Nursing Care and Pathophysiology of COPD (Chronic Obstructive Pulmonary Disease)

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.

1000 ED Triage RN Notes

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.  Six months ago she had similar symptoms and was told that she had chronic obstructive pulmonary disease.  She reports shortness of breath at rest, being forgetful, feeling chilly and needing blankets

Lungs bilateral coarse breath sounds with bibasilar rhonchi. Positive peripheral pulses, negative edema.

1010 ED Primary RN Notes

The client is lying on a stretcher, head of bed elevated at 45 degree angle. Oxygen plated at 2 liters per nasal cannula due to O2 saturation of 88% and orders to maintain O2 at 90%. Respirations shallow, labored. Complains of being cold, warm blankets placed. Lungs bilaterally coarse with bibasilar rhonchi.

Lungs bilateral coarse breath sounds with bibasilar rhonchi. Positive peripheral pulses, negative edema.

Past Medical History 

Chronic Obstructive Pulmonary Disease

Sleep apnea

No Known Drug Allergies

Social

Smokes 3 packs of cigarettes per day x 30 years

Client’s Home Meds

Fluticasone-vilanterol 100-25 mcg inhaled daily

Hydrochlorothiazide 25 mg by mouth daily

Albuterol -ipratropium inhaled every 4 hours prn

.

Home medical equipment-Bipap Ventilatory Support at home

Physical Assessment

Neurological: Alert, oriented to person and place, not date or month

Respiratory: Mild end expiratory wheezing, past FEV1FVC 0.8. Increased work of breathing, cough, use of accessory muscles, crackles bilaterally, shallow respirations, hyperresonance on percussion, pale lips and nail beds cyanotic.

Cardiovascular:  S1 and S 2 auscultated, tachycardic rhythm

Gastrointestinal: Abdomen soft, with positive bowel sounds all 4 quadrants

Genito Urinary:

Integumentary: pale, warm, dry, nail beds pale, bluish tinted

Hemoglobin 13

Hematocrit-40.5

White Blood Count 4.5 billion cells/L

Na-140

K-4.5

Cl-100

Calcium 9.5

Arterial blood gases pH 7.491, PCOD 27.6, POq 66.6 HCO3 20.6, Oxygen saturation 88% on room air. 

Creatinine kinase normal

Troponin I-negative

Brain natriuretic peptide 85pg/ml

Electrocardiogram-sinus tachycardia, no ST or T wave changes

Chest X Ray-bibasilar airway disease. Small bilateral pleural effusions. 

Sputum culture obtained

Temperature 99.3 Fahrenheit, heart rate 110 beats per minute, respiratory rate 28, Blood Pressure 104/54, weight 100 Kilograms, BMI 39.2, and Oxygen saturation 88% on room air.

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.

1000 ED Triage RN Notes

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.  Six months ago she had similar symptoms and was told that she had chronic obstructive pulmonary disease.  She reports shortness of breath at rest, being forgetful, feeling chilly and needing blankets

Lungs bilateral coarse breath sounds with bibasilar rhonchi. Positive peripheral pulses, negative edema.

1010 ED Primary RN Notes

The client is lying on a stretcher, head of bed elevated at 45 degree angle. Oxygen plated at 2 liters per nasal cannula due to O2 saturation of 88% and orders to maintain O2 at 90%. Respirations shallow, labored. Complains of being cold, warm blankets placed. Lungs bilaterally coarse with bibasilar rhonchi.

Past Medical History 

Chronic Obstructive Pulmonary Disease

Sleep apnea

No Known Drug Allergies

Social

Smokes 3 packs of cigarettes per day x 30 years

Client’s Home Meds

Fluticasone-vilanterol 100-25 mcg inhaled daily

Hydrochlorothiazide 25 mg by mouth daily

Albuterol -ipratropium inhaled every 4 hours prn

.

Home medical equipment-Bipap Ventilatory Support at home

Physical Assessment

Neurological: Alert, oriented to person and place, not date or month

Respiratory: Mild end expiratory wheezing, past FEV1FVC 0.8. Increased work of breathing, cough, use of accessory muscles, crackles bilaterally, shallow respirations, hyperresonance on percussion, pale lips and nail beds cyanotic.

Cardiovascular:  S1 and S 2 auscultated, tachycardic rhythm

Gastrointestinal: Abdomen soft, with positive bowel sounds all 4 quadrants

Genito Urinary:

Integumentary: pale, warm, dry, nail beds pale, bluish tinted

Hemoglobin 13

Hematocrit-40.5

White Blood Count 4.5 billion cells/L

Na-140

K-4.5

Cl-100

Calcium 9.5

Arterial blood gases pH 7.491, PCOD 27.6, POq 66.6 HCO3 20.6, Oxygen saturation 88% on room air. 

Creatinine kinase normal

Troponin I-negative

Brain natriuretic peptide 85pg/ml

Electrocardiogram-sinus tachycardia, no ST or T wave changes

Chest X Ray-bibasilar airway disease. Small bilateral pleural effusions. 

