Case Study 29 COPD Exacerbation
D.Z., a 68-year-old man, is admitted at 1600 to a medical floor with a diagnosis of acute exacerbation of
chronic obstructive pulmonary disease (COPD). His other past medical history includes hypertension and
type 2 diabetes. He has had pneumonia yearly for the past 3 years and has been a two-pack-a-day
smoker for 38 years. His current medications include enalapril (Vasotec), hydrochlorothiazide (HCTZ),
metformin (Glucophage), and fluticasone/salmeterol (Advair). He appears a cachectic man who is
experiencing difficulty breathing at rest. D.Z. seems irritable and anxious; he complains of sleeping
poorly and states that lately he feels tired most of the time. He reports cough productive of thick yellow-
green sputum. You auscultate decreased breath sounds, expiratory wheezes, and coarse crackles in both
lower lobes anteriorly and posteriorly. His vital signs (VS) are 162/84, 124, 36, 102° F (38.9° C), and Spo2
88%.
1. Are D.Z.'s VS and Spo2 acceptable? If not, explain why.
D.Z vitals are not appropriate, he is hypertensive at 162/84 mmHg ,tachycardic at 124 bpm, and
tachypneic at RR of 36, SpO2 88% is low, the pt has orders for O2 to maintain SpO2 of 90%> and has a
fever of 102 F. Most concerning for me are D.Z. RR of 36, pt's SpO2 needs to be closely monitored. A RR
of 36 is very close to needing assisted ventilation for efficient gas exchange (Ex. BiPAP) An infection
process may be thhe underlyingcause of D.Z. symptomatology.
, 2. Describe a plan for implementing these physician's orders.
After administering the albuterol treatment, provide the patient with 3L-5L oxygen through nasal
cannula for improve his oxygen saturation. Once the patients O2 sat is stable then I would place the 5
leads EKG electrodes (telemetry monitor), collect the sputum culture, and hang the D5W. Then I would
draw blood for the CBC and BMP, and ABG as ordered in the AM Lastly, I would make sure the chest xray
is ordered daily for the patient
3. What is the primary nursing goal at this time?
Patient maintains optimal gas exchange as evidenced by usual mental status, unlabored respirations at
12-20 per minute, oximetry results within normal range SpO290%>, blood gases within normal range,
and baseline HR for pt. Patient will maintain clear lung fields and remains free of signs of respiratory
distress
4. Based on this priority, identify three independent nursing actions you would implement.
1. Initiate the Albuterol nebulizer treatment
2. Continue administering O2 to the patient vis nasal cannula after the treatment
3. Recheck vitals and reassess the patient
5. Identify three expected outcomes for D.Z. as a result of your interventions.
1. DZ’s Spo2 level will be 90% or higher
2. The patient’s respirations will slow down and become unlabored
3. When the patient has a decrease in their anxiety level, the vital signs will return to normal
limits
D.Z., a 68-year-old man, is admitted at 1600 to a medical floor with a diagnosis of acute exacerbation of
chronic obstructive pulmonary disease (COPD). His other past medical history includes hypertension and
type 2 diabetes. He has had pneumonia yearly for the past 3 years and has been a two-pack-a-day
smoker for 38 years. His current medications include enalapril (Vasotec), hydrochlorothiazide (HCTZ),
metformin (Glucophage), and fluticasone/salmeterol (Advair). He appears a cachectic man who is
experiencing difficulty breathing at rest. D.Z. seems irritable and anxious; he complains of sleeping
poorly and states that lately he feels tired most of the time. He reports cough productive of thick yellow-
green sputum. You auscultate decreased breath sounds, expiratory wheezes, and coarse crackles in both
lower lobes anteriorly and posteriorly. His vital signs (VS) are 162/84, 124, 36, 102° F (38.9° C), and Spo2
88%.
1. Are D.Z.'s VS and Spo2 acceptable? If not, explain why.
D.Z vitals are not appropriate, he is hypertensive at 162/84 mmHg ,tachycardic at 124 bpm, and
tachypneic at RR of 36, SpO2 88% is low, the pt has orders for O2 to maintain SpO2 of 90%> and has a
fever of 102 F. Most concerning for me are D.Z. RR of 36, pt's SpO2 needs to be closely monitored. A RR
of 36 is very close to needing assisted ventilation for efficient gas exchange (Ex. BiPAP) An infection
process may be thhe underlyingcause of D.Z. symptomatology.
, 2. Describe a plan for implementing these physician's orders.
After administering the albuterol treatment, provide the patient with 3L-5L oxygen through nasal
cannula for improve his oxygen saturation. Once the patients O2 sat is stable then I would place the 5
leads EKG electrodes (telemetry monitor), collect the sputum culture, and hang the D5W. Then I would
draw blood for the CBC and BMP, and ABG as ordered in the AM Lastly, I would make sure the chest xray
is ordered daily for the patient
3. What is the primary nursing goal at this time?
Patient maintains optimal gas exchange as evidenced by usual mental status, unlabored respirations at
12-20 per minute, oximetry results within normal range SpO290%>, blood gases within normal range,
and baseline HR for pt. Patient will maintain clear lung fields and remains free of signs of respiratory
distress
4. Based on this priority, identify three independent nursing actions you would implement.
1. Initiate the Albuterol nebulizer treatment
2. Continue administering O2 to the patient vis nasal cannula after the treatment
3. Recheck vitals and reassess the patient
5. Identify three expected outcomes for D.Z. as a result of your interventions.
1. DZ’s Spo2 level will be 90% or higher
2. The patient’s respirations will slow down and become unlabored
3. When the patient has a decrease in their anxiety level, the vital signs will return to normal
limits
