CRITICAL THINKING SUMMARY
Student: _Heather Hulien_
Client Dx: __COPD exacerbation, Bronchitis_ Age: _58_
Allergies: __No known allergies_
The MEDICAL DIAGNOSIS that brought the client to the hospital is:
COPD exacerbation, bronchitis
PATHOPHYSIOLOGY of diagnosed disease: (From text)
Chronic bronchitis is defined as hypersecretion of mucus and chronic productive cough for
at least 3 months of the year for at least 2 consecutive years. Inspired irritants result in
airway infiltration of neutrophils, macrophages, and lymphocytes into the bronchial wall.
Continual bronchial inflammation causes bronchial edema and increases the size and
number of mucous glands and goblet cells in the airway epithelium. Thick, tenacious
mucous is produced and cannot be cleared because ciliary function is impaired (Huether &
McCance, 2012).
SYMPTOMS typically seen with this diagnosis include (as identified in your text):
Productive cough, dyspnea, wheezing, history of smoking, barrel chest, prolonged
expiration, cyanosis, chronic hypoventilation, polycythemia, and Cor pulmonale (Huether &
McCance, 2012).
CLIENT’S SYMPTOMS of the diagnosed disease include:
Increasing dyspnea, an increase in her chronic cough (no sputum production), shortness
of breath, and wheezing.
NUTRITIONAL ASSESSMENT:
Height (actual or estimated): _165 cm_ Weight (actual or estimated): _55.7 kg_
Estimate Ideal Body Weight (Male: 105lb + 6 lb/inch > 5’. Female: 100lb + 5lb/inch > 5’): 125
Pounds_
Does this client have characteristics of a well-nourished person? Yes _____ No __X__
Explain your answer.
The patient does not exclusively have characteristics of a well-nourished person. Although
the patient appears to eat foods from all five food groups, has shiny hair, white teeth, a
healthy skin tone, strong fingernails, and normal protein and albumin levels, she easily
becomes fatigued with activity, and she lacks energy. She is unable to finish many of her
meals because she does not have enough energy. The patient stated that she has
recently lost five pounds.
PSYCHOSOCIAL STAGE OF DEVELOPMENT
What is the client’s developmental stage?
The patient is in the stage of generativity versus stagnation (middle adulthood) (Taylor,
Lillis, LeMone, & Lynn, 2011).
Has he/she met the necessary accomplishments? Yes __X__ No _____
Explain.
The patient is involved with her children and grandchildren. She also interacts with her
community by attending church and many church events. Although she is not currently
working, she worked for several years in the food service industry.
How is this illness affecting the client’s ability to meet these necessary accomplishments?
Since the patient is in the hospital, she is not able to care for her children and
grandchildren. She is also unable to attend several church events that she had been
looking forward to attending. She recently had to quit working because her lack of energy
and shortness of breath made her physically demanding job too difficult to complete.
NURSING DIAGNOSIS/OBJECTIVES/INTERVENTIONS
Indicate below the 2 priority nursing diagnoses that are most relevant for your client.
#1 NURSING DIAGNOSIS (problem r/t)
Risk for ineffective airway clearance related to bronchoconstriction, increased sputum
production, ineffective cough, and fatigue/ lack of energy (Ladwig & Ackley, 2011).
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Absent cough; adventitious breath sounds; changes in respiratory rate and rhythm;
cyanosis; difficulty vocalizing; diminished breath sounds; dyspnea; excessive sputum;
orthopnea; restlessness; wide-eyed (Ladwig & Ackley, 2011).
OBJECTIVE/CLIENT OUTCOME for this diagnosis:
The patient will maintain a patent airway at all times during her stay in the hospital.
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1. Teach the client to deep breathe and perform controlled coughing (Ladwig &
Ackley, 2011).
2. Teach the client the proper technique for using an incentive spirometer (Ladwig &
Ackley, 2011).
3. Administer medications such as bronchodilators or inhaled steroids as ordered
(Ladwig & Ackley, 2011).
