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Improving Patient Outcomes with Chronic Obstructive Pulmonary Disease
Cari Nicole Watts
Middle Tennessee State University School of Nursing
April 14, 2008
Abstract
This paper aims to present a case study about a patient, E.M., with chronic obstructive
pulmonary disease (COPD) in order to better understand how nurses can provide the best care
for these affected individuals. E.M. was a patient at Middle Tennessee Medical Center. I cared
for her on March 18, 2008. This case study consists of a complete history and physical,
including laboratory data, current medications, and diagnostic testing, evidence-based practice
guidelines, nursing research, and the role of the nurse in caring for a patient with COPD.
Chronic obstructive pulmonary disease (COPD) is a deteriorating disease with no known
cure. Porth (2005) states COPD is a chronic and recurrent respiratory disorder that obstructs the
patients airway. Disease progression eventually results in respiratory failure. In spite of this,
nurses have the opportunity to provide teaching and care to patients to support them in living
with this illness. COPD affects approximately 14 million people in the United States alone. The
incidence of COPD increases with age and demonstrates its correlation with smoking. This
paper examines a patient, E.M., who has been diagnosed with COPD. The case study will
evaluate her biographical data in addition to her history and physical information. The
pathophysiology, evidence based practice guidelines and standards of care, current research on
available interventions, and the role of the nurse in caring for a patient with COPD will be
discussed.
Biographical Data
E.M. is a 63 year old, white female born on April 13, 1944. She was admitted to the
telemetry unit on March 17, 2008 from the emergency department at Middle Tennessee Medical
Center. All subjective data was collected from E.M. and her husband, who are both reliable
sources of history. E.M. is married with one biological daughter who is 34 years old and one
step son who is in his forties. Her granddaughter, great-granddaughter, and the father of the
child currently live with her and her husband. E.M. states she enjoys having them live with her
because it helps keep her active. She is a practicing Presbyterian in McMinnville, TN, where she
attends church every Sunday when she is able. Her husband works as a morning radio DJ in
McMinnville and E.M. is a retired lab technician. She stated her primary care physician told her
she had pneumonia and needed to come to the hospital to receive treatment. Her admitting
diagnoses were COPD and pneumonia. E.M. chose to remain a full code status.
History and Physical
E.M. has a history of breast cancer in which she received a right mastectomy. She had a
stent placed in her heart due to atherosclerosis. She also experienced seizures as a child, had
surgery to remove cataracts from both eyes, asthma, skin lupus, a hypertension history of one
year, peripheral neuropathy, hirstuism, polycytstic ovarian disease, and encephalitis. She
received both the pneumococcal and influenza vaccines in November of 2007. E.M. also had a
negative tuberculin skin test at the beginning of 2008. She states dust causes her to have asthma
attacks but does not know other triggers of attacks. Her family history indicates three previous
aunts who all died of breast cancer. One of E.M.’s aunts had diabetes and died of a stroke. She
has a niece who suffers from seizures. Her brother has a history of both hypertension and heart
disease and her uncle had T.B. of the kidney.
E.M. quit smoking in 1988. She smoked about two packs per day for 22 years. She also
drinks a glass of white wine one to three times per week. E.M. states she does not regularly see
her primary care physician regularly because he automatically refers her to the emergency
department for care. She has been to the emergency room five times within the last few months.
One of these visits includes an instance when E.M.’s husbands arrived home from work and
found her in an acute confused state and took her to the emergency room. She does not
remember this episode and can only remember waking up in the hospital two days later. The
doctors could not tell her why this event occurred even after extensive testing. She has full
dentures and does not visit the dentist on a regular basis. She states she still is able to perform all
of her self-care needs but must take activities slow to conserve her energy. E.M.’s husband does
all of the grocery shopping, and most of the housework and errands because she tries to avoid
activities that cause her to become short of breath.
