NR 601 WEEK 2: COPD CASE STUDY: PART 2 NR-601 Primary Care of the Maturing and Aged Family Susan Brown January 2023

NR 601 WEEK 2: COPD CASE STUDY: PART 2 NR-601 Primary Care of the Maturing and Aged Family Susan Brown January 2023 Primary diagnosis: 1. Chronic Obstructive Pulmonary Disease (COPD) Pertinent positives to support the diagnosis of COPD include: Spirometry results pre- bronchodilator FEV1/FV ratio 0.52 and a post-bronchodilator FEV1/FV 0.52. A FEV1/FVC ratio of less than 0.7 constitutes a diagnosis of COPD in symptomatic patients (GOLD, 2019). J.D. is a former smoker with a 20 pack -year history, over the age of 40. Individuals that smoke or have a history of smoking and are over the age of 40 are at an increased risk for COPD (Dunphy, Winland-Brown, Porter, & Thomas, 2019). Chronic cough with 6-month duration; that is productive with white-yellowish phlegm and is worse in the morning. SOB upon activity and relieved by rest. Symptoms of COPD include chronic cough, production of phlegm, and SOB, particularly upon exertion. The phlegm or mucus that is produced may be clear, white, yellow or greenish in color (Rabe & Watz, 2017). Faint forced expiratory wheezes in bilateral bases could be heard on auscultation. In COPD wheezes and crackles in the bases of the lungs can be heard upon auscultation (Rabe & Watz, 2017). O2 sat on RA 94%. Typically, normal O2sat readings should be between 95-100% on RA (Hafem & Sharma, 2019). 2. ICD-10 (J44.9) 3. Treatment plan: According to GOLD (2019), J.D. falls into group B; he is having symptoms and is at low risk for exacerbations at this time. The initial step would be to place him on a long acting bronchodilator. The first line therapy is a long-acting muscarine antagonists (LAMA) or long-acting beta-2- agonist (LABA). Rx: Olodaterol inhaled MDI: 2.5mcg per actuation Sig: 2 puffs inhaled every 24 hours Disp: #1 (one) Refills: 5 (five) [ CITATION Epo19 l 1033 ]. Additionally, it is recommended that patients with COPD have a short-acting bronchodilator or rescue inhaler as needed (GOLD, 2019). Rx: Albuterol inhaled MDI: 90mcg per actuation Sig: 2 puffs inhaled every 4 to 6 as needed for shortness of breath or wheezing Disp: #1 (one) Refills: 5 (five) [ CITATION Epo19 l 1033 ]. Additional tests/procedures: Oxygen saturation (O2) monitoring: This is a way to noninvasively assess the arterial oxygen saturation and the potential need for supplemental therapy with oxygen (GOLD, 2019). The target O2 sat for a patient with COPD is 88-92% (Lacasse, Tan, Maltias, & Krishan, 2018). Recommendations from GOLD (2019) arterial or capillary blood gases should be drawn if O2 sats are below 92%. Alpha -1 antitrypsin level: The World Health Organization has recommended that all patients with a diagnosis of COPD should be screened for alpha-1 antitrypsin deficiency (GOLD, 2019). Sleep study: Patients with COPD exhibit a common finding of obstructive sleep apnea. Identification of obstructive sleep apnea can improve outcomes. Patients with COPD and OSA have an increased risk of death, as well as hospitalizations (GOLD, 2019). Exercise testing: According to GOLD (2019), exercise testing can provide valuable information for selection of patients that are appropriate for rehabilitation. Patient Education: All patients should be educated on the disease process and the progression of disease, as well as how to identify the symptoms of an exacerbation and decompensation (GOLD, 2019) Education on a realistic goal of disease management should be included. In treatment, the primary goal is symptom control and complication prevention. It is imperative to educate the patient on the fact that COPD is an irreversible and progressive disease Development of an action plan for acute exacerbations is beneficial in reducing hospital admissions and improving quality of life Exercise training can improve physical activity in patients with COPD. Avoidance of exposures to secondhand smoke and environmental smoke. The importance of not smoking or restarting smoking. Vaccinations for influenza and pneumonia are recommended. This will help in reducing exacerbations of COPD (GOLD, 2019). They will be given today if J.D. has not been immunized. Referral: Pulmonary rehabilitation: According to GOLD (2019), pulmonary rehabilitation should be implemented early in the disease progression, as well in patients that continue to experience dyspnea in the presence of bronchodilator therapy. Pulmonary rehab has been shown to improve quality of life, reduce dyspnea, fatigue, and can reduce depression