ChronicObstructivePulmonaryDisease

Exacerbation

RandalCamus
Age:75Weight:100kgLocation:EmergencyDepartment(ED)

Background
PatientHistory
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PastMedicalHistory:Longstandinghistoryofemphysema.Acute
myocardialinfarction12yearsago.Hadanupperrespiratoryinfection
abouttwoweeksago
Allergies:PenicillinMedications:Takessomeheartmedicationsbut
doesnotknowthenames,norcanhedescribethe
pillsduetohissevereshortnessofbreathCodeStatus:Fullcode
Social/FamilyHistory:Marriedwithgrownadultchildren.Wifedid
notarrivewithhimassheiswaitingfortheirsontopickherupand
bringhertothehospital.Patientsmokesatleasttwopacksofnon
filteredcigarettesperday

HandoffReport
Situation:Thepatientisa75yearoldmalewhowasbroughtintothe
emergencydepartment(ED)fromhomecomplainingthathisbreathing
gotworsethepastfewdays.Heusesoxygenathome,andhewas
sittinginhisreclinerwiththeoxygeninplaceataflowrateof2liters
perminutebynasalcannulaandsmokingwhentheparamedicsarrived.
Hereportshealsotakessomeheartmedicationsbutdoesnotknow
thenames,norcanhedescribethepillsduetohissevereshortnessof
breath.
Background:Longstandinghistoryofemphysemaandapreviousacute
myocardialinfarction12yearsago.Stateshehadanupperrespiratory
infectionabouttwoweeksago.DespitehislongstandingCOPD,he
continuestosmoketwopacksofnonfilteredcigarettesperdayata
minimum.
ProgramforNursingCurriculumIntegration(PNCI)1
2012CAEHealthcare,Sarasota,FLv.5

ChronicObstructivePulmonaryDisease
Exacerbation
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HandoffReportContinued
Assessment:Vitalsigns:HR134,BP160/96,RR40andlabored,SpO2
hasbeen83%onroomair,Temperature37.6CGeneralAppearance:
AppearsfatiguedandolderthanstatedageCardiovascular:Sinus

tachycardiaRespiratory:WheezinginbothlobesGI:Hypoactivebowel
soundsGU:HasnotvoidedExtremities:Movementisweakinallfour
extremities(3+)Skin:Coolanddry.Circumoralandperipheral
cyanosispresentNeurological:Alertandorientedtoperson,placeand
time.Anxious.Pupilsareequalandround,reactivetolight.No
neurologicaldeficitsIVs:20gaugeIVintherightforearmwithnormal
salineinfusingat150mL/hour.SitepatentandnonreddenedLabs:
OrderedandneedtobedrawnFallRisk:HighriskPain:Deniespain
Recommendations:Implementinitialordersandmonitor
cardiopulmonarystatus.

Orders
InitialHealthcareProvidersOrders:
AdmittoEDDiagnosis:COPDExacerbationFullcodeVitalsignsevery
hourContinuouscardiacandSpO2monitoringOxygenat2LPMvia
nasalcannulaIVofNSat150mL/hourPredniSONE40mgPOdaily
PneumococcalvaccineuponhospitaldischargeInserturinarycatheter
CBC,Electrolytes,BUN,Creatinine,Glucose,BNP,ABGSTATChest
xraySTAT12leadEKGSTATI&O
ProgramforNursingCurriculumIntegration(PNCI)2
2012CAEHealthcare,Sarasota,FLv.5

ChronicObstructivePulmonaryDisease
Exacerbation
PNCILearner

Preparation
LearningObjectives

Statestheprecautionsneededforoxygentherapyandfluid
administrationforapersonwithlongtermCOPD(REMEMBERING)

PlansandprovidescareforapersonwithCOPDwhodevelops
respiratoryfailure(APPLYING)

Anticipatesdiagnosticordersandtherapies,includingmedications,for
thepersonwithanacuteexacerbationofCOPD(APPLYING)

Discussesthecardiacconsequencesoflongtermemphysema
(UNDERSTANDING)

Statestheappropriaterationaleforendotrachealintubationforthe
personinrespiratoryfailure(REMEMBERING)