Assessment
Upon assessment E.M. was alert and oriented times three. Her recent, remote, and
immediate memory were intact. Her speech pattern was clear and appropriate. Her weight upon
admission was 106.5 pounds, she is five foot four inches tall, and had a body mass index of
18.3%. She had diminished breath sounds in the lower lobes and a nonproductive cough which
causes her uncomfortable pain in her chest. Her oxygen saturation was 95% on two liters of
oxygen per nasal cannula. She uses her abdomen when breathing and has an anterior-posterior
diameter of one to one. The peripheral neuropathy in her feet and legs is the main cause of her
pain of a constant 4 on a scale of 1 to 10. She had full range of motion except for her feet and
toes which are only about 30% functional and tremor frequently. Her capillary refill was less
than three seconds when tested on her thumb and less than four seconds on her feet. Her pupils
were both three millimeters and equal, round, reactive to light and accommodation. She is
experiencing generalized weakness due to her impaired gas exchange and anemic status. She has
orthopnea and uses two pillows when sleeping to help with this symptom. On the morning of
care her vital signs were: blood pressure 148/81 taken in the right thigh, respiratory rate of 24,
temperature of 96.5° F, and pulse of 97. She was monitored on telemetry and stayed at sinus
rhythm throughout the day. Her feet were cyanotic, rigid, and had diminished pulses of two plus.
The brachial and apical pulses were graded at a normal three plus.
E.M. states her appetite has declined dramatically over the past year. She believes her
increasing fatigue has played a major role in her decreased appetite. Due to the change in her
decreased hunger level, E.M. has lost approximately 30 pounds in the past year. E.M. states that
lunch is her biggest meal of the day. She is too weak to ambulate long distances, but E.M. states
she does play in the floor with her great-granddaughter and prepare meals on occasion. Her
largely sedentary lifestyle, as well as a nutritional deficiency, has lead to the development of a
pressure wound. It was located on her sacral area and was about two inches tall and three inches
wide. It was red and sore to the touch but there was no break in the skin. She had a small
amount of bruising on her arms and thighs. She stated she bruised easily and did not know
where the bruises on her thighs came from, but the ones on her arm were due to having blood
drawn. E.M. states her dentures fit well and cause her no pain or discomfort. Her mucous
membranes were pink and moist and stated she performed mouth care two times a day and cleans
her dentures at night. E.M. has no issues with swallowing; her abdomen was soft, flat, and nontender. Her bowel sounds were active and irregular. She stated before admission she had been
having periods of constipation. She had one bowel movement on the day of care which was soft
and brown. E.M.’s urine was light yellow and caused no burning or pain with urination. She is
not sexually active and has had a hysterectomy. Her menstrual period was approximately about
seven days and a very heavy flow due to polycystic ovarian disease in E.M. has no vaginal
discharge and has not received a pap smear in the last year due to frequent hospitalizations. She
performs her self breast exams monthly due to her history of breast cancer and also receives a
yearly mammogram. Her last result showed no lumps or need for a biopsy.
E.M.’s sleep pattern at home is altered by her constant pain in her legs and feet. She
states her breathing does not affect her as long as she uses oxygen while she sleeps and props
herself up with pillows. She states during hospitals stays she gets even a less amount of rest.
Although she has lack of sleep, she is still alert and conversational. She has some concerns
about financial issues, which she says is related to her medical bills and medications. She also
shows concern for her weight and says she “is too skinny” (E.M., personal communication,
March 18, 2008). She and her husband seem to have a good relationship and interacted well
together.
Medication Data
E.M.’s current home medications include: Xopenex 1.25 milligrams (mg) per 3 milliliters
(mL) three times a day, Spiriva one puff twice a day, Advair Diskus one puff twice a day,
Astelin two sprays twice a day, Nasonex two sprays twice a day, SoluMedrol 40 mg twice a day,
Guiafensin 400 mg as needed, Cozaar 50 mg daily, Metroprolol 25 mg daily, Tylenol III as
needed, Pantoprazole 40 mg daily, Aspirin 81 mgams daily, Zocor 40 mg daily, Plavix 75 mg
daily, Spironolactone 25 mgtwice a day, Pseudoephedrine one tablet daily, Oxazepam 30 mg
twice a day, Neurontin 300 mg three times a day. She also takes a daily multivitamin,
betacarotene 100,000 international units daily, a B100 vitamin, and 600 mg of calcium.
She is allergic to Augmentin which causes nausea and vomiting, Avelox which causes
swelling, Cefaclor which caused her to need adrenalin because she could not breathe, and Sulfa
drugs which cause a rash.
