Nursing Care Plan for a Patient with COPD Exacerbation: Case Study

This assignment presents a comprehensive nursing care plan for a 57-year-old female patient admitted to the CDU medical ward with COPD exacerbation. The case study meticulously details the pathophysiology of COPD, emphasizing the role of cigarette smoking, inflammatory processes involving Th1 cells, and the impact on lung function, leading to ineffective breathing patterns, ineffective airway clearance, and activity intolerance. The care plan includes specific nursing interventions such as assessing respiratory rate, breath sounds, and activity levels, as well as patient education regarding breathing techniques and medication adherence. Furthermore, the assignment addresses the medications prescribed, amoxicillin for potential bacterial infections and metformin for potential cardiovascular complications, discussing their mechanisms of action, side effects, and implications for patient management. The student also provides detailed rationales for the nursing interventions and emphasizes the importance of ongoing assessment and evaluation to ensure optimal patient outcomes.

Medical Surgical Nursing
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Consider the patient:
Patient is a 57 yer lady, who is currently experiencing exacerbations of COPD. Hence, she
gets admitted to the CDU medical ward. Cigarette smoking is the primary reason for the
occurrence of COPD. Noxious agents present in the cigarette smoke are responsible for the
injury to the airway epithelium which lead the cascade of events resulting in airway
inflammation and airway structural changes. It results in the bronchial and lung matrix
degradation. In addition to the cigarette smoke, other inhaled irritants and bacterial infections
are also responsible for the inflammatory state in the COPD patients. Th1 cells are primarily
involved in the inflammatory process of COPD. Major inflammatory cells involved in the
COPD are neutrophil granulocytes and macrophages. This inflammatory response is
specifically brought by the inflammatory mediators such as chemotactic factors. Free radicals
and protases are also responsible for the breakdown of the lung tissues. This destruction of
the lung tissue results in the emphysema which lead to the poor airflow. Hence, imbalance in
the partial oxygen pressure and partial carbon dioxide pressure occur in patients with COPD.
Muscle wasting in COPD patients primarily occur due to the inflammatory process.
Inflammation in the airways results in the scarring of the airways which lead to the narrowing
of the airways. Narrowing of the airways is attributable to the restriction to the airflow.
Hence, COPD patients exhibit inability to breathe out to the full extent. More reduction in the
air flow occurs during breathing out because chest compresses the airways during breathing
out. It results in the more amount of air trapping in the lungs from the previous breath. It
results in the increased volume of air in the lungs which is termed as hyperinflation or air
trapping. It leads to shortness of breath in COPD patients because lungs remain already
partially filled in COPD patients (Eapen, Myers, Walters, and Sohal, 2017). COPD patients
are usually associated with low oxygen levels and high carbon dioxide levels which mainly
occur due to the poor gas exchange. Poor gas exchange mainly occurs due to reduced
ventilation due to airway obstruction, hyperinflammation and reduced desire to breath. Rose
is associated with exacerbations of COPD. In patients with exacerbations of COPD, there is
increased airway inflammation, increased hyperinflammation, decreased expiratory airflow
and impaired gas transfer. COPD patients are associated with low oxygen levels for the
longer duration of time. It results in the narrowing of the arteries in the lungs. Moreover,
emphysema condition of the COPD results in the breakdown of the capillaries in the lungs.
Both these conditions are attributable to the augmented blood pressure in the pulmonary
arteries. It might result in the development of cor pulmonale. Rose is associated with
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dyspnoea which is most common feature of the COPD due narrowing of the airways which
mainly occur due to inflammation and deposition of the inflammatory cells and mucus in the
airways. In COPD patients, there is excess production of mucus. Hence, COPD patients are
usually associated with cough to loosen the deposited cough. COPD patients might get fever
due to lung infection. Rose is also associated with cough and fever (Ko et al., 2016).
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Care plan:
Nursing problem: Ineffective breathing pattern
What it is related to? Patients with COPD exacerbations are usually associated with bronchoconstriction which results in the ineffective breathing pattern.
Goal of care Nursing interventions/actions Rationale Evaluation
To maintain and
sustain normal
breathing pattern in
Rose.
Assess and record respiratory rate and
ABG levels I Rose.
Observe and monitor breathing pattern in
Rose.
