James Robyn is a 67-year-old male client who was brought to the emergency department,
or ED, with a 3-day history of exertional breathlessness,
wheezing, fatigue, and a worsening productive cough. He states he has been having increased
difficulty with normal day to day activities such as eating, talking and going up the stairs. He
has a history of cigarette smoking, two packs per day, since he was 25 years old. However, he quit
smoking a year ago after being diagnosed with chronic obstructive pulmonary disease, or COPD.
COPD, or chronic obstructive pulmonary disease, is a type of lung disease where chronic inflammation
causes damage to the lungs and obstructs airflow. It’s usually caused by inhalation of toxic
substances, like tobacco smoke, or occupational pollutants like dust and silica. In some people
an autosomal dominant disorder called alpha-1 antitrypsin deficiency results in breakdown of the
lung parenchyma by an enzyme called elastase. COPD is characterized by long-term inflammation
of the bronchial tubes, referred to as chronic bronchitis, and alveolar destruction, referred to
as emphysema. Most people diagnosed with COPD have elements of both chronic bronchitis and emphysema.
Chronic inflammation of the bronchial tubes in COPD causes a hypersecretion of mucus by the
respiratory goblet cells. The mucus then forms a plug that obstructs the airways causing air
trapping, and it also causes chronic productive cough. Obstruction of the bronchi can also cause
exertional dyspnea, which can progress to resting dyspnea, fatigue, wheezing and chest tightness.
Destruction of the alveolar sacs impairs gas exchange, resulting in hypoxemia and hypercapnia.
Loss of elastic recoil causes collapse of the airways during exhalation, trapping the air
and dilating the airspaces. To make breathing easier, they often use the tripod position, where
they sit up and lean forward with their hands on their knees. They may use pursed lip breathing
to prolong expiration and produce positive end-expiratory pressure, or PEEP, which allows
them to breathe out as much air as possible. Because this breathing technique requires use
of accessory breathing muscles, they will expend a lot of energy just to breathe. Air trapping also
leads to an increased anteroposterior diameter of the chest, sometimes called a barrel chest.
Chronic hypoxemia can result in cyanosis, a bluish discoloration of the lips or fingertips.
It causes constriction of the pulmonary vessels and pulmonary hypertension. This increases the
workload on the right side of the heart, leading to right sided heart failure, or cor pulmonale.
Diagnosis of COPD is based on the client history, physical examination, and pulmonary function
tests, or PFTs, to evaluate the degree of airway limitation. The forced expiratory volume in one
second, or FEV1, and the vital capacity, or FVC, are measured after the client is given
a bronchodilator such as albuterol. A FEV1/FVC ratio less than 70% indicates airway obstruction.
Since COPD is an irreversible disease, giving a bronchodilator does not change the person’s
PFTs too much. Finally, alpha-1 antitrypsin deficiency screening may also be done.
Long-term management for stable COPD includes smoking cessation and the avoidance of other
triggers such as pollution and allergens. Influenza and pneumococcal vaccines should be
administered to decrease the risk of respiratory infections. Although COPD is an irreversible
disease, bronchodilators can help ease symptoms, and corticosteroids can decrease inflammation in
the lungs. Supplemental oxygen may be needed to maintain an oxygen saturation between 88 to 92
percent. For these clients, the goal is not 100 percent saturation because hypoxemia is the main
stimulus for their respiratory drive. Finally, since these individuals expend much of their
energy on simply breathing, dietary adjustments may be needed to maintain weight and muscle mass.
An exacerbation, or a sustained deterioration of their respiratory symptoms beyond their
normal day to day variability, may manifest by increased dyspnea, cough, sputum production,
and fatigue. Increased wheezing may be noted and increased hypoxia may result in confusion or
decreased level of consciousness. Arterial blood gases, or ABGs, may show decreased PaO2, increased
PaCO2, increased HCO3-, and decreased pH. Okay, let’s get back to our client Mr. Robyn.
Since presenting to the ED, he has been admitted to the pulmonary ward
for treatment of an acute exacerbation of COPD. You have been assigned to his care.
After entering his room, you introduce yourself, wash your hands, and confirm his identity. Mr.
Robyn is sitting up on the side of his bed leaning over his bedside table in a tripod position. You
begin your assessment of Mr. Robyn by asking him how he is feeling today. He states he is feeling
short of breath and very tired. You notice that he struggles to complete full sentences because he
has to stop to breathe. You notice nasal flaring and he is pursing his lips during expiration.
He states that he has had worsening respiratory symptoms for about a week
including breathlessness when doing activities such as getting up to go to the bathroom,
talking, and eating. He states he has had a chronic productive cough for years. He says
he usually coughs up clear sputum, however in the last few mornings it has increased in volume and
is a thicker consistency. Upon visual inspection of Mr. Robyn, you note he has a barrel chest
and that he is using accessory muscles to aid with breathing demonstrated by his ribs pulling inwards
during inspiration. You auscultate his lungs which reveals expiratory wheezing
and coarse crackles to the lower lobes. Capillary refill is less than 3 seconds.