Laboratory Data
E.M.’s lab values were obtained on March 18, 2008. The values of hemoglobin of 11.0
grams per deciliter, hematocrit of 35.5%, and red blood cells of 3.5 x 10^6 are related to her poor
nutritional status and confirms she is anemic. Her prolonged use of steroids has caused a
decrease in her lymphocytes to 20.5%. The blood urea nitrogen values were increased to 20
milligrams per deciliter, which is most likely related to her age since it is not a significant
increase from 18 milligrams per deciliter. As mentioned above, E.M. is currently taking
Aldactone, a potassium-sparing diuretic for hirstuism. This intervention is also related to the
increased potassium level in her blood of 5.7 milliequivalents per milliliter.
Diagnostic Testing
On the date of care, E.M. received a LT PICC placement x-ray. It showed good
placement of the PICC line in the mid superior vena cava. She had received previous x-rays
during her admission which suggested possible pneumonia and showed scarring from previous
infections.
Review of Pathophysiology
A major cause of COPD is preventable—smoking. Early signs and symptoms of this
disease are often not seen by the client, or do not exist at all. The chances for slowing or halting
the disease process are much greater if it is caught at an early stage. Porth (2005) states
manifestations of the disease occur from inflammation, fibrosis of the bronchial wall, overgrowth
of the submucosal glands, excessive secretion of mucous, and loss of elastic lungs fibers and
alveolar tissue. These problems cause airflow to be hindered as well as decreasing the surface
area for oxygen exchange. The decreased elasticity in the lungs slows the expiratory phase and
results in the trapping of carbon dioxide within the lungs. The withheld carbon dioxide give the
patient a pink color to their skin, which is why they are sometimes referred to as pink puffers.
There is also an enlargement in the air spaces which is also associated with the trapping of
carbon dioxide inside the lungs. These changes increase the energy needed for normal
respiration. The clinical findings of COPD are progressive changes in respiratory and pulmonary
function. Common signs are cough, mucous production, dyspnea, and use of accessory muscles
for help with breathing. Those affected by this disease use the seated position for maximum
breathing, and maintain normal blood gasses until end stages of the disease. They also may
present with a barrel chest of an anterior-posterior diameter of two to one. They have decreased
energy levels, increased risk for respiratory infections, and activity intolerance. Breathing
difficulties increase the amount of fatigue patients are already battling, which makes eating even
more difficult. This can result in significant weight loss.
The most significant treatment for this disease is smoking cessation. Smokers can use
nicotine gum, patches, or lozenges, or inhalers to aid in the cessation plan. Health care providers
strongly suggest receiving immunizations for pneumoccocal and influenza infections to decrease
the risk of contracting these illnesses. Pharmacological management includes bronchodilators
and oral theophylline to open airways, and corticosteroids to decrease inflammation within the
lungs. Medical interventions include oxygen therapy and surgical procedures. Lung reduction
surgery is used to reduce the volume of the lung which aid in enhancing lung elasticity. A lung
transplant is another alternative in COPD treatment for those with severe lung disease.
Evidence Based Practice
In focusing on clinical practice guidelines for COPD, I used guidelines from the National
Guideline Clearinghouse (2004). Some guidelines for care include smoking cessation,
spirometry, body mass index, sputum culture, the use of inhalers, spacers, and nebulizers,
oxygen therapy, including ambulatory oxygen, vaccination and antiviral therapy,
multidisciplinary management, follow-up importance, assessment of need for hospital treatment,
pharmacological management, education and discharge planning. These guidelines demonstrate
the quality care E.M. has received. E.M. quit smoking in 1988 therefore no smoking cessation
plan was needed. A spirometry device was not supplied to E.M. before or on the date of care,
however E.M. stated she did have one at her home and tried to use a few times a week. Her body
mass index was assessed on the date of admission by the emergency room department. She did
not use a spacer with her medications but did use both an inhaler and nebulizer. I assessed the
proper use of her inhalers and respiratory therapy administered her nebulizer treatments. E.M.
stated she already had a prescription for ambulatory oxygen if she needed to use it. She received
the pneumococcal and influenza vaccine in the fall of 2007 per the advice of her primary care
physician. E.M’s care was managed by a multidisciplinary team including nurses, respiratory
therapy and her physician. On the date of care her discharge date was not anticipated therefore a
follow-up appointments were not discussed. The emergency department evaluated E.M. and
decided that she was in need of hospitalization for further treatment. Her pharmacological
management included corticosteroids, inhaled bronchodilators, oxygen therapy, antitussive
therapy, and antioxidant therapy which are all within the guidelines for treatment of COPD.