Sputum culture obtained

Temperature 99.3 Fahrenheit, heart rate 110 beats per minute, respiratory rate 28, Blood Pressure 104/54, weight 100 Kilograms, BMI 39.2, and Oxygen saturation 88% on room air.

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.

1000 ED Triage RN Notes

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.  Six months ago she had similar symptoms and was told that she had chronic obstructive pulmonary disease.  She reports shortness of breath at rest, being forgetful, feeling chilly and needing blankets

Lungs bilateral coarse breath sounds with bibasilar rhonchi. Positive peripheral pulses, negative edema.

1010 ED Primary RN Notes

The client is lying on a stretcher, head of bed elevated at 45 degree angle. Oxygen plated at 2 liters per nasal cannula due to O2 saturation of 88% and orders to maintain O2 at 90%. Respirations shallow, labored. Complains of being cold, warm blankets placed. Lungs bilaterally coarse with bibasilar rhonchi.

Past Medical History 

Chronic Obstructive Pulmonary Disease

Sleep apnea

No Known Drug Allergies

Social

Smokes 3 packs of cigarettes per day x 30 years

Client’s Home Meds

Fluticasone-vilanterol 100-25 mcg inhaled daily

Hydrochlorothiazide 25 mg by mouth daily

Albuterol -ipratropium inhaled every 4 hours prn

.

Home medical equipment-Bipap Ventilatory Support at home

Physical Assessment

Neurological: Alert, oriented to person and place, not date or month

Respiratory: Mild end expiratory wheezing, past FEV1FVC 0.8. Increased work of breathing, cough, use of accessory muscles, crackles bilaterally, shallow respirations, hyperresonance on percussion, pale lips and nail beds cyanotic.

Cardiovascular:  S1 and S 2 auscultated, tachycardic rhythm

Gastrointestinal: Abdomen soft, with positive bowel sounds all 4 quadrants

Genito Urinary:

Integumentary: pale, warm, dry, nail beds pale, bluish tinted

Hemoglobin 13

Hematocrit-40.5

White Blood Count 4.5 billion cells/L

Na-140

K-4.5

Cl-100

Calcium 9.5

Arterial blood gases pH 7.491, PCOD 27.6, POq 66.6 HCO3 20.6, Oxygen saturation 88% on room air. 

Creatinine kinase normal

Troponin I-negative

Brain natriuretic peptide 85pg/ml

Electrocardiogram-sinus tachycardia, no ST or T wave changes

Chest X Ray-bibasilar airway disease. Small bilateral pleural effusions. 

Sputum culture obtained

Temperature 99.3 Fahrenheit, heart rate 110 beats per minute, respiratory rate 28, Blood Pressure 104/54, weight 100 Kilograms, BMI 39.2, and Oxygen saturation 88% on room air.

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.

1000 ED Triage RN Notes

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.  Six months ago she had similar symptoms and was told that she had chronic obstructive pulmonary disease.  She reports shortness of breath at rest, being forgetful, feeling chilly and needing blankets

Lungs bilateral coarse breath sounds with bibasilar rhonchi. Positive peripheral pulses, negative edema.

Past Medical History 

Chronic Obstructive Pulmonary Disease

Sleep apnea

No Known Drug Allergies

Social

Smokes 3 packs of cigarettes per day x 30 years

Client’s Home Meds

Fluticasone-vilanterol 100-25 mcg inhaled daily

Hydrochlorothiazide 25 mg by mouth daily

Albuterol -ipratropium inhaled every 4 hours prn

.

Home medical equipment-Bipap Ventilatory Support at home

Physical Assessment

Neurological: Alert, oriented to person and place, not date or month

Respiratory: Mild end expiratory wheezing, past FEV1FVC 0.8. Increased work of breathing, cough, use of accessory muscles, crackles bilaterally, shallow respirations, hyperresonance on percussion, pale lips and nail beds cyanotic.

Cardiovascular:  S1 and S 2 auscultated, tachycardic rhythm

Gastrointestinal: Abdomen soft, with positive bowel sounds all 4 quadrants

Genito Urinary:

Integumentary: pale, warm, dry, nail beds pale, bluish tinted

Pulse oximetry

Oxygen at 2L/min to maintain SPO2 at 90%,

Complete blood count

Comprehensive metabolic panel

Arterial blood gases

Creatinine kinase

Troponin I

Brain natriuretic peptide

Electrocardiogram

Chest X Ray

Sputum culture

Chest Physiotherapy per Respiratory Therapy Protocol

Temperature 99.3 Fahrenheit, heart rate 110 beats per minute, respiratory rate 28, Blood Pressure 104/54, weight 100 Kilograms, BMI 39.2, and Oxygen saturation 88% on room air.

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.

1000 ED Triage RN Notes

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.  Six months ago she had similar symptoms and was told that she had chronic obstructive pulmonary disease.  She reports shortness of breath at rest, being forgetful, feeling chilly and needing blankets

Lungs bilateral coarse breath sounds with bibasilar rhonchi. Positive peripheral pulses, negative edema.

