NSB010 Clinical Practice: Evidence-Based Nursing Care Plan - COPD/AD

This case study presents an evidence-based nursing care plan for a 72-year-old female patient, Suzanne Vorster, residing in an aged care facility with a medical history of Chronic Obstructive Pulmonary Disease (COPD) and Alzheimer's Disease (AD). The plan addresses her sudden breathing difficulties, prioritizing respiratory rate and pulse oximetry assessments. It identifies potential contributing factors such as COPD exacerbation due to medication side effects (Exelon patch) and hypoxemia. The care priorities focus on relieving acute dyspnea and reducing the risk of recurring episodes through vital sign monitoring and timely medication administration. Nursing interventions emphasize diagnostic measures like chest roentgenography and arterial blood sampling, alongside therapeutic interventions including bronchodilators, oxygen therapy, and medication review to prevent drug interactions. A detailed progress note using the SBAR framework provides a structured approach to the patient's situation, background, assessment, and recommendations for care.

Running Head: EVIDENCE-BASED PLAN FOR NURSING CARE
EVIDENCE-BASED PLAN FOR NURSING CARE
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Priority nursing assessments
According to the case scenario, there is a sudden deterioration in the respiratory
functioning of the patient manifested through a breathing difficulty. The priority assessments
are:
Respiratory Rate (RR)
Any alteration in the RR is the first indication of respiratory distress when a COPD
patient exhibits sudden breathing difficulty. RR is measured by counting the number of
breaths for a full minute. If RR goes above 20 breaths/minute, shortness of breath is indicated
(Al Rajeh & Hurst, 2016, p. 108).
Pulse oximetry
Low oxygen saturation (Sp02) in the blood is evaluated by pulse oximetry. When the
oxygen saturation level is found to be <90%, a low oxygen level in the blood is indicated,
which correlates the signs of shortness of breath (Garcia-Gutierrez et al., 2015, pp. 613-620).
Factors contributing to dyspnoea
Two vital factors which could have led to this situation are:
 Exacerbation of COPD by breathing difficulties may have developed as a potential
side effect of the daily application of Exelon 10 Transdermal patch to decrease the
symptoms of Alzheimer’s disease (Accessdata.fda.gov, 2020). Acute dystonic
reactions may be caused by the administration of rivastigmine cholinergic drugs
(Exelon patch). The underlying mechanism involves a drug-induced modification in
the dopaminergic–cholinergic stability of the nigrostriatal path, leading to spasmodic
motor disturbances (Dhikav & Anand, 2013, pp. 1385-1386).
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 Another underlying cause could be hypoxemia, common in patients with long term
CPD (Ko et al., 2016, pp. 1152-1165). In this case, the low oxygen levels in the blood
could have resulted due to an increased oxygen demand from excessive work to
breathe as well as by insufficient cardiac reserve for the higher cardiac output, thereby
contributing to the dyspnoea experienced during an acute onset.
Care priorities
Using the Specific, Measurable, Achievable, Relevant, and Timely (SMART) goal
framework, the priorities of care are:
 To provide the patient with relief from her complications of acute dyspnoea
 To reduce the risk of recurring episodes of breathlessness by a significant reduction in
her elevated respiratory rate and increase the blood oxygen levels.
 The identified goal can be successfully administered via frequent monitoring of the
vital signs and ensuring the administration of appropriate medications on time.
 At the end of every session with the patient, detailed charting and documenting every
point regarding the nurse-patient interaction while they are still fresh on the mind is
essential to detect any risk factors early. It also helps in streamlining the work for the
nurse in the next shift.
 There will be no exacerbation of COPD relapse within a week. The focus will be on
providing the patient with symptomatic relief by the end of one week.
