Running header: CLINICAL PAPER

Clinical Paper David Granados University of Texas at El Paso

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Abstract Emphysema is a type of COPD that inhibits the body to exchange gases at a cellular level (Huether, S. E., & McCance, K. L. 2004). This is a progressive disease that is related to smoking cigarettes and inhalation of pollutants. There is no cure for the disease the goal for the patient to improve the quality of life. Intervention for this type of person is focused on prevention of exasperations and the promotion of interventions for effective CO2 expulsion. The pathophysiology of emphysema is explained in detail and related to a patient that was admitted to Provenance Memorial Hospital. The psychosocial consideration of the patient is discussed as well as interventions and rationales for care of a patient with COPD. Nursing care plans for the patient include: Impaired gas exchange related to increase in dead space caused by increased residual volume as evident by PaCo2 77mmHg, increased residual volume and hypoxemia, decreased cardiac output related to increased preload and dysthymias as evident by decreased urine output, decreased peripheral pulses, crackles and excess fluid volume related to chronic renal failure as evident by edema and the need for dialysis every other day. Guidelines for the care of a COPD patient from The National Guideline Clearinghouse are compared with observed practices of the hospital staff.

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The need for ventilatory therapy is very common among critically ill patients (Zeitoun 2001). Many of the patients that are admitted to the intensive care unit require this type of therapy to sustain life. Patients that are unable to breathe and aspirate adequately and maintain lung appropriate expansion and contraction are considered to have ineffective breathing patterns (Chen, Hui-Wen ; Lee, Ya-Hsin ; Wang, Kwua-Yun 2011). There are several reasons why patients require mechanical assistance for breathing. The patient that is being focused on in this paper is diagnosed with chronic pulmonary disease (COPD) and other co-morbidities. This patient does not have the ability to breathe on her own and is being assisted by a c-pap respiration which is a noninvasive positive-pressure ventilation is the delivery of mechanical ventilation to patients with respiratory failure without the requirement of an artificial airway (Oscar Peuelas, MD, Fernando Frutos-Vivar, MD, and Andrs Esteban, MD PhD 2007). Patient M.R. came to the ICU because of respiratory failure due to an allergic reaction to a contrast that was used to locate the possibility of thrombi in her lower extremities. M.R. is a 75 year old woman that has a medical history that includes renal failure, diabetes type two, hypertension, chronic heart failure and hypothyroidism. M.R. was a heavy smoker, two packs daily, for 30 years and has since quit smoking in 2003. She is not an independent person she relies on caretakers during the day and help from her older daughter during the evening hours. She had limited mobility and is bedfast most of the time. Her family noticed that her lower extremities were warm and she complained of pain her old daughter. The daughter took M.R. to the emergency department. There they did a work up and suspected a blood clot. To confirm the findings an intravenous graph with contrast was ordered. The family failed to notify the nursing

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staff about her allergy. The patients family decided on an advanced directive of DNR; however the family changed their minds and removed that order. Discussion of Concepts This patient was diagnosed with chronic pulmonary disease (COPD) in 2003. The nursing diagnosis is impaired gas exchange. The progression of chronic obstructive pulmonary disease (COPD) is associated with increasing frequency and severity of exacerbations. COPD exacerbations are clearly linked to impoverished health status and can be life threatening, particularly in patients with advanced disease (D E ODonnell, C M Parker 2006).The cause of exacerbation is related to several factors that can be environmental or caused educed by the patient. Environmental factor that can cause an inflammation of the airways can be related to pollution or pollen that naturally found in oxygen (Huether, S. E., & McCance, K. L. 2004). In the case with this patient the inhalation of cigarette smoke over several has led to the development of COPD more specifically emphysema. Emphysema is a chronic obstructive pulmonary disease that is characterized by the loss of elasticity and abnormal and irreversible enlargement of acinus and destruction of the alveolar wall (Huether, S. E., & McCance, K. L. 2004). The body detects the presence of a foreign substance in the lungs. The natural reaction of the body is to remove the foreign substance that has entered the body. The smoke causes the white blood cell, alveolar microphages, to activate causing an inflammatory response. The alveolar microphages cells produce an enzyme known as elastase which allows the body to rid the lung of the smoke. This mechanism allows the body to eliminate the foreign substance (cigarette smoke) that is causing the inflammation. However, if the elastase if not properly regulated by the body, the enzyme will causes damage to the lungs by removing the elastic properties of the avoli. Elastase is regulated by antitrypsin, a protein that is produced in the liver.