Analyzestheeventhistory,assessmentfindingsandarterialbloodgas
resultstoanticipate,prepareforandassistwithendotrachealintubation
(EVALUATING)RecommendedeDosemodulesforlearnersto
completebeforetheSCE:MedicationDosageCalculationSkillsX
MedicationOrders&S.I.UnitsTablets&CapsulesLiquidMedicines
InjectionsXI.V.InfusionsInjectableMedicinesTherapyXSlowI.V.
InjectionsXIntermittentInfusionsContinuousInfusionsPediatrics
ThisSCEaddressesthefollowingQSENCompetencies:XPatient
CenteredCareXTeamworkandCollaborationXEvidenceBased
PracticeQualityImprovementXSafetyInformatics
ProgramforNursingCurriculumIntegration(PNCI)3
2012CAEHealthcare,Sarasota,FLv.5

ChronicObstructivePulmonaryDisease
Exacerbation
PNCILearner

PreparationQuestions

Whatisanobstructivelungdisease?
Obstructivelungdiseaseisachronicconditionwherethereisalways
limitedairflowinthelungs.Thereisconstantresistancetoairflowdue
toairwaynarrowingorobstruction.Itisaslowlyprogressivedisease
whichinvolvestheinflammationresponseoftheairwayandthelungs.

Whatshouldthenurseconsiderwhengivingoxygentothepatientwith
anobstructivelungdisorderandwhy?
Itisimportanttoadministertheoxygenatverylowflowingrates.Also,
thenurseshouldrememberthatthepatientsO2saturationlevelwillnot
becomparabletoanormalO2level.PatientswithCOPDnormally
haveO2levelsrangingfrom8590%.Iftoomuchoxygenis
administered,thenthepatientmaybecomehypercapnic.

Whatarenursingmanagementissuesrelatedtoobstructivediseases?
Nursingmanagement:

monitorforadverseeffectsofmedications
monitorO2levelsandABGs
monitorforheartsounds
nutritionaltherapy
educateptonsmokingcessation,nutrition,oxygentherapyat

home,exercising,pursedlipbreathing
educateonrecognizingsymptomsthatneedtobereportedtothe
doctor
demonstraterelaxationtechniquestoreducestressandanxiety

WhatarethecardiacconsequencesoflongtermCOPD?
COPDcanleadtocoronaryheartdiseaseandheartfailureduetothe
chronicinflammationofthelungs.Thepatientmayhavemurmurs,
jugularveindistention,tachycardia,andedema.Thereducedlevelsof
oxygencancauseanischemicproblemoftheheartandincreasesheart
overexertion.Ifpulmonaryhypertensionoccurs,thenthiscanleadto
corpulmonale.

Whatassessmentfindingswouldthenurseidentifyinapatient
experiencingacuterespiratoryfailure?

anxiousorunresponsive
hypoxia
confusionordelirium
cyanosisorflushed
lungsoundsmayincludestridor,wheezing
coughing

Whatdoesitmeantobeinacuterespiratoryfailure?
Acuterespiratoryfailuremeansthatthereisaninabilitytomaintain
levelsofoxygenorcarbondioxide.Respiratoryfailurecanbeeithera
hypoxicorhypercapnicstate.

WhatareappropriateinterventionsforapersonwithCOPDwhois
showingsignsofrespiratoryfailure?

oxygenadministration
suctioning,ifappropriateandnecessary
diureticstoremoveexcessfluid
administerbronchodilators

anxiolyticmaybeorderedtoreducepatientanxiety
monitorABGs
placepatientinhighFowlers
monitorvitals,breathsounds,andheartsoundsregularly
monitorI&O
possibleneedforintubation

WhatdoesSpO2represent?
SpO2representstheperipheralcapillaryoxygensaturation.Itprovides
anestimateoftheoxygensaturationintheblood.

AtwhatpointdonursesintervenewithanalteredSpO2?
AnormalSpO2levelis<95%andthenursewouldinterveneifitfell
below90.WithapatientwhohadCOPD,theirnormalSpO2levelsare
inalowerrange,from8590.Thenursewouldinterveneiftheirlevels
AnurseshouldaimtohaveaCOPDpatientsSpO2levelwithin8892.

Whataretheparametersthatindicatetheneedforintubation?

