University Case Study: Acute COPD Exacerbation in an Elderly Patient

This case study presents a 60-year-old woman admitted to the emergency room with acute exacerbation of chronic obstructive pulmonary disease (COPD), detailing her medical history, symptoms, and vital signs. The patient's history includes COPD, coronary artery disease, hypertension, diabetes, and a history of smoking. The study analyzes her presentation, including shortness of breath, use of accessory muscles, and abnormal vital signs. The assessment includes vital signs, TSH, chest CT scan, and echocardiogram. The differential diagnosis includes acute on chronic COPD exacerbation, and congestive heart failure. The management strategy includes oxygen therapy, BiPAP, and ICU admission with intubation and vasopressor support. The discussion section covers the patient's history, the risk factors for COPD, and the comorbidities associated with the condition, such as hypertension, coronary artery disease, hyperlipidemia, obesity, and diabetes. The case study provides a comprehensive overview of the patient's condition, assessment, and management strategies, emphasizing the complexities of treating elderly patients with multiple comorbidities.

Running head: Case scenario of an older patient
Case scenario of an older patient
Name of the Student
Name of the University
Author Note

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Case scenario of an older patient
Patient scenario
A 60-year-old woman was admitted to the emergency room with extreme shortness of
breath, with acute exacerbation of chronic obstructive pulmonary disease (COPD). The patient
was found to breathe heavily and was using accessory muscles of respiration. Symptoms started
about two days ago and slowly progressed without related, aggravating or alleviating causes.
However, she reports no chills, fever, cough, wheezing, sputum, palpitations, stresses, stomach
pain, and distensions of the intestinal muscle, nausea, vomiting and diarrhoea. She experiences
trouble breathing, exhaustion, moderate weakness, a cold sensation in need of blankets or warm
clothes, increased urinary frequency, incapacity and swelling in her lower bilateral limbs that are
beginning to develop again and deteriorating. She did not leave her bed for many days except in
the toilet because she felt weak, exhausted and breathless. Her medical background encompasses
her father's severe heart disorder and prostate malignancy. She was an active smoker and smoked
about 10 cigarettes a day. She reduced her smoking rates due to shortness of breath two years
ago, however, could not quit it completely. She denies any use of drugs and alcohol and no food
or frug allergies have been reported so far. Past medical history has been significant for Chronic
Obstructive Pulmonary Disorder (COPD), coronary artery disease, myocardial infarction,
elevated blood pressure, hyperlipidemia, peripheral vascular disorder, hypothyroidism, diabetes
mellitus, heavy smoking and obesity. The previous experience of surgery was critical for
appendectomy, heart catheterization with stent placement, hysterectomy and nephrectomy.
Reason for admission: Acute shortness of breath.

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Case scenario of an older patient
Symptoms experienced by the patient: Shortness of breath, fatigue, a cold sensation, persistent
wheezing, chest tightness, nausea, vomiting, exhaustion, weakness, restlessness, swelling lower
bilateral limbs and increased frequency for urinating.
Social history: The patient is Catholic. She lives alone in an apartment. Her husband died 5
years back due to heart attack and her daughter lives in another city. She comes often to visit her,
especially during the weekends. She is not engaged in any physical activity or exercise, instead
she spends her day lying on bed and working very less. She does not socialize much in her
community and do not take part n any social activities.
Medical history: Her medical history reveals that she is a patient of Chronic Obstructive
Pulmonary Disorder (COPD), cardiovascular disorders, hypothyroidism, hypertension, diabetes
mellitus and obesity. Besides that, she suffered from severe depression and anxiety after her
husband’s death, which needed medical attention.
Vital signs:
 Body temperature= 97.3 F
 BMI= 38.5
 Respiratory rate= 24
 BP= 160/90
 Heart rate= 89 bpm
 O2 Saturation= 90% on room air.
Current medication:
 Breo Ellipta 100-25 mcg inhaled to control her breathlessness.
 Hydralazine 50 mg by mouth for treating her high blood pressure.

