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Bedside Clinic Guidelines

Pt. Room Number: ER cubicle 4


Patient Name: Mr. J T
Problem / Case: COPD

Brief Patient History


J.T. is a 61 yo man with COPD who presents to the emergency room with a three-day history
of progressive dyspnea, cough, and increased production of clear sputum. He usually coughs
up only a scant amount of clear sputum daily, and coughing is generally worse after rising
in the morning. The patient denies fever, chills, night sweats, weakness, muscle aches, joint
aches, and blood in the sputum. He treated himself with albuterol MDI, but respiratory dis-
tress increased despite multiple inhalations.
Upon arrival at the emergency room, there were few breath sounds heard with auscul-
tation, and the patient was so short of breath that he had difficulty climbing up onto the
examiner’s table and completing a sentence without a long pause. He was placed on 4 L oxy-
gen via nasal cannulae and given nebulized ipratropium and albuterol treatments.

Past Medical History


• HTN x 10 years
• COPD diagnosed 6 years ago
• Occasional episodes of acute bronchitis treated as outpatient with antibiotics
• Mild CVA 4 months ago, appears to have no residual neurologic deficits
• (–) history of TB, occupational exposure, heart disease, or asthma

Laboratory Procedures
Laboratory Blood Test Results
Na 147 meq/L Plt 160 x10 103/mm3 Bilirubin, total 0.3 mg/dL
K 4.1 meq/L WBC 9.1 x10 103/mm3 PT 14.2 sec
Cl 114 meq/L PMNs 62% Alb 4.0 g/dL
HCO3 25 meq/L Lymphs 27% Protein, total 6.8 g/dL
BUN 29 mg/dL Eos 3% Alk phos 78 IU/L
Cr 1.1 mg/dL Basos 1% Ca 8.8 mg/dL
Glu, fasting 98 mg/dL Monos 7% PO4 3.5 mg/dL
Hb 19.3 g/dL AST 14 IU/L Mg 2.5 mg/dL
Hct 55% ALT 31 IU/L AAT 137 mg/dL

Arterial Blood Gases (on 4 L O2 by Cannulae)


• pH 7.32
• PaO2 65 mm Hg
• PaCO2 54 mm Hg
• SaO2 90%

Pulmonary Function Tests


• FEV1 1.67 L (45% of expected)
• FVC 4.10 L (85% of expected)
• FEV1/FVC 0.41 (expected 0.77)

Chest X-Rays
• Hyperinflation with flattened diaphragm
• Large anteroposterior diameter
• Diffuse scarring and bullae in all lung fields but especially prominent in lower lobes bilaterally
• No effusions or infiltrates
• Large pulmonary vasculature

Surgical Management
The patient hasn’t undergone any surgical management.

Pharmacological Management
• HCTZ 25 mg po Q AM
• Amlodipine 5 mg po QD
• Theophylline 200 mg po BID
• Albuterol 180 µg MDI 2 inhalations QID PRN
• Ipratropium 36 µg MDI 2 inhalations QID
• The patient has been compliant with his medications. However, he admits that he does not
like to use ipratropium because it causes “dry mouth” and makes him feel “edgy.”.

Course of Management
The goal of COPD management is to improve a patient’s functional status and quality of life by
preserving optimal lung function; improving symptoms and preventing recurrence of exacerbation.
Smoking cessation greatly decreases episodes of exacerbation. Oxygen therapy also helps to maintain
the patients lung functions. His medications helps control and manage the inflammation and infection
that comes with COPD. Sputum viscosity and Secretion clearance should also be properly managed to
improve symptoms.

Nursing Diagnosis and Management


1. Impaired gas exchange related to decreased lung compliance and altered level of consciousness
as evidenced by dyspnea on exertion.
2. Ineffective airway clearance related to secretions in the bronchi as evidenced by crackles on
auscultation.
3. Disturbed sleep pattern related to breathlessness as evidenced by increasing irritability.