The case study analysis is based on the details of a 65-year-old female patient named Martha Lee. The patient has been admitted to the emergency setting following an episodic event of acute onset of shortness of breath. The patient started experiencing shortness of breath two days ago along with a worsening cough and increased sputum production. Apart from these primary symptoms, the patient is denying having secondary symptoms of wheezing, chest pain and chest palpitations. The patient has a past significant medical history of Coronary artery disease, COPD, myocardial infarction, hypertension and hyperlipidaemia and type 2 diabetes. Most of these clinical comorbidities add to the overall risk of health for the patient. The patient is having evidently worsening vitals with an acute need for effective and appropriate clinical intervention management. The following case analysis will focus on the pathological and clinical findings of the underlying pathological condition the patient is currently suffering from. These findings will help in outlining three SMART goals for the patients which will be focused on enabling the most effective treatment option for the patient. The goal is to stabilize the patient and sustain improved clinical outcomes with quality of care provision.
The patient has a significant past history of Chronic Obstructive Pulmonary Disease. This factor increases her vulnerability to further catching the infection, leading to the progression of the disease. Due to prior history, the patient might have developed chronic bronchitis which is another contributory factor for poor ventilation and acute progression of the disease (Jarhyan et al., 2022). The patient was complaining of the progressive symptoms two days prior to the admission to the emergency setting. The patient was admitted due to an episode of acute shortness of breath. This is one of the most classic clinical signs of the condition where the patient might experience sudden respiratory distress (Rahman et al., 2022). The respiration rate for the patient is noted to be 21 breaths per minute. However, this is not significantly higher, it is higher than the normal respiration limit of 12-20 breaths per minute. This can also be due to increased respiratory distress noted for the patient and caused due to underlying respiratory and ventilatory compromise. The patient is also having a significantly low blood pressure. Studies have shown that lung diseases can result in low blood pressure. If the lungs are not functioning well, the patient might experience hypotension. The blood pressure readings for the patient are noted to be 105/55 mm Hg. This is indicative of the patient struggling with hypotension (Vizza et al., 2021). The patient is also having a complex history of cardiac complications with an extensive medical history. This can also be an added risk factor to the health of the patient.
The condition of Chronic Obstructive Pulmonary Disease is marked wit progressive deconditioning of the lung spaces. This is mainly due to chronic bronchitis and emphysema condition which cumulatively lead to the clinical manifestation of Chronic Obstructive Pulmonary Disease. The condition of emphysema can result in damage to the end alveoli which are responsible for ensuring effective and optimal ventilation (Hadzic et al., 2022). As the patient has a positive clinical history of the condition of Chronic Obstructive Pulmonary Disease, it can be evident that the alveoli will be damaged resulting in poor oxygenation. Shortness of breath can be a result of this concern, as a result of an acute onset.
The patient is also experiencing increased sputum and cough production. This is also secondary to the condition of emphysema. Due to poor or compromised gaseous exchange, there is an increased risk of mucus plugging. The mucus clearance is also compromised due to poor ventilation and perfusion in the lower lung spaces that directly take part in the respiration cycle (Wang et al., 2020). Mucus plugging and poor mucus expulsion can collectively result in result in enhanced mucus production and further compromising ventilation. The patient also described having a similar episodic event two years back. This might have caused some compromised ventilation and increased vulnerability to the development of the disease condition.
The arterial blood gas analysis of the patient is reflective of findings for respiratory acidosis. The patient is having ABG readings which reflect pH to be 7.30. This is within the acidic range. The partial carbon dioxide composition is on a higher level as compared with the normal ranges. The bicarbonate ions are also reflective to be on a higher level than the anticipated normal. This collective interpretation can be considered as respiratory acidosis (Tinawi et al., 2021). The condition of Chronic Obstructive Pulmonary Disease is also marked by hypoxemia. This can also be reflected in the low oxygen saturation level, even with a continuous supply of 15 litres of oxygen through a non-rebreather mask. This choice of mask is also justified for the patient, given the lower ranges of the oxygen saturation as noted for the patient. It is also indicated for patients with severe hypoxemia as noted for Martha Lee. Respiratory acidosis is an evident phenomenon for patients who suffer from chronic respiratory conditions such as the patient given in our clinical case study. The oxygenation to the tissues is overall compromised with reduced blood supply (Mendez et al., 2019). As oxygen saturation helps in defining oxygenated blood in the body, this is evident to be lowered in a state of respiratory compromise, caused due to the acute exacerbation of Chronic Obstructive Pulmonary Disease for the patient.
Prior to deciding on any ventilation settings for Martha, it is vital to check for arterial blood gas analysis. This will help in deciding and adjusting the required level of a fraction of oxygenation for the patient. The size and shape of the mask must also be ensured to fit the patientās face comfortably. The mask must also be checked for any possible leak and the straps must be easy to release in case of an emergency. The patient must be inclined on a bed or chair at an angle of less than 30 degrees (Van der Leest et al., 2019). The following must be considered ventilation settings for the patient:
A few other considerations must also be kept in mind while applying the non-invasive ventilation for the patient. IPAP must be increased to 2cm of H2O to help maintain the oxygen saturation within the normal limit. However, the patient must be able to tolerate not more than 20cm of H2O (Van der Leest et al., 2019).
Goal 1- I will be working on stabilizing the vitals of the patients with the help of hourly monitoring and documenting the details for the reference of the clinical healthcare team aligned in the care management for the patient.
