Running head: TYPICAL PATIENT CASE: COPD

Typical COPD Patient Case

Andrea Hunter
University of Arizona
NURS 660
Mary OConnell

TYPICAL PATIETN CASE: COPD

COPD is a chronic, progressive, irreversible disease that is complex in nature with a

variety of symptom manifestations and comorbidity management needs (Nici & ZuWallack,
2012). Symptom exacerbation is the cause of many readmissions, and reflects the need for this
population to have clear diagnosis, comprehensive assessments, and holistic, integrative and
patient-centered care across all transitions to support the best outcomes for this high risk
population (Nici & ZuWallack, 2012, Irene Foster, RN Case Manager, personal communication,
October 2, 2014). The following describes a typical patient case that a nurse may encounter in
their practice.
A 68-year-old woman arrives to the emergency department via ambulance with difficulty
breathing, productive cough, tachypnea, and low oxygen saturation. Her severe symptoms began
after coming back inside from smoking a cigarette to her job as a nail technician. She has had a
history of chronic coughing and sputum production for almost one year. She has a history of
diabetes, hypertension, obesity, and has been a 0.5 pack/day smoker for the last 52 years. She has
been widowed for the last 3 years and lives alone. She takes medication for high blood pressure
and metformin for her diet controlled diabetes per her report. She has never been diagnosed with
COPD, and knows little about it when asked. (Lev Korovin, MD, personal communication,
September 26, 2014, Anne Miros, Respiratory Therapist, October 2, 2014).
This case illustrates many risk factors for COPD as identified by the Centers for Disease
Control (CDC) (n.d.), including:
Over 65 years old
Female
A smoker
Widowed
In an occupation with suboptimal air quality and has a lower than average income
Pathophysiology for a typical COPD patient differs depending on disease manifestation,
whether originating from chronic bronchitis, emphysema, or refractory asthma.
In general, COPD is a hyper-inflammatory response by the immune system to irritants in
the respiratory tracts.
Chronic bronchitis is identified by excessive mucus secretion caused by irritants that
promote the increase in cells that produce and excrete mucus (Campbell, Gilbert &
Lausten, 2014)
o This causes alveoli to become plugged with mucus and bacteria, causing cilia to
malfunction, which further perpetuates the inflammatory response and airway
obstruction (Campbell, Gilbert & Lausten, 2014).
Emphysema is characterized by the hyperinflation and destruction of alveoli in the lungs,
caused by an inflammatory response reducing alveolar elastin and subsequent recoil
(Campbell, Gilbert, & Lausten, 2014)
o The alveoli then become enlarged and stretched out, smooth muscle tone is
destroyed along bronchioles, eventually causing alveolar collapse preventing
adequate exhalation (Campbell, Gilbert, & Lausten, 2014, Mosenifar, 2014)
o Alveolar wall destruction also leads to decreased blood oxygenation ability,
causing hyperventilation in decreased cardiac output in compensation (Mosenifar,
2014).
Refractory asthma is characterized by chronic airway inflammation and constriction in
response to irritant stimulus in the lungs (Campbell, Gilbert, & Lausten, 2014).

TYPICAL PATIETN CASE: COPD

o Shortness of breath is caused by histamine acting on and swelling smooth muscles