Throughout your assessment, Mr. Robyn appears alert and oriented but continues to be short
of breath. His vital signs are as follows: blood pressure 135/80, heart rate 80/min, temperature,
98.6 F or 37.0 C, oxygen saturation 87% on room air, respiratory rate 26/min, 0/10 pain. You
review his latest lab values which includes complete blood count, basic metabolic panel,
and arterial blood gases. You make note of his ABG values: pH = 7.34, PaO2 = 62 mmHg, PaCO2 = 65
mmHg, HCO3 = 32 mEq/L. You document your assessment findings before leaving the room.
Based on the assessment data you have collected, the nursing diagnoses include ineffective
breathing pattern related to increased work of breathing, ineffective airway clearance related
to increased production of secretions, impaired gas exchange related to airway destruction,
activity intolerance related to imbalance between oxygen supply and demand,
and deficient knowledge related to chronic disease management.
Now that you’ve gathered all the assessment data, relevant diagnostic information,
lab values, and created some nursing diagnoses, you outline several important goals to achieve.
By the end of your shift, Mr. Robyn will have an effective breathing pattern as evidenced by
breathing at a normal rate and depth, the absence of dyspnea, and no use of accessory muscles;
and he will maintain clear, open airways as evidenced by clear breath sounds and ability
to effectively cough up secretions. Optimal gas exchange will be demonstrated by unlabored
respirations at 12 to 20 per minute, pulse oximetry at therapeutic levels during rest and
exertion, and blood gases closer to normal range. Increased activity tolerance will be evidenced by
enhanced capacity and energy to ambulate 25 feet without feeling breathless. Finally,
prior to discharge Mr. Robyn will verbalize an understanding of COPD, demonstrate how to use his
inhaler, avoid triggers for exacerbations, and understand the long-term management of COPD.
After collaborating with Mr. Robyn’s healthcare team and receiving orders, you review the plan
of care. While completing Mr. Robyn's vital signs, ordered every two hours, you continue
to monitor his respiratory status by listening to his lungs and observing his breathing rate, depth,
and use of accessory muscles. Mr. Robyn’s other orders include supplemental oxygen therapy at 2L
via nasal cannula, with continuous monitoring of his saturations through pulse oximetry.
His target oxygen saturation is ordered to be between 88 and 92 percent.
Several medications have been ordered, including albuterol, a bronchodilator, administered via
inhaler with a spacer, and prednisone, an oral corticosteroid. While administering
these medications, you review with Mr. Robyn the proper technique for using the inhaler,
and remind him that he will need to adhere to his medication regimen after discharge.
You stress the importance of continued smoking cessation,
and measures to decrease the risk of infections, including hand washing and vaccinations.
You collaborate with the physical therapist, or PT, who is helping Mr. Robyn with techniques and
exercises to help ease his work of breathing and conserve energy while completing ADLs.
The respiratory therapist, or RT, helps him learn breathing and airway clearance techniques and
draws blood for blood gas analysis. Throughout your shift, you’ll monitor closely for signs of
deteriorating respiratory status. Any increased dyspnea, cyanosis,
and decreased level of consciousness will be reported to the ordering physician immediately.
It is near the end of your shift and it’s time to evaluate and see how Mr. Robyn is doing.
His breathing appears less labored, he is no longer using accessory muscles,
and he has been effectively coughing up his secretions. He has remained on 2L of oxygen
via nasal cannula throughout your shift. His oxygen saturation remains at 91% while resting
but decreases to 87% when standing up or ambulating a few steps. He remains alert and
oriented throughout the shift but he tires quite easily. His vital signs are blood pressure 125/79,
heart rate 90, temperature, 98.6 F or 37.0 C, respiratory rate 22/min, pain 0/10.
His ABGs are pH = 7.40, PaO2 = 72 mmHg, PaCO2 = 48 mmHg, HCO3 = 28 mEq/L. Mr. Robyn is improving!
You continue to re-assess, re-evaluate, and document Mr. Robyn’s response to interventions
to determine if his goals are being met and if his plan of care should be revised.
All right, as a quick recap…. Your assigned client, James Robyn, presented to the ED with
an exacerbation of COPD, which is characterized by inflammation, hypersecretion of mucus,
airway obstruction and alveolar destruction.
Inhalation of toxic substances like tobacco smoke or environmental pollutants are common causes.
An acute exacerbation of COPD is usually the result of an infection but can also be caused by
seasonal allergies or inhalation of irritants. Signs and symptoms of an acute exacerbation
include increased dyspnea, cough, and sputum production, along with wheezing, fatigue,
confusion and disorientation. Your assessment revealed that Mr. Robyn had dyspnea while
completing ADLs, he was using accessory muscles while breathing, he had an increase in amount and
consistency of secretions, he was tachypneic, and had wheezing and crackles in his lungs.
Your nursing diagnoses were ineffective breathing pattern, ineffective airway
clearance, impaired gas exchange, activity intolerance, and deficient knowledge.
The goals you identified when planning care for Mr. Robyn included establishing an effective
breathing pattern, maintaining clear airways, increased activity tolerance, and understanding
his medication regimen, effective breathing techniques, and risk factors for exacerbations.
Interventions will continue to be implemented and evaluated to determine if his goals are being met.