UNRS 367 Pathophysiology Nursing Case Study: Acute COPD Exacerbation

This is a UNRS 367 pathophysiology case study focusing on a 68-year-old male patient, Ronald M Mercy, admitted for acute exacerbation of COPD. The case details the patient's extensive medical history, including chronic obstructive pulmonary disease, diabetes mellitus type 2, dyslipidemia, anxiety disorder, hypertension, colon cancer, coronary artery disease, chronic respiratory failure, atherosclerosis, malnutrition, atrial fibrillation, emphysema, squamous cell carcinoma, and impingement syndrome. The patient presented with shortness of breath, nausea, coughing, chest congestion, rhinorrhea, and fever. The case study includes a comprehensive physical assessment, laboratory data, arterial blood gas analysis revealing respiratory acidosis, diagnostic tests, intake and output monitoring, and a detailed medication review with rationales for each drug. The head-to-toe assessment covers integumentary, musculoskeletal, neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, endocrine, and psychosocial aspects, providing a holistic view of the patient's condition and care.

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University
School of Nursing
UNRS 367
Data Form
for
Pathophysiology Case Study
Prof. MAEd, MA, PHN, MSN,
Monrovia (LVN-BSN Program)
Student: _________________________
Date: ___________
University
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School of Nursing: Pathophysiology
Nursing Process Data Form
Student: ___________________________________ Date of Care: __________________
Patient Initials: Ronald M Mercy -- Age: 68_ Gender: male Allergies: 1. Profolol 2. Niacin _
Primary Language: _English__ Ethnicity: white Religion: Christian
Marital Status: Married Occupation: _Retired (Worked for SBC-a telephone company)
Insurance: none
Family Composition: has 3 children
Home/Living Situation: temperature of 101.8 F
Date/s of Care: Date of Admission: 2/25/2019 Date/s of Surgery: 11/14/2017
Physician(s)/Specialty: Dr. Shinde-garg
Raquel Herrera- diabetic retinopathy
Admitting Diagnosis/es: Acute exacerbation of COPD
Surgical Procedure(s) this hospitalization: Tracheostomy temporary
1. Past Medical/Surgical History/Chronic Conditions:
Ronald M Mercy has experience in several past medical conditions. He was first diagnosed with
Chronic obstructive pulmonary, DM 2 dyslipidemia, anxiety disorder and hypertension on
2/10/2011. Thereafter he was screened for colon cancer stage 3 on 04/06/2011 and DM 2
diabetic chronic disease on 07/01/2012. Ronald was found to be having coronary artery disease
on 06/06/2015. On 05/18/2016, chronic respiratory failure was discovered and he needed home
oxygen supplement. An abdominal sonogram was done on 2/12/2016 and was diagnosed with
atherosclerosis of aorta on 10/05/16. Ronald was further diagnosed with malnutrition on
UNRS 367 / J. David
A. Identifying Data
B. Biological

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10/30/17, atrial fibrillation on 11/06/17, critical illness myopathy 11/14/17 and a week later
(11/21/14) diagnosed with emphysema. On 11/07/2018, he was found to be having a history of
squamous cell carcinoma in situ and skin cancer. He was further diagnosed with impingement
syndrome of bilat shoulders on 11/13/ 2018.
2. Recent Medical History/Reason for Admission/Course of Hospitalization:
The patient presented a recent medical history of shortness of breath, nausea, coughing, chest
congestion, rhinorrhea and fever (where he reports a temp 101.8 F at home). He was on
albuterol but when the symptoms progressively worsen he came to the emergency department
for further evaluation. The patient received azithromycin, solumedrol 125mg, magnesium sulfate
2mg and Atrovent, 2 rounds of albuterol which lead to improvement of SOB. His wheezing also
improved. Mild atelectatic were seen on both bases but lung fields were clear. Ekg done, normal
ECG.