Nursing interventions
Diagnostic interventions should emphasize on chest roentgenography and arterial
blood sampling to achieve specif results. Literature suggests evidence of routine chest X-rays
being particularly useful in the initial detection of acute exacerbation of COPD. Similarly,
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analyzing arterial blood gases helps in evaluating the severity of exacerbation episodes
correctly. This is an effective method of assessing hypoxemia and hypercarbia than other
indirect tests like pulse oximetry and also highlights the requirement of additional support of
ventilation for the patient (Halpin et al., 2017, pp. 2891). Therapeutic interventions are
essential in preventing acute dyspnoea for COPD patients with other comorbidities such as
Alzheimer's disease. Reviewing medications at regular intervals to check for possible drug
interactions can reduce the risk of developing complications, which is the case here. By
combining bronchodilators, continual oxygen therapy, and antibiotics, any worsening of
pulmonary functions can be avoided (Yawn, 2013, pp. 75-80).
Progress notes
A detailed progress note is presented according to the Situation, Background,
Assessment, and Recommendation (SBAR) framework (Lancaster, Westphal &
Jambunathan, 2015). (S) Suzanne, a resident of the aged care facility, complained of
difficulty in breathing during her routine nursing checkup. (B) Her medical history includes
longterm smoking-induced COPD for which she is on inhaled bronchodilators,
corticosteroids, and continual oxygen therapy and Alzheimer’s disease from the past one
year, for which she uses Exelon 10 transdermal patch daily. She received influenza and
pneumonia vaccination four months ago. To this context, her acute dyspnoea symptoms could
have arisen from a possible side effect of transdermal patch treatment and increased
respiratory efforts leading to hypoxemia. (A) Initially, her respiratory rate was 44 bpm, and a
pulse oximetry test indicated her oxygen saturation level at 76%. Indications of blue lips were
also present. This confirms with the clinical assessment of dyspnoea manifested as an
exacerbation of COPD. (R) Based on these findings, she received primary care for reducing
exacerbation through the removal of the cholinesterase drug from medications and increasing
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the vital sign monitoring at regular intervals. Evaluation in terms of lessened episodes of
difficulty breathing and the absence of any airway obstruction is ensured during nurse
checkup. Continuous risk monitoring performed to detect new signs of acute respiratory
distress along with frequent reviewing of the medication side effects that might trigger
respiratory distress.
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References
Accessdata.fda.gov. (2020). Retrieved 18 March 2020, from
https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/020823s016,021025s008l
bl.pdf
Al Rajeh, A. M., & Hurst, J. R. (2016). Monitoring of physiological parameters to predict
exacerbations of chronic obstructive pulmonary disease (COPD): a systematic review.
Journal of clinical medicine, 5(12), 108.
Dhikav, V., & Anand, K. S. (2013). Acute dystonic reaction with rivastigmine. International
psychogeriatrics, 25(8), 1385-1386. DOI:10.1017/S104161021300029X
Garcia-Gutierrez, S., Unzurrunzaga, A., Arostegui, I., Quintana, J. M., Pulido, E., Gallardo,
M. S., ... & IRYSS-COPD group. (2015). The use of pulse oximetry to determine
hypoxemia in acute exacerbations of COPD. COPD: Journal of Chronic Obstructive
Pulmonary Disease, 12(6), 613-620. DOI: 10.3109/15412555.2014.995291
Halpin, D. M., Miravitlles, M., Metzdorf, N., & Celli, B. (2017). Impact and prevention of
severe exacerbations of COPD: a review of the evidence. International journal of
chronic obstructive pulmonary disease, 12, 2891.
https://dx.doi.org/10.2147%2FCOPD.S139470
Ko, F. W., Chan, K. P., Hui, D. S., Goddard, J. R., Shaw, J. G., Reid, D. W., & Yang, I. A.
(2016). Acute exacerbation of COPD. Respirology, 21(7), 1152-1165. DOI:
10.1111/resp.12780
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Lancaster, R. J., Westphal, J., & Jambunathan, J. (2015). Using SBAR to promote clinical
judgment in undergraduate nursing students. Journal of Nursing Education. DOI:
10.3928/01484834-20150218-08
Yawn, B. P. (2013). Early identification of exacerbations in patients with chronic obstructive
pulmonary disease. Journal of primary care & community health, 4(1), 75-80.
https://doi.org/10.1177%2F2150131912443827
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