Patient Case Study: Respiratory Distress Management

Room: 412
Patient: John Doe, 68-year-old male
Attending: Dr. Sarah Johnson, Pulmonology
Consults: Dr. Michael Chen, Cardiology
Allergies: Penicillin
Admit date: September 5, 2024
Isolation: None
Code status: Full code

Primary diagnosis: Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD)

CC/HPI: Mr. Doe presented to the emergency department with worsening shortness of breath, increased cough with purulent sputum, and low-grade fever for the past three days. He has a history of COPD and reports using his rescue inhaler more frequently without relief.

Past medical history: COPD, Hypertension, Type 2 Diabetes Mellitus

Past surgical history: Appendectomy (1985)

Neuro/Psych:
GCS: Eyes 4, Verbal 5, Motor 6, Total 15
Level of consciousness: Alert and oriented x3
Mood/behavior: Anxious but cooperative
Pupils: PERRLA
Muscle strength: LUE 5/5, RUE 5/5, LLE 5/5, RLE 5/5

Labs:
BGM frequency: Q6H
07: 132 mg/dL
11: 145 mg/dL
17: 138 mg/dL
21: 140 mg/dL

GFR: 75 mL/min/1.73m²
HgbA1C: 7.2%
Troponin: <0.01 ng/mL Lactate: 1.2 mmol/L BNP: 85 pg/mL Procal: 0.08 ng/mL Cardiac: Echo EF: 55% Heart rate trends: 80-95 bpm Tele rhythm: Normal sinus rhythm SBP/MAP trends: 130-145/85-95 mmHg Temp trends: 37.2°C - 38.1°C (oral) Pulses: L rad 2+, R rad 2+, L ped 2+, R ped 2+ Edema: 1+ bilateral lower extremities Respiratory: IS: 1500 mL max Lung sounds: Diffuse wheezes and crackles bilaterally O2 delivery: 2 L/min via nasal cannula O2 sat trends: 92-95% Secretions: Moderate, yellow-green, thick ABG (09/06/2024): pH 7.35, pCO2 48 mmHg, HCO3 26 mEq/L, pO2 65 mmHg GI: Last BM: 09/15/2024, formed Bowel sounds: Active in all quadrants Abdomen: Soft, non-tender, non-distended Diet: Regular with 2L fluid restriction GU: Continent Voiding method: Spontaneous Shift urine output: 800 mL/8 hours Urine character: Clear, yellow Now, let's proceed with the Medication Administration Record (MAR) for the five most critical medications: Medication Administration Record Generic & trade name: Albuterol (ProAir HFA) Pharm class: Short-acting beta-2 agonist (SABA) Dose: 2 puffs Route: Inhaled Freq: Q4H and PRN Indication(s) r/t patient: Bronchodilation for COPD exacerbation Common SEs/ADEs: Tremors Tachycardia Nervousness Nursing considerations: Assess respiratory status before and after administration Monitor heart rate and blood pressure Teach proper inhaler technique Generic & trade name: Methylprednisolone (Solu-Medrol) Pharm class: Corticosteroid Dose: 40 mg Route: IV Freq: Q12H Indication(s) r/t patient: Reduce airway inflammation in COPD exacerbation Common SEs/ADEs: Hyperglycemia Increased susceptibility to infections Fluid retention Nursing considerations: Monitor blood glucose levels Assess for signs of infection Administer with food to reduce GI upset Generic & trade name: Tiotropium (Spiriva) Pharm class: Long-acting anticholinergic Dose: 18 mcg Route: Inhaled Freq: Daily Indication(s) r/t patient: Long-term COPD management Common SEs/ADEs: Dry mouth Constipation Urinary retention Nursing considerations: Assess for anticholinergic side effects Ensure proper inhaler technique Advise patient to rinse mouth after use Generic & trade name: Piperacillin-Tazobactam (Zosyn) Pharm class: Extended-spectrum penicillin/beta-lactamase inhibitor Dose: 3.375 g Route: IV Freq: Q6H Indication(s) r/t patient: Empiric treatment of suspected bacterial infection Common SEs/ADEs: Diarrhea Nausea Rash Nursing considerations: Monitor for signs of allergic reaction Assess renal function Administer over 30 minutes to reduce phlebitis risk Generic & trade name: Enoxaparin (Lovenox) Pharm class: Low molecular weight heparin Dose: 40 mg Route: Subcutaneous Freq: Daily Indication(s) r/t patient: DVT prophylaxis in hospitalized patient Common SEs/ADEs: Bleeding Bruising at injection site Thrombocytopenia Nursing considerations: Monitor for signs of bleeding Rotate injection sites Assess platelet count periodically Plan of Care (Clinical Judgment Plan) Priority problem #1 [hypothesis]: Ineffective Breathing Pattern related to COPD exacerbation Pertinent assessment data [cues]: Shortness of breath Increased use of accessory muscles Wheezes and crackles on auscultation O2 saturation 92-95% on 2 L/min nasal cannula S.M.A.R.T. goal/outcome #1 [solution]: Patient will demonstrate improved breathing pattern, evidenced by respiratory rate 12-20 breaths/min, minimal use of accessory muscles, and O2 saturation >95% on current oxygen therapy within 48 hours.