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Case scenario of an older patient
 Hydrochlorothiazide 25 mg, used for managing hypertension and other cardiac
conditions.
 Aspirin 81 mg.
 An antiplatelet drug, Clopidogrel 75 mg taken orally.
Discussion
The patient reports severe shortness of breath and found to breathe heavily using her
asessory muscle for respiration. Assessory muscles are the muscles that lead to inhalation and
exhalation, allowing the thoracic cavity to extend and contract. The diaphragm and intercostal
muscles, to a lesser degree, induce respiration in silent respiration. Further Assessory extension
muscles are usually utilized only in elevated aerobic (e.g. exercise) or respiratory impairment
circumstances. However, the width of the rib cage may be reduced in situations when these
attachment muscles are rigid and stiff. Maintenance of the elasticity of the muscles is important
for the protection and operation of the respiratory system.
History: The patient’s past medical history include Chronic Obstructive Pulmonary Disorder
(COPD) coronary artery disease, myocardial infarction, elevated blood pressure, hyperlipidemia,
peripheral vascular disorder, hypothyroidism, diabetes mellitus, heavy smoking and obesity. The
previous experience of surgery was critical for appendectomy, heart catheterization with stent
placement, hysterectomy and nephrectomy. It is important to understand patient’s history in
order to identify her risks. Also, family history is indeed a documentation of an individual and
their close relatives 'health records. A complete history provides records on kids, brothers and
sisters, siblings, aunts and uncles, nephews and nieces, relatives, and cousins over three
generations of family members. Families share several factors, such as genes, their culture and
their lifestyle. Such factors can together provide clues to a family's medical conditions. Through

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Case scenario of an older patient
analysing trends of diseases in family members, health clinicians may assess if the probability of
contracting a certain disease is greater for a person (ghr.nlm.nih.gov, 2020). Family background
can predict people who are more likely to suffer from chronic disorders, such as cardiac disease,
asthma, diabetes, stroke and cancers. The variation of chromosomes, environmental factors and
lifestyle preferences are affected by these dynamic diseases. Therefore, learning the medical
background of the relatives helps someone to take action to reduce the risk (ghr.nlm.nih.gov,
2020).
The patient here has medical history of Chronic Obstructive Pulmonary Disorder (COPD)
which was diagnosed 2 years back. (COPD) is a permanent airway obstruction-type persistent
condition and a significant public health issue. COPD is induced primarily by the use to
cigarettes, weather and occupational exposure. This is a debilitating condition because of
recurrent exacerbations as well as the primary cause of morbidity and mortality (Durmaz et al.,
2015). Thus, the patient is at an increasing hazard of developing COPD exacerbation worsening
the condition. Also, the patient is a heavy smoker and used to smoke 10 cigarettes a day which is
a major risk factor for COPD. Also, smoking is responsible for clinical manifestations of COPD
mechanisms including alteration in lung functions. Furthermore, the patient here is a 60 year old
lady which is again, a risk factor for COPD. According to the study by Kim et al. (2018) suggest
that COPD is an age related condition and there are any evidences that have found a link
between increasing age and incidence of COPD. Additionally, aging may act as the fundamental
cause for COPD (Kim et al., 2018).
Hypertension is also a risk factor for COPD. Patients with COPD are generally suffered
from hypertension that further increases the risk of cardiovascular diseases and other heart
related complications (Kim et al., 2017). Chronic obstructive pulmonary disorder (COPD)

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Case scenario of an older patient
patients are at significant risk of experiencing cardiovascular disease. Airflow deficiency is an
indicator of the potential likelihood of hypertension and cardiovascular problems. COPD is now
known as a chronic inflammatory condition, centred on inflammation in the lungs. A mixture of
inflammation and sympathetic overactivity has also been identified in this disease (Imaizumi,
Eguchi & Kario, 2014). Owing to this, the patient had coronary artery disease and other cardiac
conditions that have contributed to her current medical condition. Evidences have suggested that
patients with COPD are more likely to suffer from several cardiac conditions including
pulmonary hypertension (PH), arrhythmia, right ventricular (RV) dysfunction, coronary artery
disease (CAD). COPD-associated pulmonary artery disorder reduces morbidity and slows
down recovery. Patients with COPD may have a greater chance of mortality due to arrhythmia,
congestive heart failure or myocardial infarction relative to the patients who do not (Morgan,
Zakeri & Quint, 2018). Other comorbidities of the patient include hyperlipidemia, obesity and
diabetes. The study by Kahnert et al. (2017) suggests that hyperlipidemia is a major risk factor
for cardiovascular diseases in patients suffering from COPD, which is currently evident in this
patient. Diabetes mellitus (DM) is a metabolic condition, and research shows that low-grade
chronic inflammation is a characteristic of the disease of insulin resistance and is associated with
DM development. Chronic systemic inflammation is still theoretically one of the main COPD
and DM denominators. Epidemiological trials have found that DM is more severe in patients
with COPD, and is likely to affect their prognosis. In the other side, a variety of research has
documented a correlation between DM and decreased lung function (Ho et al., 2017). According
to Zewari et al. (2017) the incidence of obesity in COPD patients is complex and it is found that
obesity is more prevalent in COPD patients relative to non-COPD patients that increase the risk
of other comoridities that are evident in this patient.

