum Culture
Ordered
Waiting for patient to express sputum.
Specimen cup provided to patient on bedside
table to collect when able.
Dose: 0.5mg
Ipatropium/3mg albuterol
Frequency:Q4H PRN
Route: Inhaled MDI
Tiotropium
Dose: 18mcg/cap
Frequency: QD
Route: Inhalation
LABORATORY VALUES
CBC
Results
Normal
Values
BMP
Results
Normal
Values
WBC
12.56
4.0-9.0
Glucose
188
70-99
RBC
3.42
3.90-4.98
Calcium
8.1
8.4-10.5
Hemoglo
bin
10.9
12.-15.5
Sodium
135
135-145
Hematocr 34.3
it
35-45
Potassium
4.6
3.5-5.0
MCV
100.3
81-93
CO2
25
23-29
MCH
31.9
27-33
BUN
42
6-20
Platelet
124
150-450
per mcL
Creatinine
1.89
0.5-1.0
Beclomethasone
Dipropionate
Dose: 40mcg
Frequency: BID
Route: Inhalation