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The action of antitrypsin is to deactivate elastase preventing lung tissue damage (Huether, S. E., & McCance, K. L. 2004). In this case years of smoking has led to the chronic inflammation and caused the overproduction of elastase. The production of antitrypsin was not able to meet the demand that was required to deactivate elastase to prevent damage to the lungs. This caused the lung to lose elasticity. Elasticity is needed for the lung to recoil and expel C02 from the lung. Due to the loss of elasticity the proper expulsion of C02 is not possible, causing air trapping and increasing the lung volume which causes a prolonged exhalation. Prolonged exhalation is caused because of the loss of elasticity and the ability to recoil to help push out all the CO2. The result of not having a proper gas exchange causes V/Q levels to be off due to the lower paO2 (75) levels this will result in a hypoxic drive (Huether, S. E., & McCance, K. L. 2004). The major mechanism of airflow obstruction is the loss of elasticity. This leads to the nursing diagnosis of impaired gas exchange related to COPE evident by decreased blood oxygenation as seen in ABG of CO2 of 65 mmHg and lower O2 levels below 75mmHg. Cor pulmonale is another danger that arises due to air trapping (Huether, S. E., & McCance, K. L. 2004). This happens because of the constriction that is placed on the capillary beds that run parallel to the alveolar walls. The pressure is so great that the blood exchange encounters resistance and therefore increasing pressure need to exchange blood. This adds stress to the right ventricle and over time causing heart failure which the patient has already presented with. Due to this possibility the patient is also on hemodynamic monitoring. Nursing Process Assessment

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Assessment for the patient that suffers from COPD is essential. The ongoing assessments that would be require to give competent patient care are assessments for altered breathing pattern, focusing on increased work of breathing, abnormal rate, rhythm, depth of respiration and any abnormal chest excursion (Gulanick, M. 2003). Monitoring of ABGs and oxygen saturation. Increasing PaCo2 and decreasing Pao2 indicate that the patient is in respiratory distress. We are already are aware of this patients respiratory distress; however this allows the healthcare professionals to assess the degree of intervention that is needed. This patient is on assisted ventilation therapy and these assessments are essential for proper ventilation settings. The current settings on the vent 14/6, breaths per minute were 12 @ 50% O2 the oxygenation saturation is at 95% and is be monitored with a continuous pulse oximetry. The patients ABGs PH7.2mmHg, PCo2 71mmHg and HCo3 22.6 this indicated that the patient is acute respiratory failure. These lab values also reflect the patient have uncompensated respiratory acidosis with normal oxygenation. The oxygenation is normal only because of the ventilation therapy. An acidosis state among patient with COPD is an expected finding as they have a hypoxsive drive due to the patient not being able to expel all the C02 in the lungs. This increased the residual volume of the Co2 in the lungs. The patient also has a history of congestive heart failure (CHF). CHF assessment will include the rate and quality of the apical pulses, peripheral pulses and ECG continuous monitoring. Assessment of LOC and lung sound would be critical as these are early signs that the patient might be going into fluid overload (Gulanick, M. 2003). This is caused because of right heart failure. The patient has a history of atrial fibrillation which is being controlled through amiodarone at a maintenance dose of 200mg/daily. During my observation I did not see any abnormal rhythm strips, the patient had a normal sinus bradycardic rhythm. Patient is have a