Interventions with frequency & rationale [actions]:

Assess/monitor:

Assess respiratory rate, depth, and pattern Q4H
Auscultate lung sounds Q4H
Monitor oxygen saturation continuously
Manage:

Administer prescribed bronchodilators and corticosteroids as ordered
Position patient in high Fowler’s or semi-Fowler’s position to facilitate breathing
Encourage use of incentive spirometry Q2H while awake
Educate:

Teach pursed-lip breathing technique and diaphragmatic breathing exercises
Instruct on proper use of inhalers and spacer devices
Educate on energy conservation techniques
Evaluation [evaluate]: Met / Not met
Recommendations (If goal/outcome not met):

Consider adjusting medication regimen in consultation with pulmonologist
Assess need for non-invasive ventilation support
Priority problem #2 [hypothesis]: Risk for Infection related to COPD exacerbation and current antibiotic therapy

Pertinent assessment data [cues]:

Low-grade fever (max 38.1°C)
Increased purulent sputum production
Current antibiotic therapy (Piperacillin-Tazobactam)
S.M.A.R.T. goal/outcome #2 [solution]:
Patient will remain free from signs and symptoms of new or worsening infection throughout hospital stay, as evidenced by temperature <37.5°C, white blood cell count within normal limits, and absence of new respiratory symptoms. Interventions with frequency & rationale [actions]: Assess/monitor: Monitor temperature Q4H Assess characteristics of sputum daily Monitor white blood cell count daily Manage: Administer antibiotics as prescribed Encourage deep breathing and coughing exercises Q2H while awake Maintain good hand hygiene and use personal protective equipment as needed Educate: Teach importance of hand hygiene to patient and visitors Instruct on proper technique for productive coughing Educate on signs and symptoms of worsening infection to report Evaluation [evaluate]: Met / Not met Recommendations (If goal/outcome not met): Reassess antibiotic efficacy and consider culture and sensitivity testing Evaluate for potential hospital-acquired infections Priority problem #3 [hypothesis]: Activity Intolerance related to respiratory distress and COPD exacerbation Pertinent assessment data [cues]: Reports fatigue with minimal exertion Increased shortness of breath with activity Anxiety related to breathlessness S.M.A.R.T. goal/outcome #3 [solution]: Patient will demonstrate improved activity tolerance, able to ambulate 50 feet with minimal shortness of breath and oxygen saturation remaining >92% within 72 hours.

Interventions with frequency & rationale [actions]:

Assess/monitor:

Assess activity tolerance daily using Borg Scale
Monitor oxygen saturation before, during, and after activities
Evaluate fatigue levels using numeric rating scale Q shift
Manage:

Implement progressive mobility plan, starting with bed exercises and advancing as tolerated
Coordinate activities with peak effectiveness of bronchodilator medications
Provide oxygen therapy as needed during activities
Educate:

Teach energy conservation techniques and importance of balancing rest and activity
Instruct on use of pursed-lip breathing during exertion
Educate on the benefits of regular physical activity in COPD management
Evaluation [evaluate]: Met / Not met
Recommendations (If goal/outcome not met):

Consult physical therapy for individualized exercise plan
Assess need for additional supportive devices or home oxygen therapy
This comprehensive care plan addresses the primary concerns for a patient with COPD exacerbation, focusing on improving respiratory function, preventing complications, and promoting gradual increase in activity tolerance. The interventions are evidence-based and tailored to the patient’s specific needs.

References:

Global Initiative for Chronic Obstructive Lung Disease. (2023). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Retrieved from https://goldcopd.org/2023-gold-report-2/

Lareau, S. C., & Fahy, B. (2018). Patient information series: Pulmonary rehabilitation. American Journal of Respiratory and Critical Care Medicine, 198(1), P1-P2. https://doi.org/10.1164/rccm.1981P1

Rabe, K. F., & Watz, H. (2019). Chronic obstructive pulmonary disease. The Lancet, 393(10165), 1931-1939. https://doi.org/10.1016/S0140-6736(19)31222-9

Vogelmeier, C. F., et al. (2020). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2020 Report. American Journal of Respiratory and Critical Care Medicine, 201(5), e56-e69. https://doi.org/10.1164/rccm.202003-0625SO

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The patient is in the hospital for a respiratory destress he came in September 5th. all the information you need you can come up with. patient is fictional so you can put whatever you like. if it doesn’t apply to the patient you don’t have to fill it in. Include 5 medications in the MAR you only need to put there 5 medication.