E.M. received education on deep breathing, pursed lipped breathing, relaxation, and spacing out
activities of daily living during the date of care. I was pleased to see the standards of care are
being met for E.M. over the course of the disease process.
Utilization of Nursing Research
The journal article, The effect of a pulmonary rehabilitation programme on older patients
with chronic pulmonary disease, discusses whether or not an implemented exercise regimen
improves dyspnea and activity intolerance in patients. The exercise procedure included upperlimb exercise, breathing exercises, and inspiratory muscle training. There were 20 older
individuals, average age of 68.7, with COPD that participated in the study over a four week
period. A pre-test, post-test design was used in which measurements were taken before the
exercise program was implemented and were compared to values obtained after the study was
completed. The study used pulmonary function test, oxygen saturation after a six minute walk, a
clinical rating of dyspnea on a scale from 0 to 10, heart rate, and respiratory rate were measured
and compared. Chin and Hyung (2005) found that although there was no increase in gas
exchange patients did show minor changes in their lung function. The most important finding of
the study were the patients showed a decrease in dyspnea after completion of the program.
Dyspnea is a major concern for E.M. and affects her daily functioning. I ensured the proper
techniques on pursed-lipped breathing and deep breathing as she had been previously coached on
these practices. A light arm exercise could be added to the daily routine to enhance the effects of
the program. If E.M. was given a schedule using these techniques approximately three times a
day, her dyspnea during activity could decrease and aid in the discomfort she experiences.
The second article, COPD: Help your patients breathe easier, covered COPD more
collectively by including smoking cessation, signs and symptoms of early and late stages of the
disease, treatment options, and managing exacerbations (Crawford & Harris, 2008). It includes
teaching that should be given to sufferers of the disease. The article explains the “tripod
position” by a patient leaning forward and resting on the arms to breathe easier, and the need to
coach the patient in pursed lip breathing to help in exhaling retained CO2. The appropriate use of
inhalers is discussed by using pursed lipped breathing before beginning administration of the
drug and the need to tell the patient to hold their breath to allow the medication to diffuse in the
airways. It instructs the nurse to ensure the proper use of the inhaler which I did with medication
administration on the date of care. The article advises to use breathing and strengthening
exercises which is crucial to E.M.’s quality of life. It states to use relaxation and sit in a semifowlers position to lung expansion. E.M. uses these interventions after becoming dyspneic. The
article discusses the importance of vaccines; E.M had already received this instruction from her
primary care physician and was vaccinated in September of 2007. This article relates to E.M.
because it covers many problems associated with COPD and interventions available her to help
cope with the disease.
The last article related to E.M. is from the Hospital Nursing journal and is titled Nutrition
for a patient with COPD can be complicated (O’Neill, 2004). It focuses on nursing interventions
related to issues associated with eating specific to problems associated with COPD. The article
states there is an increased work of breathing, metabolic rate, and energy needs for the patient
with COPD. E.M.’s poor appetite and inadequate caloric intake has resulted in a 30 pound
weight loss over the past year. The article also reports white blood cells are made from protein
which affects a patient’s barrier to infections. This is related to E.M.’s recent diagnosis of
pneumonia in which her nutritional status of anemia hindered her ability to fight off the
infection. Interventions included within this article are eat three small meals and three small
snacks, limit carbonated beverages, and regulate the intake of gas forming foods to avoid feeling
to full. E.M. does drink cokes but she only drinks one or two per day. She does eat small meals
and snack throughout the day. The article suggest to eat larger meals earlier in the day when the
patient is rested which is good since E.M. states she eats best at lunch time. Additionally, E.M.
was provided at least a half an hour rest period before her meal arrived to ensure she was
adequately relaxed. E.M. showed a considerable concern for her weight and was very receptive
of the education offere to her.