3. Home Medications:
Generic/Trade Name Dose Frequency Purpose
triamcinolone 40mg 1
prednisolone 20 mg * 3 Tds
Fluticasone 50 mcg 1
Insulin NPH human 70 units 2 To control blood
sugar
Insulin regular
human
30 units 2 To control blood
sugar
Melatonin 5 mg 1
multivitamin 300mcg 1
Metformin 500 mg *2 2
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Metoprolol tartrate 25 mg 2
Tamsulosin 0.4 mg 1
Atorvastatin 80 mg 1 To lower cholesterol
and keep arteries
open
Lisinopril 10 mg 1
Tiotropium 2.5 mcg 2
Fenofibrate 160 mcg 1
Aspirin 81 mg 1
Albuterol 90 mcg *2 puffs 6 For SOB or
wheezing or cough
4. Definition of Medical Diagnosis with patient’s signs & symptoms at the time of admission:
Acute exacerbation of COPD is when the signs and symptoms of COPD suddenly worsens and
lasts for several days. These clinical manifestations include shortness of breath, fever, coughing.
5. Physical Assessment:
Ht 1.778 m Wt 94.6 kg BSA BMI 29.92 kg/m²
VITAL SIGNS/HEMODYNAMICS:
Time Temp F/C Pulse (apical/radial)
BPM
Resp/min BP in mmHg
R or L
Pulse Ox %
12.10 98⁰ F (36.7
⁰C)
101 21 105/64 96%
/
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PAIN ASSESSMENT:
Patient denies feeling pain
Time Pain Tool
Used
Pain
Rating
Pain Description
(OLDCART)
Functional
Pain Goal
pain medication
(or other care)
Response To
Intervention
LABORATORY DATA:
TEST NORMAL
VALUE
RESULTS RESULTS RATIONALE FOR ABNORMALS
CHEMISTRY Date / Time
2/25/2019
Date / Time State the reason why this pts. lab
values are abnormal
Na 135 – 145
mE/L
135 normal
K 3.5- 5.0
mE/L
4.6 normal
Cl 101-111
mE/L
98 normal
Mg
HCO3-
Glucose 70- 140
mg/dL
125 normal
BUN 16
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Creatinine 1.30 mg/dL 1.40 Diet changes
T. Protein
Albumin
Uric Acid
Calcium 8.8 11/282017
Phosphorus
Bilirubin 1.0 mg/dl 0.8 No much variation
Alk Phos 43 11/09/2017
ALT (SGPT) 63 U/L 66 Heart infections
AST (SGOT) 34 U/L 39 Heart infections
LDH
Cholesterol
LDL
HDL
Troponin 0.03 mg/mL 0.02
CPK isos
MM, MB, BB
CBC Normal Date/Time Date/Time Rational for Abnormals:
Hgb 14.0 – 18.0
g/dL
17 Normal
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Hct 42.0 – 52.0 53.1
WBC 4.0 – 11.0
*1000/mcl
7.1 Normal
RBC 4.70 – 6.10
Mill/mcL
5.61 Normal
Diff
Plates 130- 4000 *
1000/mcL
224 Normal
PT/INR 0.8-12 0
PTT
Other Normal Date/Time Date/Time Rationale for Abnormals:
C & S
Cultures
ARTERIAL BLOOD GASES:
ABGs RESULTS
Date / Time:
RESULTS
Date / Time:
pH 7.34 2/25/2019
pO2 68 2/25/2019
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O2 Saturation 96% 2/25/2019
pCO2 69 2/25/2019
HCO3 34 2/25/2019
Overall Interpretación: Respiratory acidosis
DIAGNOSTIC TEST & PROCEDURES:
(Include 12 Lead EKG, CXR, Cardiac Cath, CT, MRI, Ultrasound, Endoscopy, Echocardiogram, etc)
Test: Pt. Results:
(Date/Time)
Normals:
(referenced)
Rationale For Test Being
Performed On This
Patient:
Rationale for Abnormal
Test Results:
CXR Mild atelectatic
changes were
seen at both
bases of lungs
Clear lung
fields with no
atelectatic
bases
To check for
pneumonia
Partially collapsed
lungs
Influenza A
virus
Negative negative To confirm presence
of influenza virus
Normal
colonoscopy
Done on
4/6/2011
Stage 3 cancer
No cancer To diagnose cancer or
check the stages
Presence of stage 3
cancer
Ekg
2/25/19
Normal ECG
Normal ekg Done to detect heart
rhythm problems and
heart attack
Normal
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INTAKE AND OUTPUT Past 24º Balance ___+/-____________
Does the patient have a positive or negative fluid balance as of this date? How much?_250__ML
Intake 1º 12º Output 1º 12º
PO / Enteral 250 Source: 0 ml
IV 0 ml 0ml
Blood Products none none
Medications
IV Solutions/Parenteral Nutrition/Blood Products :
Name of Infusant: Rate: Site:
(describe the appearance)
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IV Solution: none
Not given none
Lipids/TPN: potassium
chloride
Oral liquid Clear
Blood Products: none
None None
Routine/PRN Medications
List all the patient’s medications ordered. Why would THIS patient have this medication
specifically? Consider diagnosis, medical history, lab values, procedures when discussing the
rationale for each medication.