Medication
(Generic & Brand Names) Class
(Therapeutic & Pharmacologic) Indications
(Why is pt. taking this drug?) Dose
Route Frequency Contraindications Nursing Considerations Side Effects Pt. Teaching

Medication
(Generic & Brand Names) Class
(Therapeutic & Pharmacologic) Indications
(Why is pt. taking this drug?) Dose
Route Frequency Contraindications Nursing Considerations Side Effects Pt. Teaching

Room Patient/Age/Sex Attending & consults Allergies Admit date Isolation & organism Code status
Primary diagnoses
CC/HPI
Past medical hx
Past surgical hx
Neuro/Psych GCS
Primary language Eyes _____
Level of consciousness Verbal _____
Orientation & follow commands Motor _____
Mood/behavior Total _____
Pupils
Muscle strength: LUE _____ / RUE _____ / LLE _____ / RLE _____
Labs BGM frequency _____ / 07 _____ 11 _____ 17 _____ 21 _____

GFR ________ HgbA1C ________
Troponin ________ Lactate ________
BNP ________ Procal ________
CK ________ CRP ________
D-dimer ________ ESR ________
Fibrinogen ________ Amylase ________
Ammonia ________ Lipase ________
UA _________________________________
Cultures ___________________________
____________________________________
Cardiac Echo EF _____ %
Heart rate trends
Tele rhythm trends
SBP/MAP trends & goal parameters
Temp trends & method/fevers & Tmax
Pulses: L rad _____ / R rad _____ / L ped _____ / R ped _____
Edema & grading
[ ] Pacemaker / [ ] AICD
Respiratory IS [ ] & trends/max _____ ml
Lung sounds & work of breathing/rhythm
O2 delivery _____ @ _____ LPM / _____%
O2 sat trends
Secretion amt & character/suction method
Chest tube(s) output & character
ABG date _____: pH _____ / pCO2 _____ / HCO3 _____ / pO2 _____
GI Lt NG / Rt NG taped @ _____ cm / PEG
Continent/incontinent Suction __________ / Output _____ ml
Last BM & character Current TF rate @ _____ ml/hr
Bowel sounds TF goal rate _____ ml/hr
Abdomen appearance & palpation TF max residual _____ ml
Diet/TF formula
Rectal tube/colostomy output & character
Fluid restriction _____ ml/day
Diagnostics/Imaging 12-lead ECG
XR
CT
MRI
Ultrasound
EEG
GU Foley insert date _____ Indication __________
Continent/incontinent Last bladder scan _____ ml @ _____
Voiding method Last I&O cath _____ ml @ _____
Shift/hourly urine output
Urine character
HD sched __________ & last HD amt removed _____ ml
Specialty: Advanced Med/Surg
Neuro/Psych – Richmond Agitation-Sedation Scale
RASS
Cardiac – Hemodynamics
PA cath @ _____ cm
CI _____ / SvO2 _____ / CVP _____ / PAP _____ / SVR _____
Respiratory – Artificial airway & mechanical ventilation
ETT size _____ taped @ _____ cm @ teeth / gum / lip
Trach brand __________ & size _____
Vent mode ____________
Rate _____ VT/PS _____
FiO2 _____% PEEP _____
GI – Enteral tube
OG taped @ _____ cm
Musculoskeletal/Safety & Mobility [ ] SCDs [ ] VTE ppx meds
Pain & scale utilized
Assistive devices
Level of assist
Calls for assist/safety concerns
Restraint type & location
Sitter/tele-sitter
Rehab consults: [ ] PT [ ] OT [ ] SLP
Skin & Drains/Tubes
Pressure injuries/wounds
Wound tx/dressings output & character
Drains/tubes output & character
Wound care consult [ ]
OTOs/PRNs given & time last given To-do/Follow-up/Notes
IV Lines

Continuous IV Drips
Hct
Hgb
WBC Plt
Na Cl BUN
Glu
K CO2(HCO3) Cr
Bili
AST ALT
PT
aPTT
INR
Phos
Ca Mag
Alk
Phos
Alb
Shift Notes Vitals 08/20 12/00 16/04
07/19 08/20 09/21 10/22
Temp &
source
HR &
rhythm
11/23 12/00 13/01 14/02
BP & MAP
Resp
rate
15/03 16/04 17/05 18/06
SpO2 &
delivery
method
Pain &
pain
scale
used
Medication Administration Record – provide 5 most critical/priority medications
Generic & trade name Pharm class Dose Route Freq Indication(s) r/t patient Common SEs/ADEs (at least 3) Nursing considerations (at least 3)
Plan of Care (Clinical Judgment Plan)
Priority problem #1 [hypothesis]:
Pertinent assessment data [cues]:
S.M.A.R.T. goal/outcome #1 [solution]:
Interventions with frequency & rationale [actions]:
Assess/monitor:
Manage:
Educate:
Evaluation [evaluate]: Met / Not met
Recommendations (If goal/outcome not met):
Priority problem #2 [hypothesis]:
Pertinent assessment data [cues]:
S.M.A.R.T. goal/outcome #2 [solution]:
Interventions with frequency & rationale [actions]:
Assess/monitor:
Manage:
Educate:
Evaluation [evaluate]: Met / Not met
Recommendations (If goal/outcome not met):
Priority problem #3 [hypothesis]:
Pertinent assessment data [cues]:
S.M.A.R.T. goal/outcome #3 [solution]:
Interventions with frequency & rationale [actions]:
Assess/monitor:
Manage:
Educate:
Evaluation [evaluate]: Met / Not met
Recommendations (If goal/outcome not met):

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