Running head: DELIVERY OF CLINICAL CARE (DOCC) PROJECT

Delivery of Clinical Care (DOCC) Project:

Typical Patient Description and Comprehensive Assessment Guide
Clinical Systems Leadership Immersion
Melissa Ritchey
The University of Arizona

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Case Study: Chronic Obstructive Pulmonary Disease (COPD)

Mrs. Smith a 59 year old female women presents to the Emergency Department (ED).
She has had a mild productive cough for the last 4-5 months. The cough is accompanied by
yellow mucus. She has had no fever or chills with the cough. The patient states she has noticed
she is short of breath when she takes her daily evening walk. Today during her walk she could
not stop coughing and felt extremely short of breath. Her husband drove her to the ED. Mrs.
Smith appears to be short of breath and anxious. Mrs. Smith denies chest pain, back pain and
arm pain. Per hospital guidelines an electrocardiogram is obtained which shows a normal sinus
rhythm. Her blood pressure is 145/92, Heart rate is 72, Respiration Rate is 26, Oxygen level is
94% on Room air and she is afebrile. A chest x-ray was obtained and was negative for infiltrates,
masses, or edema. Dr. Rosenthal, the medical director for the ED states that spirometry should be
assessed for any patient suspected of having COPD (personal communication, February 6, 2015).
Spirometry is a pulmonary function test in which the patient blows forcefully, a patient with
healthy lungs can exhale most of the air in their lungs in one second, this is called the forced
expiratory volume in one second (FEV1) (Krieger, 2012). People with COPD take longer to
blow the air out, the FEV1 is at least 70% in these patients (Krieger, 2012). Mrs. Smith has a
FEV1 of 85% indicating mild COPD.
Pathophysiology of COPD and symptoms
In consultation with Karen Popp, the Director of Care Coordination for Arizona
Connected Care and Dr. Rosenthal, Mrs. Smith presents with symptoms of mild COPD (personal
communication, February 6, 2015). COPD is the fourth leading cause of death (Campbell,
Gilbert & Laustsen, 2014). Patients with COPD have an increased amount of carbon dioxide in
their blood (Campbell, Gilbert & Laustsen, 2014). The most common cause of COPD is tobacco
smoke. The nicotine paralyzes the protective cilia, therefore; mucus and bacteria remain in the

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lungs (Campbell, Gilbert & Laustsen, 2014). The trapped mucus and bacteria increase the risk
for infection and affects the ability to clear the airway appropriately (Campbell, Gilbert &
Laustsen, 2014). Over time the bronchial walls become inflamed and thicken (Campbell, Gilbert
& Laustsen, 2014). The persistent inflammation leads to bronchospasm causing a permanent
narrowing of the large bronchi and ultimately of the smaller airways too (Campbell, Gilbert &
Laustsen, 2014). The toxins from the smoke release cytokines which increases the action of
protease (Campbell, Gilbert & Laustsen, 2014). The increase of protease on the elastin of the
alveoli reduces the elastic recoil and traps air in the alveoli (Campbell, Gilbert & Laustsen,
2014). It then causes hyperinflation which leads to difficulty exhaling air (Campbell, Gilbert &
Laustsen, 2014). The air trapping occurs because of the mucus plugs in the alveolar tissue
resulting in narrowing of the airways (Campbell, Gilbert & Laustsen, 2014). With emphysema,
the lungs compensate during inhalation, during exhalation the decreased recoil of the small
airways causes the walls of the airways to collapse trapping the air inside the alveoli (Campbell,
Gilbert & Laustsen, 2014). Common symptoms of COPD include a cough lasting over 3 months
of the year, a barrel chest, prolonged expiration, green or yellow sputum, and dyspnea
(Campbell, Gilbert & Laustsen, 2014).
A cough is a protective reflex that increases the mucociliary clearance of airway
secretions (Ritchey, 2015). It is a symptom that involves the reflex arc that originates in
peripheral cough receptors (Ritchey, 2015). A disease process can cause irritation along the
reflex arc and cause a cough (Ritchey, 2015). The cough is caused by the intra thoracic pressures
against a closed glotitis, it is then followed by forceful expulsion of air and secretion when the
glottis opens (Ritchey, 2015).
Sputum production is common in smokers because they have an increased number of
goblet cells which relate to the epithelial mucin stores (Ritchey, 2015). The mucus