Auscultate breath sound after regular
intervals.
Observe and monitor nostrils retractions.
Encourage and train Rose for
diaphragmatic breathing.
Encourage and ensure that Rose is clearing
her airway through secretion mobilization
and coughing.
Ensure Rose is adopting accurate breathing,
coughing and splinting methods.
Abnormal breathing rate indicate
respiratory dysfunction. Assessment of
ABG is useful in evaluation of
ventilation efficiency (Ladwig, Ackley,
and Makic, 2016).
Abnormal breathing pattern is the
prominent sign in COPD patients
(Swearingen, 2015).
As a result of slower breathing rate,
lessened breathing sound can be
observed (Ladwig, Ackley, and Makic,
2016).
It indicates respiratory abnormality.
It relaxes muscles and improves
oxygenation.
It is useful in clearing all the secretions
form the airways.
It is helpful in complete mobilization of
It is evident that normal breathing pattern
sustained in Rose.
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Educate Rose for efficacy and side effects
of prescribed medications. Also train her to
accurate use of metered-dose inhaler and
nebulizer.
the secretions.
It is helpful in accurate consumption of
medication and medication adherence
(Gulanick and Myers, 2016).
Nursing problem: Ineffective Airway Clearance
What it is related to? Ineffective airway clearance can occur in patients with COPD exacerbations due to inflammatory response and secretion deposition in the
airway.
Goal of care Nursing interventions/actions Rationale Evaluation
To maintain clear and
open airways in Rose.
Assess and observe airway obstruction in
Rose.
Auscultate lungs for breath sound.
Observe and monitor cough for
productivity.
If necessary, perform nasotracheal
suctioning.
Proper functioning of the respiratory
system depend on the clear airway
without any type of obstruction
Gulanick and Myers, 2016).
Fluid and mucus deposition in the
respiratory tract results in the abnormal
breath sound (deWit, and Kumagai,
2014).
Deposition of the mucus and other
secretions can result in the ineffective
cough (deWit, and Kumagai, 2014).
It is beneficial in removal of thick
mucus plugs.
Airway of Rose get cleared; since, there are
no secretions in his airway.
Nursing problem: Activity intolerance.
What it is related to? Activity intolerance in COPD patients usually associated due to breathlessness and its consequent psychological effect
Goal of care Nursing interventions/actions Rationale Evaluation
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To ensure Rose perform
all her activities on her
own.
Assess physical activity and mobility level
of Rose. Moreover, measure resting pulse,
BP, HR, heart rhythm and pulse quality in
Rose.
Assess and monitor nutrition in Rose.
Assess and monitor quality and quantity of
sleep in Rose.
Assessment of these parameters in Rose
is helpful planning necessary
intervention (Gulanick and Myers,
2016).
Optimum amount of energy is essential
for carrying out activities.
Adequate amount of sleep is essential
for carrying out routine activities
(Ladwig, Ackley, and Makic, 2016).
Rose started performing all his activities
properly.
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Patient education:
Rose should be provided with education about the regular consumption of medication
including use metered inhaler and practicing breathing techniques.
Older people are usually associated with the unwillingness to consume medications on the
regular basis and they do not adhere to the medication consumptions. However, patients with
COPD should consume medications on the regular basis because discontinuation of the
medications in the COPD condition can exaggerate and worsen the condition. COPD
pathology is an ongoing process and it gets exaggerated due to external stimulation. Hence, it
is essential to control inflammatory processes in COPD patients through medications.
Moreover, Rose should be educated about the outcome of the medications. Hence, rose can
inform nurses and healthcare providers; if prescribed medications are not working for her. In
case, medications are not working for Rose, she should be advised not to change the
medications without discussing with healthcare providers. Moreover, Rose should be advised
to keep her medicines always with her. Since, she is experiencing exacerbations of COPD,
these exacerbations can occur any time. Most importantly, it is essential for her to consume
medications during exacerbation to avoid worsening of the condition. Metered dose inhalers
are useful in relieving the COPD patients form breathlessness. Metered dose inhalers produce
bronchodilator effect in the COPD and other respiratory disease patients. However, optimum
effect can be achieved through metered dose inhaler through its accurate use. Hence, it is
essential to provide education to the Rose about the use of metered dose inhaler. Rose is
advised to keep schedule of medication consumption and she should fix an alert for
medication consumption along with her. It would be helpful for her for the in regular
consumption of medications (Alison et al., 2017).