and anxiety that is commonly associated with the diagnosis of COPD. No referral to Pulmonology at this time. If patients are nonresponsive or have poor response to therapy with verified adherence and inhaler technique a refer to Pulmonology would be indicated (Hollier, 2018). If that patient has financial issues or limited resources a referral to case management or social work may be necessary. Additionally, if the patients function begins to decline a case management and home health consult may be indicated (Hollier, 2018). Follow up: Schedule follow up with J.D. in 1 month to evaluate the effectiveness of medication management (GOLD, 2019). Follow up should occur monthly in patients with unstable COPD and 3 to 6 months is patients with stable COPD (Hollier, 2018). Oxygen saturation measurement should be obtained at each visit. Arterial or capillary blood gases should be drawn if O2 sats are below 92% (GOLD, 2019). If O2 sat is less than 88% or less oxygen therapy should be initiated (Hollier, 2018). Poor inhaler device technique leads to poor symptom control and exacerbations. Practitioners should evaluate inhaler technique at every opportunity. It is estimated that 80 % of patients do not use their inhalers correctly. It is imperative for the practitioner to choose the correct device for the patient, check technique, correct improper use, and confirm the correct use of each type of inhaled device prescribed (GINA, 2019). Spirometry should be repeated annually to measure FEV1 so that identification of patients who are declining at a fast rate can be identified (GOLD, 2019). Problem List: • COPD • HTN • Obesity • Former smoker with 20-year pack history • Impaired physical activity • KDA: PCN (hives) Changes to the overall plan of care? I would proceed with the current plan to start the patient on Olodaterol (Striverdi Respimat) 2 puffs inhaled every 24 hours, as well as a SABA; Albuterol 2 puffs every 4-6 hours as needed for shortness of breath or wheezing. If J.D. had not had the flu or pneumonia vaccines; they would be given today. Additionally, J.D. also had elevated BP readings of 156/94 and 152/90; although he is taking Metoprolol succinate ER (Toprol XL) 50mg QD. I would like him to take his BP at home daily for 2 weeks and bring those readings into the office at that time for a BP check. I would also like him to adhere to a DASH diet. The Dash diet has been proven to consistently lowers blood pressure in patients with hypertension and prehypertension (Steinberg, Bennett, & Svetkey, 2017). Furthermore, I would like to see if the Olodaterol is improving his symptoms of SOB that could be contributing to his elevated BP readings due to increased work of breathing. Patients are much more likely to adhere to a medication regimen that has fewer medications and is less complicated (Woo & Robinson, 2016). Therefore, I would like to evaluate the effectiveness of the Olodaterol, and lifestyle modification has an effect. However, if his BP is still elevated an adjustment, change, or addition to his blood pressure medication management would be necessary (Hollier, 2018). References Dunphy, L., Winland-Brown, J., Porter, B., & Thomas, D. (2019). Primary care: The art and science of advanced practice nursing-An interprofessional approach (5th ed.). Philadelphia: F.A.Davis. Epocrates. (2019). COPD: Management and treatment. Retrieved from In Epocrates Essential for Android (Version 19.10.1) [Mobile application software}: Global Initiative for Asthma. (2019). Pocket guide for asthma management and prevention. Retrieved from : Global Initiative for Chronic Obstructive Lung Disease. (2019). Global strategy for the diagnosis, management, and prevention of COPD. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Retrieved from Hafem, B., & Sharma, S. (2019). Oxygen saturation. In: StatPearls [Internet]. Treasure Island (FL): StatPearls. doi: Hollier, A. (2018). Clinical Guidelines in Primary Care. Lafayette: Advanced Practice Education Associates Inc. Lacasse, Y., Tan, A., Maltais, F., & Krishnan, J. (2018). Home oxygen in chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine, 197(10), . doi:10.1164/rccm.-0382CI Rabe, K., & Watz, H. (2017). Chronic obstructive pulmonary disease. The Lancet, 389(10082), . doi:10.1016/S(17)31222-9 Steinberg, D., Bennett, G., & Svetkey, L. (2017). DASH diet, 20 years later. JAMA, 317(15), . doi:10.1001/jama.2017.1628 Woo, T. M., Robinson, M. V. (2016). Pharmacotherapeutics For Advanced Practice Nurse Prescribers. (4th ed., Vol. 1). Philadelphia, PA: F.A. Davis Company.