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hypersecretion can be caused by neutrophil activation (Ritchey, 2015). In the case of Mrs.
Smith, smoking cigarettes for forty years would cause a constant neutrophil activation and it
permanently releases inflammatory cytokines and proteases which results in permanent
hypersecretion (Ritchey, 2015).
Shortness of breath or dyspnea results when the brain processes afferent signals (the need
for ventilation) and efferent signaling (the need is not being met by physical breathing) (Ritchey,
2015). There are chemoreceptors in the carotid bodies and the medulla that supply information
regarding the blood gas levels of oxygen, carbon dioxide and hydrogen (Ritchey, 2015). The
muscle spindles in the chest wall signal the stretch and tension of the respiratory muscles which
causes poor ventilation and leads to the feeling of shortness of breath (Parshall et al., 2012).
Assessment
Comprehensive clinical history At the time of triage, Mrs. Smith reports that she has
been smoking since she was 19 years of age and has smoked approximately pack of cigarettes
per day for the last 40 years. She reports a past medical history of hypertension and takes
atenolol once a day. She does not have any other medical problems and does not take any
additional medications. She had her appendix removed when she was fourteen years of age, no
other surgical history. She denies a psychiatric history. Mrs. Smith has had two children, both
vaginal deliveries with no complications. Mrs. Smith has very light periods and is beginning to
exhibit symptoms of menopause. She denies any other medical conditions.

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Physical assessment guide and rationale

Physical Assessment Exam

Elements

Rationale

Physical Assessment
Findings of COPD
Patient
Assess level of
Patient appears to
consciousness.
be reported age
Evaluate level of
All body parts are
orientation and
equal bilateral
level of
Maintains eye
responsiveness.
contact with
An overall view or
appropriate
first impression a
expressions
nurse has of a
Appears well
persons well-being.
groomed
No signs of acute
(Assessment
distress.
Technologies Institute:
Nursing Education,
2010).
Critical to assess
Alert and oriented
mental status.
to time, place and
time
Level of
Pupils equal,
consciousness.
round, reactive to
Testing for motor
light &
function and
accommodation
balance.
Facial features
(Assessment
symmetric
Technologies Institute: Gait is steady
Nursing Education,
Speech is clear
2010).

General Survey

Appearance
Behavior
Apparent Distress

Neurological

Mental Status
Pupils
Motor
Coordination/Gait
Reflexes
Sensory

Cardiac

Radial pulses

Dorsalis pedis pulses

Capillary refill
Heart sounds
Murmurs
Edema
Cyanosis

Patients with
cardiac disease can
present with
shortness of breath,
this assessment is
key to identifying
whether it is cardiac
or pulmonary.

(Assessment
Technologies Institute:
Nursing Education,
2010).

Pulses strong, 2+
Capillary refill
brisk, 2 sec
Heart sounds: S1,
S2 normal
No murmurs
No pitting edema
No cyanosis

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Respiratory

Rate
Effort
Listen for abnormal
sounds
Observe for
retractions/use of
accessory muscles
Chest asymmetry
Trachea midline
Percussion-normal,
dull, hyperresonant

Assess for
circulation.

(Campbell, Gilbert &

Laustsen, 2014).
This assessment can
tell us whether the
patient has lung
disease or not,
identifying the
meaning of the
abnormal results
can help us hone in
on the disease
process: asthma,
bronchitis,
emphysema, etc.
(Assessment
Technologies Institute:
Nursing Education,
2010).

Gastrointestinal

Inspect

Auscultate:
o RUQ
o RLQ
o LUQ
o LLQ
o Epigastric
o Suprapubic
Percuss/Palpate:
o RUQ
o RLQ
o LUQ
o LLQ
o Epigastric

o Suprapubic
Palpation of the liver
Palpation of the
spleen
Rebound tenderness

In this assessment it
is important to do
palpation and
percussion last. In
my assessment I did
palpation first, this
is not correct
because
manipulation of the
abdomen may
stimulate peristalsis
and alter the exam
findings.
You can detect
peristalsis,
abdominal aortic
aneurysm, masses,
enlarged liver,
appendicitis, a
spleen injury, and
constipation
especially if the

Rate is 24
Shortness of breath
with exertion,
expiratory rate is
prolonged
Decreased breath
sounds
No wheezing, no
crackles, no
rhonchi
No use of
accessory muscles
Chest symmetrical
No deviation of
trachea
Percussion sound
was hyperresonant
Abdomen appears
symmetrical, round
and non-distended
Auscultation:
Normal bowel
sounds in all
quadrants

Percussion: Sounds
are tympanic in all
quadrants

Liver: Liver about

2 cm below right
costal margin

Spleen: Not
palpable

No rebound
tenderness

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Musculoskeletal

Genitourinary

Assess for signs of

musculoskeletal
disease:
o Pain
o Redness
o Swelling
o Increased
warmth
o Deformity
o Loss of function
Active ROM: move
each joint through
full ROM
Passive ROM: in a
relaxed state,
examiner supports
the extremity and
moves through
ROM
Urinary: frequency,
urgency, dysuria,
pyuria, polyuria,
nocturia, renal
calculi, hematuria,
incontinence,
retention, testicular
pain.
Female:
Mammogram and
Pap Smear

abdomen is
distended.
(Assessment
Technologies Institute:
Nursing Education,
2010).
Functional
assessment for
safety. You can tell
if the patient has
strength, balance
and joint range of
motion to carry out
the activities of
daily living.