Role of the Nurse
The priority nursing diagnosis for E.M. was ineffective breathing pattern related to
airway obstruction as evidenced by dyspnea, infection, and fatigue. The short term goals were
the patient performs deep breathing to promote lung expansion every two hours and patient will
demonstrate pursed lipped breathing techniques during the seven to three shift on 3/18/08. The
nursing interventions (Ackley, 2008) I chose were to explain and demonstrate proper pursed
lipped breathing, coach patient in deep breathing exercises, and schedule rest periods and
relaxation to control dyspneic episodes. In evaluating the goals E.M. performed deep breathing
exercises every two hours on her own after initial coaching at 9:00 A.M. and demonstrated
correct pursed lipped breathing technique. The interventions were met by observing E.M.’s
pursed lipped breathing technique and giving an initial coaching for deep breathing exercises. I
observed relaxation was when E.M. rested in semi-fowlers and closed her eyes after becoming
mildly dyspneic with her morning self care activities.
The second priority nursing diagnosis was imbalanced nutrition less than body
requirements related to poor nutritional intake and increased work of breathing as evidenced by
fatigue, dyspnea, decreased hemoglobin, hematocrit and red blood cells, weight loss, poor
appetite, and a decubitus. The short term goals were to maintain a current weight of 106.5
pounds and to increase appetite as stated by E.M. during seven to three shift on 3/19/08. The
nursing interventions I selected (Ackley, 2008) were to provide oral hygiene before and after
meals to increase appetite, and allow the patient to rest 20 minutes before meal consumption to
decrease fatigue related dyspnea, and assist client with feeding. In addition interventions
included increase breakfast and lunch intake to at least 50%, encourage high protein, high calorie
intake of meals by assisting in food choices, and ensure her dentures fit properly and are cleaned
daily to aid in percent of meal intake. In evaluating the goals the patient was not weighed on the
date of care and E.M. stated the hospital food did not appeal to her. The effectiveness of
interventions were as follows: E.M. did oral care after breakfast had been brought at 7:00 a.m.,
the rest time before lunch decreased her dyspnea so that it did not interfere with her meal, and
E.M. fed herself succesfully after a period of rest. E.M. ate approximately 50% of her breakfast
and 75% of her lunch. Her husband had ordered her meals in advance, but meal choices were
appropriate and her dentures caused her no problems with eating.
In conclusion, this case study explores one individual’s hardships with chronic
obstructive pulmonary disease. The information covered directly relates to E.M. and the care
she received. This case study illustrates how one disease can affect everything about a person
from body image to not being able to do simple everyday activities. In my research I have been
able to address situations specific to E.M. that were crucial to her care such as explaining COPD,
addressing her deteriorating nutritional status, and interventions that may help her over the
course of the disease process. Although COPD is chronic and has no cure, it is treatable, both
from a medical and nursing perspective. To effectively treat this disease both perspectives must
be utilized. As nurses, it is our duty to ensure all needs are being met for our patient to help
them live with this chronic and debilitating disease.
References
Ackley, B.J., Ladwig, G.B. (Eds.). (2008). Nusing Diagnosis Handbook: An Evidence-Based
Guide to Planning Care. St. Louis, MO: Mosby, INC
Crawford, A., & Harris, H. (2008). COPD: help your patients breathe easier. RN, 71(1), 21-27.
Retrieved April 3, 2008, from CINAHL with Full Text database.
Kyung, K., & Chin, P. (2008). The effect of a pulmonary rehabilitation programme on older
patients with chronic pulmonary disease. Journal of Clinical Nursing, 17(1), 118-125.
Retrieved April 11, 2008, from CINAHL with Full Text database.
National Guideline Clearinghouse. (2004, July 12). Chronic obstructive pulmonary disease,
National clinical guideline in management of chronic obstructive pulmonary disease in
adults in primary and secondary care. Retrieved April 4, 2008, from National Guideline
Clearinghouse website:
http://www.guideline.gov/summary/summary.aspx?doc_id=5061&nbr=003545&string=
COPD
O'Neill, P. (2004, December). Nutrition for a patient with COPD can be complicated. Nursing,
34(12), 32hn6. Retrieved April 6, 2008, from CINAHL with Full Text database.
Porth, C (2005). Pathophysiology: Concepts of Altered Health Status. (701-707). Philadelphia,
PA: Lippincott Williams & Wilkins.