in the lungs (Campbell, Gilbert, & Lausten, 2014).
o Permanent airway remodeling due to chronic obstruction occurs with this type of
asthma (Mosenifar, 2014), rendering it irreversible and appropriate to place under
the COPD umbrella diagnosis.
Symptom manifestation occurs body-wide, in response to an overall compensation by the
body to balance from lack of oxygen or perfusion based on specific diagnosis pathophysiology.
Assessment data should be taken both from a verbal conversation of clinical history as well as
physical assessment, as history often predicts particular disease manifestation, such as smoking
in emphysema (Lev Korovin, MD, personal communication, September 26, 2014, Anne Miros,
Respiratory Therapist, October 2, 2014)..
Barrel chest and an overall wasted, thin-looking appearance, especially in individuals
with emphysema, can be seen upon general survey (Campbell, Gilbert, & Lausten, 2014,
Mosenifar, 2014).
Noted use of accessory muscles with normal breathing also can be seen upon general
survey (Mosenifar, 2014).
Tachypnea, dyspnea and prolonged expiration (Campbell, Gilbert, & Lausten, 2014).
o Pursed lip breathing may be present in attempts by the patient to slow respirations
in cases of acute exacerbation of shortness of breath.
Lung sounds are especially important to accurately assess, taking into account acute
patient needs during in response to assessment findings, such as oxygen needs or
respiratory treatments (Anne Miros, Respiratory Therapist, personal communication,
October 2, 2014).
o Wheezing can be noted with lung auscultation, especially in instances of symptom
exacerbation and assessment in acute care areas and after activity (Mosenifar,
2014, Anne Miros, Respiratory Therapist, personal communication, October 2,
2014).
o Coarse crackles and rhonchi may be heard with inspiration and alveoli re-inflation
that often dont clear with coughing (Mosenifar, 2014, Anne Miros, Respiratory
Therapist, personal communication, October 2, 2014).
o Decreased breath sounds throughout the lungs (Mosenifar, 2014, Anne Miros,
Respiratory Therapist, personal communication, October 2, 2014)
o Complaints of shortness of breath and difficulty breathing are common with
clinical history compilation (Mosenifar, 2014, Anne Miros, Respiratory Therapist,
personal communication, October 2, 2014).
Chronic cough, both productive and non-productive, is often associated with COPD. This
is often not reported until later by patients due gradual symptom onset (Mosenifar, 2014).
Edema or cyanosis may be noted with assessment of advanced cases of COPD, reflecting
right-sided heart failure (Mosenifar, 2014).
Chronic illnesses associated with COPD are common. It is necessary with any assessment
to also identify symptoms related these illnesses as well as to the primary diagnosis.
Depression is a common chronic illness associated with COPD (Mosenifar, 2014).
Assessing patient support, risk for suicide, anxiety, spiritual health and personal views on
health and wellness is essential for the integrative assessment of the COPD patient in
monitoring for depression or risk for depression.

TYPICAL PATIETN CASE: COPD

Respiratory failure can occur in all COPD manifestations related to the destruction of
airways caused by disease pathophysiology. Assessment of COPD level through accurate
and thorough spirometry can assess disease progression and prognosis (Lev Korovin,
MD, personal communication, September 26, 2014).
Right-sided heart failure occurs in patients with chronic bronchitis from increased cardiac
output and decreased breathing, resulting in CO2 retention and hypoxemia, respiratory
acidosis and pulmonary artery vasoconstriction (Mosenifar, 2014).
Muscle wasting and weight loss can occur chronically in patients with emphysema, in
response to the low cardiac output and hyperventilation and tissue hypoxia characteristic
of the disease (Mosenifar, 2014, Irene Foster, RN Case Manager, personal
communication, October 2, 2014).

TYPICAL PATIETN CASE: COPD

5
References

Campbell, L., Gilbert, M. A., & Laustsen, G., R. (2014). Pathophysiology and pharmacology:
Making connections and mastering dosage calculations. In L. Campbell, M. A. Gilbert, &
G. R. Laustsen (Eds.), Capstone Coach for Nursing Excellence (pp. 23-82). Philadelphia,
PA: F. A. Davis Company.
Centers for Disease Control and Prevention (n.d.). What is COPD? Retrieved from
http://www.cdc.gov/copd/index.htm
Mosenifar, Z. (2014). Chronic obstructive pulmonary disease: Pathophysiology. Retrieved
from http://emedicine.medscape.com/article/297664-overview#aw2aab6b2b3
Nici, L., & ZuWallack, R. (2012). An official American Thoracic Society workshop report:
The integrated care of the COPD patient. Proceedings of the American Thoracic Society,
(9)1, 9-18. doi 10.1513/pats.201201-014ST