This is critical to
help assess the risk
for fall.

(Assessment
Technologies Institute:
Nursing Education,
2010).

To diagnose

disorders or
diseases of the
genitourinary tract.
Production of urine.
Elimination of urine
Kidney, ureter,
bladder and urethra

function.
The bladder is a
storage reservoir, if
it does not empty
efficiently, it can be
caused by
obstruction, bladder
irritation, or
neuromuscular
disease.

No pain
No redness
No swelling
No increased
warmth
No deformity
Full ROM in all
extremities
Normal strength
Appropriate
flexion/extension,
pronation/
supination, plantar
flexion and
dorsiflexion.

No retention, pain,
burning or
increased
frequency with
urination
Sexual
development is
appropriate
Defer mammogram
and pap smear-to
be completed by
GYN

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Skin

Skin color
Temperature
Moisture
Hair Pattern
Rashes/lesions
Edema

(White, 1990)
Skin color can tell you
about the patients
circulation.
Its important to
inspect hair for
quantity,
distribution,
texture, color and
parasites.
Wounds/lesions
should be assessed
for infection.
Rash should be
assessed for
communicable
diseases.
Assess for pressure
ulcers-Nonblanchable
erythema indicates
skin has been
damaged by
pressure.

Skin is pink
Warm
Dry
Full head of hair
No rashes/lesions
noted on skin
No edema

(Assessment
Technologies Institute:
Nursing Education,
2010).
Symptom Assessment

Cough
Sputum
Dyspnea

Symptoms of
COPD dont appear
until there is
significant lung
damage.
If a cough persists
at least 3-4 months
out of the year, it
strongly indicates
bronchitis or
emphysema
(COPD).
An increase in
sputum production
is also an indicator

Cough is course and

dry, patient reports
sputum is yellow and
has not changed color.
Patient becomes short
of breath when she
coughs.

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of COPD because
toxins like smoke
cause an increase in
sputum production.

Psychosocial

Establish rapport
Obtain and
understanding of the
current illness and
its impact
Identify recent life
changes/stressors
Identify their coping
strategy
Any previous
psychiatric history
SI/HI
Diet
Exercise
Drugs/Alcohol
Violence/Abuse

(Mayo Clinic, 2015)

Living with a

disease can be a
challenge especially
as a person has to
start giving up
things they enjoyed
to do.

A person may feel

depressed or
overwhelmed by

the changes in their

life and the burden
of the disease.
(Mayo Clinic, 2015)

Social

Housing
Family
Finances
Support System

Sharing feelings
and fears with
family, friends and
doctors can help a
person adjust.
If the person does
not have a support
group or perhaps
one that is having a
hard time adjusting
to the changes,
there are support
groups available
with people with

Current illness has

affected the ability
to play with her
grandchildren as
much as she used
to
This has affected
her sleeping
patterns
Worried if she will
need to stop
working-she is an
accountant for a
small auditing
company
No previous
psychiatric history
Denies SI/HI
Is still trying to
take her daily
walks
Denies use of
alcohol/drugs
States she feels
safe in her home
Lives at home with
her husband
Has 2 adult
children who are
married and live in
town
3 Grand children
Financially stable
and has insurance
through work
Has a great support
system at work
Her husband also

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COPD.

Spiritual

Key risk factors

Key Health & Wellness

Faiths/Beliefs-what
is your faith belief?
Do you consider
yourself
spiritual/religious?
Is it important in
your life?
Are you part of a
spiritual or religious
community
How would you like
me, your healthcare
provider to address
these issues in your
healthcare?

Smoking Cigarettes,
present/past
Packs per day
Exposure to smoke

(Mayo Clinic, 2015)

Spirituality
provides a
foundation of inner
strength that can
help people find
hope and keep a
positive outlook.
Spirituality can be a
set of values and
beliefs that bring
meaning to ones
life.
(Mayo Clinic, 2015).

The most
significant risk
factor for COPD is
cigarette smoking.
The more years one
smokes and the
more packs a day a
person smokes, the
greater the risk is.

smokes so she is
also exposed to
second hand smoke
Patient states she is
catholic
Her faith is
important to her,
she attends mass
weekly to ask for
health and
happiness
She belongs to a
church in her
neighborhood-has
been attending the
same church for 3
years
If she is
hospitalized she
wants to receive
the holy Eucharist
on a weekly basis
Pt has smoked for 40
years
pack/day
Husband also smokes,
he smokes pack/day
also

(Mayo Clinic, 2015).