1010 ED Primary RN Notes

The client is lying on a stretcher, head of bed elevated at 45 degree angle. Oxygen plated at 2 liters per nasal cannula due to O2 saturation of 88% and orders to maintain O2 at 90%. Respirations shallow, labored. Complains of being cold, warm blankets placed. Lungs bilaterally coarse with bibasilar rhonchi.

Past Medical History 

Chronic Obstructive Pulmonary Disease

Sleep apnea

No Known Drug Allergies

Social

Smokes 3 packs of cigarettes per day x 30 years

Client’s Home Meds

Fluticasone-vilanterol 100-25 mcg inhaled daily

Hydrochlorothiazide 25 mg by mouth daily

Albuterol -ipratropium inhaled every 4 hours prn

.

Home medical equipment-Bipap Ventilatory Support at home

Physical Assessment

Neurological: Alert, oriented to person and place, not date or month

Respiratory: Mild end expiratory wheezing, past FEV1FVC 0.8. Increased work of breathing, cough, use of accessory muscles, crackles bilaterally, shallow respirations, hyperresonance on percussion, pale lips and nail beds cyanotic.

Cardiovascular:  S1 and S 2 auscultated, tachycardic rhythm

Gastrointestinal: Abdomen soft, with positive bowel sounds all 4 quadrants

Genito Urinary:

Integumentary: pale, warm, dry, nail beds pale, bluish tinted

Hemoglobin 13

Hematocrit-40.5

White Blood Count 4.5 billion cells/L

Na-140

K-4.5

Cl-100

Calcium 9.5

Arterial blood gases pH 7.491, PCOD 27.6, POq 66.6 HCO3 20.6, Oxygen saturation 88% on room air. 

Creatinine kinase normal

Troponin I-negative

Brain natriuretic peptide 85pg/ml

Electrocardiogram-sinus tachycardia, no ST or T wave changes

Chest X Ray-bibasilar airway disease. Small bilateral pleural effusions. 

Sputum culture obtained

Temperature 99.3 Fahrenheit, heart rate 110 beats per minute, respiratory rate 28, Blood Pressure 104/54, weight 100 Kilograms, BMI 39.2, and Oxygen saturation 88% on room air.

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.

1000 ED Triage RN Notes

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.  Six months ago she had similar symptoms and was told that she had chronic obstructive pulmonary disease.  She reports shortness of breath at rest, being forgetful, feeling chilly and needing blankets

Lungs bilateral coarse breath sounds with bibasilar rhonchi. Positive peripheral pulses, negative edema.

1010 ED Primary RN Notes

The client is lying on a stretcher, head of bed elevated at 45 degree angle. Oxygen plated at 2 liters per nasal cannula due to O2 saturation of 88% and orders to maintain O2 at 90%. Respirations shallow, labored. Complains of being cold, warm blankets placed. Lungs bilaterally coarse with bibasilar rhonchi. 

1030 ED Primary RN Notes

Client’s vital signs reassessed. Breathing slightly less labored since Oxygen placed.

Past Medical History 

Chronic Obstructive Pulmonary Disease

Sleep apnea

No Known Drug Allergies

Social

Smokes 3 packs of cigarettes per day x 30 years

Client’s Home Meds

Fluticasone-vilanterol 100-25 mcg inhaled daily

Hydrochlorothiazide 25 mg by mouth daily

Albuterol -ipratropium inhaled every 4 hours prn

.

Home medical equipment-Bipap Ventilatory Support at home

Physical Assessment

Neurological: Alert, oriented to person and place, not date or month

Respiratory: Mild end expiratory wheezing, past FEV1FVC 0.8. Increased work of breathing, cough, use of accessory muscles, crackles bilaterally, shallow respirations, hyperresonance on percussion, pale lips and nail beds cyanotic.

Cardiovascular:  S1 and S 2 auscultated, tachycardic rhythm

Gastrointestinal: Abdomen soft, with positive bowel sounds all 4 quadrants

Genito Urinary:

Integumentary: pale, warm, dry, nail beds pale, bluish tinted

Hemoglobin 13

Hematocrit-40.5

White Blood Count 4.5 billion cells/L

Na-140

K-4.5

Cl-100

Calcium 9.5

Aterial blood gases pH 7.491, PCOD 27.6, POq 66.6 HCO3 20.6, Oxygen saturation 88% on room air. 

Creatinine kinase normal

Troponin I-negative

Brain natriuretic peptide 85pg/ml

Electrocardiogram-sinus tachycardia, no ST or T wave changes

Chest X Ray-bibasilar airway disease. Small bilateral pleural effusions. 

Sputum culture obtained

Fenoterol 100 micrograms every 6 hours via nebulizer

Prednisone 40 mg orally daily x 5 days.

Temperature 98.3 Fahrenheit, heart rate  100 beats per minute, respiratory rate 24, Blood Pressure 110/68,  and Oxygen saturation 89% on 2L/nasal cannula.