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Case scenario of an older patient
Assessment:
Initial nursing assessment includes the comprehensive and continuous processing of the
information; the data being collected, evaluated, arranged and recorded and shared. Rational
thinking techniques developed through the clinical phase include a decision-making structure to
create and direct a patient care strategy that integrates evidence-based professional principles.
This principle of detailed tailoring instruction focused on the specific cultural, moral, and
physical requirements of an individual instead of a trial or test by error. The nursing assessment
involves gathering of knowledge regarding the medical, sociological, psychological and spiritual
needs of the individual. It is the first phase towards a patient's positive evaluation. Nurses are
responsible for collection of both subjective as well as objective data that directs the treatment
process. Part of the assessment consists of data collection collected conducting necessary
assessment to acquire vital signs, such as pulse rate, temperature, blood pressure, respiratory
rate, and pain intensity. The assessment determines the patient's present and potential treatment
requirements by medical services (Toney-Butler, & Unison-Pace, 2019).
For this, patient, the vital signs indicated a higher respiratory rate and a higher blood pressure.
Her respiratory rate was 24 per minute indicating a need to administer oxygen. For certain
respiratory and cardiac emergencies, emergency oxygen may be provided. These can help boost
hypoxia and minimize pain and respiratory pressure (insufficient cient oxygen enters the cells).
The assessment also involves TSH, chest CT scan, and echocardiograms. The
hypothyroidism of TSH and free T4 is measured. BNP assesses the degree of fluid load and
potential congestive heart failure. The chest CT scan checks for anomalies in the anatomy. An
echocardiogram evaluates several mechanisms such as pulmonary artery pressure, left

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Case scenario of an older patient
ventricular ejection fraction, pericardial effusion, valvular function, right ventricular function
and any hypokinetic area.
TSH: 7.2 (underactive)
ECG: The rhythm of the usual sinus with inferior leads varies in non-specific ST. The voltage of
leads I, III, aVR, aVL, aVF was lower.
Chest x-ray:
Findings- Airspace bibasilar disorder, which may be alveolar oedema. Noted Cardiomegaly.
Noted important interstitial marks.
Radiologist Impression- Radiographic variations in congestive failure with more anterior
pleural effusion on the left than on the right.
Differential Diagnosis:
 Acute on chronic COPD exacerbation
 Congestive heart failure
 NSTEMI
 Acute chronic renal failure
 Hypothyroidism
 Pericardial effusion
 Pulmonary embolism
 Pulmonary edema
Echocardiogram: The systolic activity of the left ventricular is regular. A border is dilated on
the left ventricular cavity. The aortic valve is structurally irregular and displays sclerosis. The

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Case scenario of an older patient
mitral valve is structurally irregular. There is slight mitral annular calcification. Bilateral
thickening is observed.
Management strategy:
Immediate management strategy:
Following the patient’s admission, she was taken to the emergency department and was
administered oxygen therapy. However, the breathing trouble persisted and thus, she was given
with Bilevel positive airway pressure (BiPAP) therapy used for the treatment and management of
chronic obstructive pulmonary disease (COPD). However, her condition deteriorated and thus,
she was immediately shifted to the Intensive Care Unit (ICU). In ICU, the patient was
emergingly intubated in order to improve metabolic acidosis and airway safety. Her airways have
broad tongues, small neck and severe obesity as a consequence of elevated risk. As the patient's
heart depended on preload, a standard salt bolus of 1 litre was initiated as secondary to
pericardial effusion. Low doses of Norepinephrine to initiate vasopressor support and low dose
ketamine Propopol for sedation were initiated. It was established that the pericardial effusion is
hemodynamically stable. The cardiac failure of this individual was diastolic, as demonstrated by
an ejection of 66 to 70%. Cultures of blood, urine and sputum have been collected. The count of
white blood cells was usual for the case. It is presumably due to hypothyroidism and diabetes
because she becomes immunocompromised.
Following admission to the emergency room, she showed a creatinine of 1.8. As
hypothyroidism induces fluid accumulation partly because the thyroid hormone stimulates free
water excretion and partly because of reduced lymphatic activity in fluid recovery. Aggressive
diuresis was conducted. As a consequence, her creatinine eventually increased but following
continuous evaluation, her creatinine gradually improved. Platelet counts and WBC were found