Rationale- The vitals of the patient are rather unstable and can further deteriorate due to her given the state of clinical condition. It is crucial to note for hourly changes in the vital as the clinical picture can modulate as per the alteration in the body's physiology (Seyma et al., 2021). Hourly vitals monitoring will also assist the nurse and the clinical team in comparing the vitals with the normal range and enabling required care intervention on a timely basis. This will also be helpful in documenting the details for inter-team reference of the clinical team and providing specialist reconciliation as per the patientās clinical demands and needs.
Goal 2- I will work on restoring normal ventilatory patterns for the patient with the help of hourly vitals monitoring and effective oxygenation support, for enabling resolve of ventilatory distress and compromised clinical status for the patient.
Rationale- The patient is struggling with a compromised respiratory state. This is bound to cause poor ventilation and perfusion. The body is also struggling to maintain a state of effective oxygenation and thus, requires significant supplement oxygenation for normal functioning. Additional oxygenation support is required to maintain a normal respiratory pattern and prevent any complex situation of respiratory compromise. This must be ensured with regular monitoring of oxygen saturation levels and continuous assessment with the help of arterial blood gas analysis. Oxygenation levels must also be sustained with a focus on preventing oxygen overdosing. This will also assist in preventing the secondary complication of oxygen toxicity and restoring normal ventilatory functions.
Goal 3- I will work on educating the patient regarding self-care management and home-based solutions with the help of family and patient education along with ensuring regular follow-ups for review and medication reconciliation every month end.
Rationale- The patient is struggling with multiple clinical comorbidities and thus, she is required to be managed with the help of long-term care and regular follow-ups. The patient is also having a significant past history of cardiac complications and diabetes. This cumulatively adds to a potential risk to the health of the patient. Patient and family education is required for timely medication and managing care within home settings. The patient is also required to ensure regular follow-ups with the physicians and specialist considerations for managing her multiple clinical comorbidities (Yang et al., 2019). Regular follow-ups must also be inclusive of an interdisciplinary team approach which will help in enabling holistic care management for the patient.Ā
The presenting case study was based on the analysis of a 65-year-old female named Martha Lee. The patient was admitted to the emergency care unit, following an episodic event of acute shortness of breath and increased sputum and cough production for the past two days. The centrally focused clinical diagnosis of the patient was noted to be Chronic Obstructive Pulmonary Disease. The case analysis highlighted the underlying clinical concerns of the patient. These clinical signs and symptoms were related and connected with the clinical diagnosis of the patient. The presenting complaints and worsening signs were well connected with the central diagnosis of Chronic Obstructive Pulmonary Disease. The case presentation was also analysed from the perspective of SMART goals and objectives defined as an integral part of the nursing care plan. These SMART goals were focused on the patient from the perspective of enabling positive clinical outcomes and ensuring quality care management for the patient post-discharge from the clinical care facility. The focused treatment also reflected light on the SMART goals for home-based care management for the patient while assisting her with a sustainable independent state of functioning.
Ā
Hadzic, S., Wu, C. Y., Avdeev, S., Weissmann, N., Schermuly, R. T., & Kosanovic, D. (2020). Lung epithelium damage in COPDāan unstoppable pathological event?. Cellular Signalling, 68, 109540.
Jarhyan, P., Hutchinson, A., Khaw, D., Prabhakaran, D., & Mohan, S. (2022). Prevalence of chronic obstructive pulmonary disease and chronic bronchitis in eight countries: A systematic review and meta-analysis. Bulletin of the World Health Organization, 100(3), 216.
Mendez, Y., Ochoa-Martinez, F. E., & Ambrosii, T. (2019). Chronic obstructive pulmonary disease and respiratory acidosis in the intensive care unit. Current Respiratory Medicine Reviews, 15(2), 79-89.
Rahman, H. H., Niemann, D., & Munson-McGee, S. H. (2022). Association between asthma, chronic bronchitis, emphysema, chronic obstructive pulmonary disease, and lung cancer in the US population. Environmental Science and Pollution Research, 1-12.
Seyma, Z. K., Meral, Y. C., & Atiye, E. (2021). Nursesā Knowledge Levels About the Care of the Patients with Chest Tube. International Journal of Caring Sciences, 14(2), 1334.
Tinawi, M. (2021). Respiratory acid-base disorders: respiratory acidosis and respiratory alkalosis. Archives of Clinical and Biomedical Research, 5(2), 158-168.
Van der Leest, S., & Duiverman, M. L. (2019). Highāintensity nonāinvasive ventilation in stable hypercapnic COPD: Evidence of efficacy and practical advice. Respirology, 24(4), 318-328.
Vizza, C. D., Hoeper, M. M., Huscher, D., Pittrow, D., Benjamin, N., Olsson, K. M., ... & GrĆ¼nig, E. (2021). Pulmonary hypertension in patients with COPD: results from the comparative, prospective registry of newly initiated therapies for pulmonary hypertension (COMPERA). Chest, 160(2), 678-689.
Wang, C., Zhou, J., Wang, J., Li, S., Fukunaga, A., Yodoi, J., & Tian, H. (2020). Progress in the mechanism and targeted drug therapy for COPD. Signal Transduction and Targeted Therapy, 5(1), 248.
Yang, H., Wang, H., Du, L., Wang, Y., Wang, X., & Zhang, R. (2019). Disease knowledge and self-management behavior of COPD patients in China. Medicine, 98(8).
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