Vsim care plan: COPD
Vincent Brody is a 67-year-old male admitted directly from the provider’s office several hours
ago for exacerbation of his chronic obstructive pulmonary disease (COPD). He is maintaining O2
saturations at 94% on 2 L/min of oxygen per nasal cannula. IV of potassium chloride in 5%
dextrose and normal saline is infusing at 100 mL/hr in his right hand. He has responded well to
medications and treatments and appears to be resting. He continues to have a productive cough.
Patient has a 50-year history of smoking 2 packs a day. During the last year he has had two
exacerbations. Physical findings include a barrel chest and clubbed fingers.
Chronic Obstructive Pulmonary Disease (COPD) is defined as “a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not
fully reversible. The airflow limitation is usually progressive and associated with an abnormal
inflammatory response of the lung to noxious particles or gases.”
Common signs and symptoms of COPD include:
-An ongoing cough or a cough that produces a lot of mucus; this is often called smoker's cough.
-Shortness of breath, especially with physical activity.
-Wheezing or a whistling or squeaky sound when you breathe.
-Chest tightness.
Head to toe assessment.
General appearance
-Patient is alert and oriented X4
-No obvious airway obstruction.
-Patient is clean and well groomed,
-No congenital or acquired physical deformities noted.
-Independent, mobile and no use of assistive device. Full range of motion present in
bilateral upper and lower extremities.
-Patient can speak without any difficulties.
-Lots of audible wheezing
-Vital signs: : Heart rate: 102. Pulse: Present. Blood pressure: 127/76 mm Hg.
Respiration: 19. Conscious state: Appropriate. SpO2: 94%. Temp: 99 F (37
C). -Skin, hair, and nails:
-Patient skin is free of lesion, rashes and bruising.
-Patient skin is warm and moist to touch.
-No pressure area noted.
-No edema noted
-No lice on hair.
-Patient Nails capillary refill less than 2 seconds bilateral and is consistent.
Head and Face
1.Scalp, hair, cranium
Head round, symmetric skull, and appropriate proposition to body size and shape.
2.Face, stroke check
Face symmetrical, no facial skin pigmentation or abnormalities noted. Client had calm and relaxed facial expression.
3.Temporomandibular joint
No pain full range of motion temporomandibular joint. No grunting sound heard or felt during jaw opening and closing.
4.Maxillary sinuses, frontal sinuses palpation
No visible or palpable maxillary and frontal sinus swelling noted.
Vincent Brody is a 67-year-old male admitted directly from the provider’s office several hours
ago for exacerbation of his chronic obstructive pulmonary disease (COPD). He is maintaining O2
saturations at 94% on 2 L/min of oxygen per nasal cannula. IV of potassium chloride in 5%
dextrose and normal saline is infusing at 100 mL/hr in his right hand. He has responded well to
medications and treatments and appears to be resting. He continues to have a productive cough.
Patient has a 50-year history of smoking 2 packs a day. During the last year he has had two
exacerbations. Physical findings include a barrel chest and clubbed fingers.
Chronic Obstructive Pulmonary Disease (COPD) is defined as “a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not
fully reversible. The airflow limitation is usually progressive and associated with an abnormal
inflammatory response of the lung to noxious particles or gases.”
Common signs and symptoms of COPD include:
-An ongoing cough or a cough that produces a lot of mucus; this is often called smoker's cough.
-Shortness of breath, especially with physical activity.
-Wheezing or a whistling or squeaky sound when you breathe.
-Chest tightness.
Head to toe assessment.
General appearance
-Patient is alert and oriented X4
-No obvious airway obstruction.
-Patient is clean and well groomed,
-No congenital or acquired physical deformities noted.
-Independent, mobile and no use of assistive device. Full range of motion present in
bilateral upper and lower extremities.
-Patient can speak without any difficulties.
-Lots of audible wheezing
-Vital signs: : Heart rate: 102. Pulse: Present. Blood pressure: 127/76 mm Hg.
Respiration: 19. Conscious state: Appropriate. SpO2: 94%. Temp: 99 F (37
C). -Skin, hair, and nails:
-Patient skin is free of lesion, rashes and bruising.
-Patient skin is warm and moist to touch.
-No pressure area noted.
-No edema noted
-No lice on hair.
-Patient Nails capillary refill less than 2 seconds bilateral and is consistent.
Head and Face
1.Scalp, hair, cranium
Head round, symmetric skull, and appropriate proposition to body size and shape.
2.Face, stroke check
Face symmetrical, no facial skin pigmentation or abnormalities noted. Client had calm and relaxed facial expression.
3.Temporomandibular joint
No pain full range of motion temporomandibular joint. No grunting sound heard or felt during jaw opening and closing.
4.Maxillary sinuses, frontal sinuses palpation
No visible or palpable maxillary and frontal sinus swelling noted.