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Case scenario of an older patient
to be normal. Electrolyte balance was monitored focusing on sodium, potassium, calcium and
chloride.
Medication management:
Bronchodilators
For elderly people with COPD, the primary goals of care and treatment are to improve
the pulmonary capacity and to avoid exacerbations. Inhaled medications are the key
pharmacology products used to meet such targets, such as short-acting and long-acting beta2-
selective adrenergic agonists, corticosteroids and short-acting and long-acting cholinergic
antagonists. Typical with the usage of such agents is three forms of appliances, i.e. inhalers with
pressure metered dose inhalers (MDI), dry powder inhalers (DPIs) or nebulizers (Taffet,
Donohue & Altman, 2014). Bronchodilators are also referred to as a foundation of COPD
treatment. Stable diseases also require the usage of anticholingeric agents and b2-adrenoceptor
agonists on a daily or as required basis for the treatment of the symptoms. For Acute
Excacerbation of COPD, long-acting bronchodilators, such as tiotropium and salmeterol, provide
little benefits and are substituted by regularly administered short-acting bronchodilators
(SABDs).
Steroid inhalers
When the patient is feeling breathless by using a long-acting inhaler or if the patient
has repeated flare-ups, GP can consider using a steroid inhaler as part of the care. Corticosteroid
medications include inhalers and may help lower airway inflammation. As part of a combined
inhaler that often contains a therapeutic drug, steroid inhalers are typically recommended.
Some of the common corticosteroids that can be prescribed to the patient are:

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Case scenario of an older patient
 Fluticasone (Flovent) comes in aninhaler and is usually prescribed to take twice daily.
Common adverse effects may include sore throat, nausea, headache, a changed voice,
thrush and cold-like symptoms.
 Budesonide (Pulmicort) comes as a handheld inhaler or can even be used like a nebulizer.
Common side effect includes thrush or cold.
 Prednisolone, comes as pill, shot or liquid generally prescribed during emergency
situations. Common side effects are muscle weakness, headache, upset stomach, and
weight gain.
Self-management strategies
According to Korpershoek et al. (2017) Self-care should focus on commitment to
pharmacotherapy, influenza vaccine, physical activity / exercise, stimulus avoidance, smoking
avoidance, early diagnosis of symptom worsening, therapeutic treatment of exacerbations, stress
and anxiety control, and knowledge of repeated exacerbations (Korpershoek et al., 2017).
COPD treatment focuses primarily on the avoidance of further worsening and the
preservation of respiratory capacity and quality of life. The only therapy that has been found to
reduce the long-term worsening in COPD-associated lung function is to support smokers quit.
Two key COPD treatments that may help improve quality of life and minimize complications
include respiratory rehabilitation, drugs, and long-term breathing treatment for patients with
extremely significant illnesses. Reduction of overall personal exposure to cigarette smoke,
occupational contaminants and toxins, and indoor and outdoor environmental contaminants are
effective goals to reduce the emergence and persistence of COPD (Who.int, 2020). Smoking
cessation is the most efficient and cost-effective way of reducing the likelihood of developing

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Case scenario of an older patient
COPD and halt its development. The general method to treating stable COPD will be defined by
a step-by-step change in care, based on the nature of the condition. Medical awareness may play
a part for COPD patients in developing their abilities, their skills to deal with disease, and their
health status. This is successful in fulfilling other goals, including the prevention of smoking
(Who.int, 2020). None of the approved medications for COPD have been found to change the
long-term deterioration in lung capacity that is a characteristic of this disorder. Thus, COPD
pharmacotherapy is being used to reduce effects and complications.
Pulmonary rehabilitation
Pulmonary rehabilitation is considered to be one of the most common treatments for
COPD and is prescribed for those people with COPD who become out of breath. This is a
treatment program that involves education, instruction and psychosocial counselling supported
by an interdisciplinary team of clinicians. Pulmonary therapy decreases complications,
impairment and injury, eliminates hospitalization and increases physical and mental
performance. It will allow individuals to reach and sustain an optimal degree of equality and
participating in the society. This has beneficial associations with other treatments, such as dietary
counselling and pharmacotherapy. It includes exercise education, training, nutrition counselling
and psychosocial support (Australian Institute of Health and Welfare, 2020). The patient must
be recommended with these for improving these conditions. Exercise will also help to control her
obesity.
Handover:
Clinical handover applies to the transfer of medical competence and liability regarding
any or more areas of health treatment or health services to another individual or medical
community on a temporarily or permanently basis. Clinical handover is, by nature, an