Whatneedstobedonetoprepareforintubation?

Howdonursesassessforcorrectplacementofanendotrachealtube
immediatelyaftertheintubation?

Whatarekeynursingcareissuesforapersonwithanendotracheal
tube?

Definesthefollowingtermsrelatedtoamechanicalventilator:oMode
oRateoTidalVolumeoFIO2oPEEPoPressureSupport
ProgramforNursingCurriculumIntegration(PNCI)4
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References
ChronicObstructivePulmonaryDisease
Exacerbation
PNCILearner

Ackley,B.J.,&Ladwig,G.B.(2010).Nursingdiagnosishandbook:An
evidencebasedguidetoplanningcare(9thed.).St.Louis,MO:
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Carrera,M.,Marin,J.M.,Anton,A.,Chiner,E.,Alonso,M.L.,Masa,
J.F.,..Barbe,F.(2009).Acontrolledtrialofnoninvasiveventilation
forchronicobstructivepulmonarydiseaseexacerbations.Journalof
CriticalCare,24(3),473.e7473.e14.doi:10.1016/j.jcrc.2008.08.007
Celli,B.R.(2008).UpdateonthemanagementofCOPD.Chest,
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learning,teaching,andtechnology.DepartmentofEducational
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%27s_Taxonomy
Giger,J.N.,&Davidhizar,R.E.(2008).Transculturalnursing:
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GlobalInitiativeforChronicObstructivePulmonaryDisease(GOLD).
(2011).Globalstrategyforthediagnosis,management,andprevention

ofchronicobstructivepulmonarydisease.RetrievedJanuary30,2012
fromhttp://www.goldcopd.org/guidelinesglobalstrategyfor
diagnosismanagement.html
Hurst,J.R.,&Wedzicha,J.A.(2009).Managementandpreventionof
chronicobstructivepulmonarydiseaseexacerbations:Astateoftheart
review.BMCMedicine,7(1),40.doi:10.1186/17417015740
JohnsonRussell,J.(2010).Facilitateddebriefing.InW.M.Nehring&
F.R.Lashely(Eds.),Highfidelitypatientsimulationinnursing
education,pp.369385.Sudbury,MA:JonesandBartlett.
Lewis,S.L.,Dirkse,S.R.,Heitkemper,M.M.,&Bucher,L.(2011).
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problems(8thed.).St.Louis,MO:ElsevierMosby.
Lockwood,C.,ConroyHiller,T.,&Page,T.(2004).Vitalsigns.
InternationalJournalofEvidenceBasedHealthcare,2(6),207230.
doi:10.1111/j.14796988.2004.00012.x
MacIntyre,N.,&Huang,Y.C.(2008).Acuteexacerbationsand
respiratoryfailureinchronicobstructivepulmonarydisease.
ProceedingsoftheAmericanThoracicSociety,5(4),530535.
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Melnyk,B.M.,&FineoutOverholt,E.(2010).Evidencebasedpractice
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Philadelphia,PA:LippincottWilliams&Wilkins.
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ChronicObstructivePulmonaryDisease
Exacerbation

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ReferencesContinued
NationalCouncilofStateBoardsofNursing.(2010).2010NCLEXRN
testplan.Retrievedfromhttps://
www.ncsbn.org/2010_NCLEX_RN_Testplan.pdf
Nava,S.,&Hill,N.(2009).Noninvasiveventilationinacute
respiratoryfailure.TheLancet,374(9685),250259.
doi:10.1016/S01406736(09)604967
QualityandSafetyEducationforNurses.(2011).Qualityandsafety
competencies.RetrievedJuly6,2011from
http://www.qsen.org/competencies.php
TheJointCommission.(2012).Nationalpatientsafetygoals.Retrieved
January26,2012fromhttp://
www.jointcommission.org/standards_information/npsgs.aspx

Authors
RussGeorge,KathyHerrinandNeilFried,TexasWomansUniversity
Dallas,TX.ReviewedbyNeilFried,TexasWomansUniversity
Dallas,TX,2011andChristieSchrotberger,DianeMathe,Lynde
Rabine,GwenLeighandDonnaWalls,CAEHealthcareSarasota,FL,
2012

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