Rose should also be tought about the breathing technique. It is essential for the COPD
patients like Rose to follow and adopt breathing technique to improve breathing efficiency.
Patients with COPD exacerbations are always associated with the breathlessness due to
narrowing of the airways. In such cases, breathing techniques would be beneficial in
improving breathing and improve oxygen inhalation. Shortness of breath which is common
feature of COPD patients can be effectively managed through the controlled breathing
technique. Accurate training should be given to the Rose about the Pursed-Lips breathing and
breathing from the diaphragm. Rose should be advised to follow all the steps of the controlled
breathing accurately because inaccurate practice of controlled breathing techniques can lead
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to several other health related complications. Nurse should convince Rose to follow the
controlled breathing techniques because these techniques can improve her breathlessness
problem without taking much efforts. It is essential for Rose to follow these techniques on the
regular basis. Hence, Rose should be informed that controlled breathing practice can be
followed while doing other daily routine activities such as long walks, stair climbing, all daily
activities and while exercising. This knowledge would be helpful for the Rose to practice
these activities on daily basis (Reddel et al., 2017).
Medication:
Amoxicillin is an antibiotic useful in the treatment of bacterial infections. In this case, it
might be prescribed for the pneumonia because COPD patients are usually associated with
pneumonia. Amoxicillin exhibit its action through attaching to the cell wall of susceptible
bacteria and it results in the death of bacteria. Hence, it is considered as the bactericidal drug.
It exhibits its bactericidal activity through inhibiting the cross-linkage between the linear
peptidoglycan polymer chains. This cross-linkage inhibition results in the death of bacteria
because it is the major component of the bacterial cell wall. Amoxicillin exhibit more
absorption upon oral intake; hence, it exhibits more concentration in the blood. Rose has been
prescribed with amoxicillin because patients with COPD exacerbations might develop
bacterial infection due to Pneumococci. Hence, this infection can be effectively managed
through administration of amoxicillin (Herath, Normansell, Maisey, and Poole, 2018).
Amoxicillin is associated with sudden onset of allergic reactions; hence, it is essential to
continuously monitor the patient for allergic reaction after amoxicillin administration. It is
essential to complete amoxicillin course after its treatment initiation because there are
chances of reinfection due to discontinuation of the medication. Clinical guidelines also
mentioned not to stop consumption of amoxicillin; if there is improvement in the condition.
Moreover, amoxicillin administration should not be discontinued immediately, if it does not
exhibit expected outcome. Amoxicillin administration should not be stopped immediately
because amoxicillin usually does not exhibit immediate effect. Literature indicated that
amoxicillin administration is associated with increase in the glucose levels. Hence, it is
essential to perform blood glucose test on the regular basis for the patients with amoxicillin
administration (Yang et al., 2017).
Metformin is a drug which is useful in the management of type 2 diabetes. Multiple
mechanisms have been proposed for the metformin. Different mechanisms proposed for the
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metformin include mitochondrial respiratory chain (complex I), activation of AMP-activated
protein kinase (AMPK), inhibition of glucagon-induced elevation of cyclic adenosine
monophosphate (cAMP) with reduced activation of protein kinase A (PKA), inhibition of
mitochondrial glycerophosphate dehydrogenase, and an effect on gut microbiota. However,
activation of AMPK is useful in inhibiting the liver glucose production. AMPK plays
significant role in the insulin signalling. AMPK is also responsible for GLUT4 deployment to
the plasma membrane. It results in the insulin independent glucose uptake. Moreover, clinical
and treatment guidelines indicated that in addition to the management of type 2 diabetes;
metformin is also beneficial in the management of cardiovascular conditions. Hence,
metformin can be more beneficial in case of Rose, she is associated with multiple clinical
complications. Most of the patients with the metformin administration are associated with
occurrence of lactic acidosis. Such patients are associated with renal insufficiency. In such
patients, non-steroidal anti-inflammatory drugs should be administered with caution. Lactic
acidosis is also responsible for the occurrence of hypoxia. Hence, metformin should be
administered in COPD patients because COPD patients experience state of dyspnoea (Moon
et at., 2016).
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