#2 NURSING DIAGNOSIS (problem r/t)
Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction,
and airway irritants (Ladwig & Ackley, 2011).
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Alterations in depth of breathing; altered chest excursion; assumption of three-point
position; bradypnea; decreased minute ventilation; decreased vital capacity; dyspnea;
increased anterior-posterior diameter; nasal flaring; orthopnea; prolonged expiration
phase; pursed-lip breathing; tachypnea; use of accessory muscles to breathe (Ladwig &
Ackley, 2011).
OBJECTIVE/CLIENT OUTCOME for this diagnosis:
The patient will demonstrate a breathing pattern that supports blood gas results within the
client’s normal parameters during her stay in the hospital.
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1. Teach the patient to use pursed-lip and controlled breathing techniques (Ladwig &
Ackley, 2011).
2. Coach the client to slow respiratory rate (Ladwig & Ackley, 2011).
3. During hyperventilation, instruct the patient to breathe in and out of a paper bag as
tolerated (Ladwig & Ackley, 2011).
COMPLICATIONS:
If this client’s condition were to worsen, what would be the most likely reason and why?
If the patient’s condition were to worsen, the most likely reason would be respiratory
alkalosis due to ineffective breathing. When breathing becomes labored, the body’s
reaction is to breathe faster. Fast breathing causes the body to blow off carbon dioxide
and leads to abnormally low levels of carbon dioxide in the blood.
How would you know this is happening?
The nurse would know this is happening because the patient could experience dizziness,
confusion, tingling of extremities, convulsions, and coma.
What will you do if this happens?
If this happens, the nurse would encourage the patient to slow respiratory rate and notify the
physician immediately. The nurse would expect an order for arterial blood gases.
PHYSICIAN PRESCRIBED MEDICATIONS AND INTERVENTIONS
MEDS/IVs/TX/DIET
(Include dose, route,
frequency)
REASON PRESCRIBED
(Drug Classification,
What is it treating?)
Albuterol: 5mg; NEB; every
4 hours
Bronchodilators/
adrenergics; used to control
and prevent reversible
airway obstruction caused
by COPD
Ipratropium: 0.5 mg; NEB;
ever 4 hours
Bronchodilators/
anticholinergics;
maintenance therapy of
reversible airway
obstruction due to COPD
Rifampin; 300 mg; PO;
every Monday, Wednesday,
and Friday
Antituberculars; active
tuberculosis
ethambutol: 800 mg; PO;
every Monday, Wednesday,
and Friday
Antituberculars; active
tuberculosis
NURSING IMPLICATIONS
FROM TEXT
(Checking for adverse
reactions, preparation &
administration concerns)
Shake inhaler well, and
allow at least 1 minute
between inhalations
Administer adrenergic
bronchodilators first,
followed by ipratropium, the
corticosteroids. Wait 5
minutes between
medications; solution for
nebulization can be diluted
with preservative-free 0.9%
NaCl
Administer medication on
an empty stomach at least
1 hour before or 2 hours
after meals with a full glass
of water
Given as a single daily
dose; should be given at
the same time each day;
administer with food or milk
to minimize GI irritation;
tablets may be crushed and
mixed with apple juice or
apple sauce
CLIENT DATA FROM
YOUR ASSESSMENT
(What data is important to
know before & after
giving)
Assess lung sounds, pulse,
and BP before
administration and during
peak of medication. Note
amount, color, and
character of sputum
produced; monitor
pulmonary function tests
before initiating therapy and
periodically during therapy;
observe for paradoxical
bronchospasm (wheezing);
may cause transient
decrease in serum
potassium concentrations
Assess for allergy to
atropine and belladonna
alkaloids; assess
respiratory status before
administration and at peak
of medication
Mycobacterial studies and
susceptibility tests should
be performed before and
periodically during therapy
to detect possible
resistance; assess lung