Medication: prednisone Dose: 40 mg Route: po Frequency: daily
Classification: Corticosteroids
Action: Reduces the response of immune system to allergic conditions
Safe dose range for age/wt: 5mg-60mg/day
Rational for use in THIS
patient:
Reduced the inflammatory reactions
Desired Effect: Opening and expansion of the airways
Side Effects: Insomnia, diarrhea, vomiting, constipation, decreased appetite,
increased blood pressure, restlessness, and vertigo
Toxic Effects: Cataract, worsening diabetes, growth of facial hair, glaucoma,
worsening diabetes, moon face, obesity, convulsion, anaphylaxis,
anaemia, pancreatitis, hypothyroidism, allergic dermatitis
Nursing Implications: Monitor the side effects of the drugs
Pt/Fam teaching needs: Educate the patient on the side effects of the drugs
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Medication: azithromycin Dose: 500 mg Route: iv Frequency:
Classification: Aminoglycosides
Action: Inhibit bacterial protein synthesis, reduces the formation of the
biofilm,
Safe dose range for age/wt: 500 mg/day
Rational for use in THIS
patient:
Its ability to modulate host responses facilitates its long-term
therapeutic benefits in exacerbations of chronic obstructive
pulmonary disease (COPD)
Desired Effect: Prevent bacterial infections
Side Effects: Nausea, vomiting, stomach, cramping, and loss of appetite
Toxic Effects: Troubled breathing
Nursing Implications: To monitor for the side effects of this medication
Pt/Fam teaching needs: Teach the patient on the correct dosing of the drug to avoid toxic
effects
Medication: albuterol Dose: Route: nasal Frequency: 3
Classification: bronchodilators
Action: Relaxes bronchial muscles
Safe dose range for age/wt: 90mcg/ actuation. 2.5mg nebulized
Rational for use in THIS patient: To alleviate asthma symptoms
Desired Effect: To treat bronchospasm
Side Effects: Tremor, insomnia, nausea, fever, vomiting, headache, cough,
otitis media, urinary tract infection, dry mouth, chills,
difficulty in speaking
Toxic Effects: Fatal, serious adverse effects results
Nursing Implications: Advise the patient not to take more than the recommended
dose
Pt/Fam teaching needs: Educate the patient on how the right dosage of the drug and
also on the side effects
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Medication: aspirin Dose:81mg Route: po Frequency:1
Classification: Salicylate; NSAID
Action: Used to reduce fever and alleviate pain that is mild to moderate
Safe dose range for age/wt: 81mg
Rational for use in THIS patient: To reduce fever and also prevent blood clots
Desired Effect: To reduce fever
Side Effects: Heartburn, stomach upset
Toxic Effects: Confusion, burning pain in stomach, mood changes, rapid
breathing, fainting, seizures.
Nursing Implications: Make sure the patient takes the right dosage of the medication
Pt/Fam teaching needs: Teach the patient about the medication, why he is given and the
side effects that may occur
Medication: atorvastatin Dose: 80mg Route: oral Frequency: 1
Classification: statins
Action: Reduces the amount of cholesterol produced by the liver
The safe dose range for age/wt: 80mg/ day
Rational for use in THIS patient: Decrease the risk of heart disease
Desired Effect: Less cholesterol in the body
Side Effects: Confusion but rare
Toxic Effect: Peripheral neuropathy, myopathy, acute renal failure
Nursing Implications: Advise the client to avoid alcohol during this medication regime
Monitor for adverse drug reaction
Pt/Fam teaching needs: Teach the patient the correct prescription of the drug.
Educate him on the side effects of this medication and to report
in case of any problem arising.
Medication: fenofibrate Dose:160mg Route: oral Frequency: 1
Classification: fibrates
UNRS 367 / J. David