Have you stopped
A person can take

smoking?
steps to feel better
and slow down the
Do you have a desire
damage to their
to stop smoking?
lungs.
Exercise

Avoid smoking and

Diet

avoid second hand

Alternative
smoke, the toxins
medicine:
contribute to further
o Magnesium
lung damage.

relaxes and

Exercising
can
opens the
improve overall
airways

Pt agrees that she

needs to stop
smoking to slow
down the
progression of the
disease.
Needs help for
herself and her
husband
Takes a 3 mile
walk every night,
but it has been

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o Fish oil reduces
inflammation

strength and
endurance and
strengthen
respiratory muscles.
Eating health helps
a person who is

overweight lose
weight to help with
their breathing

especially during
exertion.

(Mayo Clinic, 2015)

difficult to do
without stopping
for breaks
Pt does not eat
breakfast regularly
Eats lunch on the
go since she is out
performing audits
They eat a salad or
bowl of cereal for
dinner
Takes a womens
multivitamin on a
daily basis

Physical Assessment A physical assessment of the patient should be relevant to the chief
complaint and symptoms. A thorough and efficient assessment is fundamental in todays fast
paced health care delivery system (Campbell, Gilbert & Laustsen, 2014). Please copy and paste
the following link to the internet to access the video presentation of the physical assessment:
http://youtu.be/wBsGQVYM76Y
Summary of assessment and key findings
The physical assessment produced five key findings expected for a COPD patient. The
patient was short of breath because the increased mucus production and the decrease in lung
function make it harder for the alveoli to exchange carbon dioxide for oxygen (Vermillion,
2015). Upon auscultation of the patients lung sounds, the expiratory phase was prolonged. The
airflow limitation with the forced expiration suggests the presence of airway obstruction and
lung parenchymal destruction with a loss of elastic recoil (Yamauchi, Kohyama, Jo & Nagase,
2012). I also heard a decrease in breath sounds in all lobes, this can be caused by over-inflation
of a part of the lung (Yamauchi, Kohyama, Jo & Nagase, 2012). During percussion of the lungs,
the sound was identified as hyperresonant. According to the Stanford School of Medicine, the

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hyper resonance becomes dull over the diaphragm due to hyperinflation from a contracted
diaphragm (2015). Lastly while the patient coughed during the exam, sputum production was
noted. Although it is normal for the airways to produce sputum, a patient with COPD produces
an increased amount of sputum because toxins like smoke cause enlarged glands that produce
two to three times the normal amount of mucus (American Thoracic Society, 2014).

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References
American Thoracic Society. (2014). What are the signs and symptoms of COPD? Retrieved
from

http://www.thoracic.org/clinical/copd-guidelines/for-patients/what-are-the-signs-

and-

symptoms-of-copd.php

Assessment and Technologies Institute: Nursing Education. (2010). Physical Assessment: Adult.
Retrieved from http://www.atitesting.com/ati_next_gen/skillsmodules/content/physicalassessment-adult/equipment-noplay.html
Krieger, A. (2012). Spirometry is an all-important test for those with COPD, but do you know
why? Retrieved from http://www.everydayhealth.com/copd/managing-copd-whats-yourfev1.aspx
Mayo Clinic. (2015). Disease and Conditions: COPD. Retrieved from
http://www.mayoclinic.org/diseases-conditions/copd/basics/definition/con-20032017
Parshall M.B., Schwartzstein, R.M., Adams, L., Banzett, R.B., Manning, H.L., Bourbeau, J.,
ODonnell, D.E. (2012). An unofficial American Thoracic Society statement:
Update on

the mechanisms, assessment, and management of dyspnea. American Journal of

Respiratory Critical Care, 185(4), 435-452.

Ritchey, M. (2015). Delivery of clinical care project: Population specific overview of
pathophysiology paper. Unpublished manuscript. University of Arizona.
Stanford School of Medicine. (2015). Pulmonary exam: Percussion and inspection. Retrieved
from http://stanfordmedicine25.stanford.edu/the25/pulmonary.html
Taliercio, R.M., Hatipoglu, U. (2014). Pulmonary Disease: Cough. In Carey, W.M., (Eds), The
Cleveland Clinic Disease Management Project. Retrieved from

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http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/pulmonary/coug
h/
Vermillion, F. (2010). Lung symptoms of COPD. Retrieved from
http://www.livestrong.com/article/112499-lung-symptoms-copd/
White, M.J. (1990). An overview of the genitourinary system. In Clinical Methods: The History,
Physical, and Laboratory Examinations (3rd Ed). Boston: Butterworths. Retrieved from
http://www.ncbi.nlm.nih.gov/books/NBK290/
Yamauchi, Y., Kohyama, T., Jo, T., Nagase, T. (2012). Dynamic change in respiratory
resistance during Inspiratory and expiratory phases of tidal breathing in patients with
chronic obstructive pulmonary disease. International Journal of Chronic Obstructive
Pulmonary Disease, 7, 259-269. Doi; 10.2147/COPD.S30399

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