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rating of +1 pedal pulses bilaterally and a+1 pulse of the radial pulses bilaterally. GCS of 10. The patient has also has a diagnosed of chronic renal failure. This type of assessment need for this patient is assessment for vital signs that may indicate fluid volume excess. The type of vital that the nurse would need to be vigilant for are elevated blood pressure, tachycardia, tachypnea, edema and crackles throughout the lungs. These assessments are essential as the elevated blood pressure is caused by sodium retention and increased fluid in the intracellular tissue. Kussmauls respirations, dyspnea and crackles indicated that there is a presence of fluid in the small airways that require immediate intervention. The patient was in the early stages of fluid overload and this was due to all the factors that were in the above mention. COPD,CRF and CHF were all contributing factors that lead to the patient having early signs of fluid overload. The clinical presentations that were manifested for the patient were crackles and edema. CRF in this patient was caused because of ischemia that was secondary to COPD. This patient undergoes regular dialysis. Nursing Diagnosis Impaired gas exchange related to increase in dead space caused by increased residual volume as evident by PaCo2 77mmHg, increased residual volume and hypoxemia (Gulanick, M. 2003). Decreased cardiac output related to increased preload and dysthymias as evident by decreased urine output, decreased peripheral pulses and crackles (Gulanick, M. 2003). Excess fluid volume related to chronic renal failure as evident by edema and the need for dialysis every other day (Gulanick, M. 2003).

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Outcome Identification and Planning The expected outcome is that the patient will maintain optimal gas exchange as evident by arterial blood gases within base line for the patient (PH: 7.35, Co2: 71mmHg, O2: 79mmHg, HCo3: 49.3). This patient will have no decline in mental status through 02/29/2012. M.R. will never have normal ABGs because of the COPD that does not allow the proper gas exchange and promotes Co2 trapping and causes the patient to run acidotic. Assessment of the patients respiratory rate for rhythm and character will allow the nurse to determine if the patient is in further respiratory distress. Another aspect of the patient care is vigilant monitoring of the patient vital signs and paying special attention to the assessment of central venous pressure, pulmonary capillary wedge pressure and blood pressure. As well as monitoring oxygen saturation through pulse oximetry and ABGs lab work daily. Implementing Helping the patient reach the outcome is accomplished through nursing interventions. The outcome goal of the patient will have optimal gas exchange, remain oriented and have no mental decline while that patient is in the hospital. Some of the nursing interventions that will help the patient are the administration of medications on time. Rocephin levofloxacin are medications that are being used as precautionary measures. Other interventions include the proper and timely respiratory treatments. This will allow the patient to maintain a therapeutic level of medication. The nurse will be prepared in case there is a malfunction of the machinery by having an Ambu bag at the bedside. Having this precautionary will allow the nurse to manually ventilate the patient if the need arises. The position of the patient is also important.

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The nurse will position the patient at a semi-Fowlers to full-Fowlers position at all time to facilitate the gas exchange process and allows the lung to expand better. Evaluation Goal was met on 02/29/2012 patient was able to maintain optimal gas exchange as evident by arterial blood gases within base line for the patient (PH: 7.35, Co2: 71mmHg, O2: 79mmHg, HCo3: 49.3). This patient had no decline in mental status. Discussion of Psychosocial M.R. is a 75 year old widowed Hispanic female. She lives with her oldest daughter. The family has a nurse come and take care of M.R. during the day while the oldest daughter works. The mothers has never had a job outside the home, this was a traditional Mexican family were the mother would stay home and raise the children while the father earned the income. Elementary school was the highest level of education that was achieved my M.R. The information from the family states that she is able to read and write in Spanish. The growth and developmental stage that the patient is at wisdom: ego integrity vs. despair (Taylor, C. 2008). The main question that is being asked of this patient is: has she lived a full life. A person that is in the stage of life has the ability to reflect on past accomplishments. The patient is able to reflect on life experiences, as successful or stress on the path that was not taken. Family involvement of care for the patient is circuital part of the recover for the patient. M.R.s family was eager to learn how to provide oral care for their mother. The family demonstrated a readiness to lean by asking several question about procedures. They also wanted to play an active part in the care of their mother. The approach of teaching that my nurse used for the oral care of the patient was the she explained the procedure and the equipment needed.