sounds and character and
amount of sputum
periodically during therapy;
evaluate renal function,
CBC, and urinalysis
periodically and during
therapy
Mycobacterial studies and
susceptibility tests should
be performed before and
periodically during therapy
to detect possible
resistance; assess lung
sounds and character and
amount of sputum
periodically during therapy;
assessments of visual
function should be made
frequently during therapy;
montelukast: 10 mg; PO;
every night
Bronchodilator/ leukotriene
antagonists; prevention of
bronchoconstriction
Administer once daily in the
evening; assess for rash
during therapy; monitor
closely for changed in
behavior that could indicate
the emergence or
worsening of depression or
suicidal thoughts
Alprazolam: 0.5 mg; PO;
three times a day PRN
Antianxiety
agents/benzodiazepines;
anxiety associated with
depression
Administer with food if GI
upset occurs; administer
greatest dose at bedtime to
avoid daytime sedation
Furosemide: 20 mg, PO,
twice a day PRN
Diuretics/ loop diuretics:
edema
Give last dose no later than
5 pm to minimize disruption
of sleep cycle; may be
given with food or milk to
minimize gastric irritation;
tablets may be crushed
(Vallerand, Sanoski & Deglin, 2014)
monitor renal and hepatic
functions, CBC, and uric
acid levels
Assess lung sounds and
respiratory function prior to
and periodically during
therapy; assess allergy
symptoms before and
periodically during therapy;
may cause an increase in
AST and ALT
concentrations
Assess degree and
manifestations of anxiety
and mental status prior to
and periodically during
therapy; assess patient for
drowsiness, lightheadedness, and dizziness;
assess CNS effects and
risk of falls; monitor CBC
and liver and renal function
periodically during longterm therapy; may cause
decreased hematocrit and
neutropenia
Assess fluid status; monitor
daily weight, intake and
output ratios, amount and
location of edema, lung
sounds, skin turgor, and
mucous membranes;
monitor BP and pulse
before and during
administration; assess
patient for tinnitus and
hearing loss; assess for
allergies to sulfonamides;
assess patient for skin rash
during therapy; monitor
electrolytes renal and
hepatic function, serum
glucose, and uric acid
levels before and
periodically throughout
therapy
Analysis of Diagnostic Tests
DIRECTIONS:
1.
List all diagnostic and laboratory tests pertinent to the patient's medical diagnosis or medical
treatments (i.e. medications) and provide the patient values for each test. Explain why they are
pertinent for this patient.
2.
List any screening diagnostic and laboratory tests that are not within normal limits. Explain why
these tests are increased or decreased in relation to your patient's medical condition.
Diagnostic/Lab Test
Chest X ray
Glucose
Patient Values
Lungs are mildly hyperextended;
mild diffuse interstitial
coarsening
122 High
ALT
Neut Auto
48 High
87.4 High
Lymph auto
Lymph absolute
8.5 low
0.67 Low
(Van Leeuwen, Poelhuis-Leth & Bladh, 2013)
Analysis of Values
COPD
Could indicate impaired fasting
glucose
Could indicate liver damage
Could be a result of tuberculosis;
could indicate acute infection or
acute stress
Could be a result of steroid use
Could be a result of steroid use
References
Huether, S.E., & McCance, K.L. (2012). Understanding pathophysiology. (5th ed., p. 114-693).
Elsevier Inc.
Ladwig, G.B., & Ackley, B.J. (2011). Mosby’s guide to nursing diagnosis. (3rd ed.). Maryland
Heights, MO: Mosby Elsevier
Taylor, C.R., Lillis, C., LeMone, P., & Lynn, P. (2011). Fundamentals of nursing: The art and
science of nursing care. (7th ed., p. 366). Philadelphia, PA: Lippincott Williams &
Wilkins.
Vallerand, A.H., Sanoski, C.A., & Deglin, J.H. (2014). Davis’s drug guide for nurses. (13th ed.).
Unbound Medicine, Inc.
Van Leeuwen, A.M., Poelhuis-Leth, D.J., & Bladh, M.L. (2013). Davis’s comprehensive
handbook of laboratory and diagnostic tests with nursing implications. Unbound
Medicine, Inc.