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After doing so she asked the oldest daughter for returned demonstration and explanation of the procedure. The nurse then allowed the daughter to provide the next oral care. National Practice Guidelines The National Guideline Clearinghouse NGC-7907 clinical policy includes: 1. Assessment of need for hospital treatment. 2. Investigations of exacerbation (e.g., chest radiograph, arterial blood gas, electrocardiogram, full blood count, theophylline level, sputum sample for microscopy and culture, blood cultures, pulse oximetry). Providence the patient was receiving daily blood draws for the monitoring of ABGs. The patient was also getting chest radiograph and blood cultures. Constant monitoring of the pulse ox along with heart monitoring. The hospital was compliant with this guideline. 3. Consideration of hospital-at-home and assisted discharge schemes. 4. Pharmacological management, including inhaled bronchodilators, delivery systems for inhaled therapy, systemic corticosteroids, antibiotics, theophylline and respiratory stimulants. Providence: rocephin 1g=50mL. Antibiotic is also a recommendation of the guidelines that was followed by the hospital. 5. Oxygen therapy. Oxygen therapy is used with the patient. The oxygen however is kept at a lower concentration as this patient does have a hypoxic drive. The improper amount of O2 and the patient respiratory rate would be suppressed. 6. Noninvasive ventilation.

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Recommendations for patients with COPD is that Noninvasive mechanical ventilation in exacerbations improves respiratory acidosis, increases pH, decreases the need for endotracheal intubation, and reduces PaCO2, respiratory rate, severity of breathlessness, the length of hospital stay, and mortality The patient is on c-pap 14/6, Br12, @ 50% O2. The compliance for this guideline was also met. 7. Invasive ventilation and intensive care. M.R. is currently being housed in the ICU unit. This lower the nurse to patient ratio as this person will require more supervision. This is also in accordance with the guidelines 8. Respiratory physiotherapy. 9. Monitoring recovery and discharge planning. The guidelines for Providence Memorial Hospital were not available for viewing. The national guidelines were followed by the hospital and staff in the care of this patient. This proves that the hospital staff is able to provide competent care for patients that having an acute exacerbation of COPD. The nursing staff at the hospital was very knowledgeable about information related to treating patients with respiratory depressions. The team consists of registered nurses and respiratory nurses. Conclusion COPD is a progressive disease that cannot be cured. Early diagnosis is key with this disease to prevent further damage to the lung and improve the quality of life of the patient. This disease has no cure so the major focus that the medical professions have is helping the patient cope with COPD and improving the quality of life of the patient. M.R. COPD was under control

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for the most part; however the acute exasperation happened because of an allergic reaction to contrast. The main concern now is to make sure that all her organs get the adequate amount of oxygen need to maintain life. The psychosocial consideration of the patient was discussed as well as interventions and rationale for care of a patient with COPD. Nursing care plans for the patient included: Impaired gas exchange related to increase in dead space caused by increased residual volume as evident by PaCo2 77mmHg, increased residual volume and hypoxemia, Decreased cardiac output related to increased preload and dysthymias as evident by decreased urine output, decreased peripheral pulses and crackles and excess fluid volume related to chronic renal failure as evident by edema and the need for dialysis every other day. Guidelines for the care of a COPD patient from The National Guideline Clearinghouse were compared with observed practices of the hospital and staff.

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References

National Guideline Clearinghouse | Home. (n.d.).

National Guideline Clearinghouse | Home.

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Zeitoun, S. S., Battura Leite de Barros, A. L., Marlene Michel, J. L., & Cassia de Bettencourt, A. R. (2007). Clinical validation of the signs and symptoms and the nature of the respiratory nursing diagnoses in patients under invasive mechanical ventilation. Journal of Clinical Nursing, 16(8), 1417-1426. Sole, M. L., Klein, D. G., & Moseley, M. J. (2009). Introduction to critical care nursing (5th ed.). St. Louis, Mo.: Saunders. Taylor, C. (2008). Fundamentals of nursing: the art and science of nursing care (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Vorrink, S., Kort, H., Troosters, T., & Lammers, J. (2011). Level of daily physical activity in individuals with COPD compared with healthy controls.. Respiratory Research, 12, 33. Wissman, J. (2007). Registered nurse adult medical-surgical review module (7.1 ed.). Sitwell, KS: Assessment Technologies Institute.