Introduction to the Patient Status

Mr. “K” is a 68-year-old male patient. He was admitted to the emergency department on 23
March 2023, he was fully conscious complaining of severe chest tightness and difficulty
breathing. monitoring of vital signs, ECG, and bronchodilator sessions (nebulizer) were done for
the patient, the patient was kept in the chest department. Within three days, the patient had
tachycardia, tachypnea, dyspnea, a low-grade fever of 37.6, and abdominal pain. He was
transferred to the intensive care unit with these symptoms and diagnosed with acute exacerbation
of COPD. On arrival to the unit, my assessment showed that the patient was unconscious with 4
GSC. He was connected to a mechanical ventilator via ETT, NGT, subclavian central venous
catheter, and urinary catheter.
The past medical history of the patient includes Hypertension (HTN), and type 2 diabetes
mellitus (DM) for 40 years. His dad had DM and HTN. There was no surgical or allergy history
from food or drugs. The patient was a smoker for 40 years. The medical order for Mr. H to
remain NPO and his nutrition was Ringer lactate, Kidmin, and Dextrose 25% through IV (Osilla
and Sandeep Sharma, 2019). He should avoid using a lot of sodium and carbohydrates in his diet
because they produce more CO2 for the amount of oxygen used (Lancet, 2022).

Identification of the Problems:

Regarding the pathophysiology of the patient's health problem. Acute exacerbation of COPD
occurs due to the narrowing of the airway because of the accumulation of secretions, and the
main reason for its occurrence is smoking.it is a progressive pulmonary disease that causes
airflow obstruction and can be classified into emphysema and chronic bronchitis (Lancet 2012).
Emphysema (Pink Puffers): is enlargement of the alveoli so it will decrease the alveoli elasticity,
and surface area and damage the alveoli wall so it will limit the airflow entry (NIH , 2023).
Chronic Bronchitis (Blue Bloater): airway obstruction due to over-productivity of mucus (NIH
2022).(See appendix 1, 2, 3) (MacIntyre and Huang, 2018).
Assessment:
During my nursing assessment of the patient: the patient’s heart rate was 122 bpm,
respiratory rate 28, blood pressure 160/50 mmHg, and oxygen saturation 81% on room air.
wheezing was in both lungs, and the patient had a cough that was stimulated by suctioning.
Mr.’k abdomen bowel sound was hypoactive. he has very dry skin elasticity, sacrum ulcer level
1, redness in his right arm, hematoma in his left arm, and edema in both upper and lower
extremities. The patient was under the effects of opioids, and he risked falling. He did chest X-
ray, VBG, ECG, ABG and CBC.
Laboratory studies and investigations:
The laboratory studies and investigation of the patient include ABG: PH7.35, PCO2 57, HCO3
31.5 respiratory acidosis fully compensated (increase PCO2) (Castro and Keenaghan, 2022).
Also, he did CBC, and it was normal except HGB 12.6, WBC of 14.1thousand, RBCs 4 million
and an abnormal percentage of urea 26 indicated anemia, inflammation, and infection (Mayo
Clinic, 2023).
the doctor ordered the following Medication for the patient: The patient took this
medication in ICU: Levofloxacine750mg antibiotic (A sensitivity test should be done to any
antibiotic). Flagyl 500mg for infection caused by bacteria. Pantoprazole 40mg for peptic ulcer.
Perfalgan 10mg to relieve pain and reduce fever. Hydrocortisone 100mg to treat infection and
allergies. Magnesium sulfate 50% for constipation. Lasix 40mg for diuresis. Calcimate 10mg as
a nutritional supplement to increase the percentage of calcium in the body. Kapron 500mg to stop
bleeding. Gastrobiotic 550mg for diarrhea and irritable bowel syndrome. Acetylecistein 200mg
to reduce mucus secretion in the lung. Clexane 40mg to treat blood clots. Pulmicort, Atrovent,
Farcolin are bronchodilators.

Nursing management :
During the physical examination of the patient, some health problems were identified and ranked
in order of priority: Ineffective airway clearance related to accumulation of secretions, Fluid
volume deficit related to decrease fluid intake, Constipation related to poor nutrition and
immobility, Impaired skin integrity related to poor nutrition and immobility, Risk for infection
related to connections and invasive lines, Activity intolerance related to immobility, Risk for fall
related to cognitive impairment.
Ineffective airway related to the accumulation of secretion, evidenced by dyspnea,
restlessness, diminished crackles and wheezing. The desired outcome is to maintain a patent
airway with breath sound clearance. “Interventions: I periodically evaluated and assessed Mr.
H’s 1) auscultate breath sounds such as crackles and wheezing as some, degree of bronchospasm
is present with obstruction in the airway and may be manifested in breath sounds such as moist
crackles. 2) assess and monitor respiratory rate, tachycardia is usually present. 3) Assist the
patient in a semi or high-flower comfortable position to ease breathing and reduce muscle fatigue
and can aid chest expansion. 4) administer medication as prescriptive, for example: the goal of
pharmacological management of COPD is to reduce shortness of breath, control coughing and
wheezing and prevent exacerbation. Drug classes to accomplish this include short and long-
acting bronchodilators like corticosteroids and phosphodiesterases such as Artovent and
Pulmicort. 5) provide supplemental humidification such as a nebulizer which helps in
humidifying to reduce the viscosity of secretion and reduce or prevent the formation of thick
mucus plugs in bronchioles. 6) Monitor ABGs, and pulse oximetry to establish a baseline for
monitoring the progress or regression of the disease process and pulse oximetry to detect changes
in saturation. 7) suction, only as needed, for example, oxygen desaturation related to airway
secretion to stimulate cough to clear the airway of the unstable patient to do because of
ineffective cough or patient with a decreased level of consciousness.” (Doenges et al. 2019). All
the interventions have been done without any barriers and the goal has been partially met.

Or
Ineffective airway clearance related to accumulation of secretion: Secretions accumulate
inside the airway over time blocking them, which reduces the level of oxygen in the blood.
Therefore, these secretions must be eliminated by giving warm fluids, turning his position to
semi sitting position, doing back rub and chest percussion, (Doenges, Moorhouse and Murr,
2019). breathing and coughing exercises, doing bronchodilator sections (nebulizer), apply
oxygen source, giving respiratory medication with doctor order and doing suction. The patient
was given warm fluids, his position was turned, avoid alcohol, caffeine and smoking, back rub
was done, nebulizer, oxygen, medication and suction and a sample of secretions was taken for
analysis to take the appropriate antibiotic for the case (Doenges, Moorhouse and Murr, 2019).
Breathing and coughing exercises were not performed because the patient was unconscious.
Fluid volume deficit related to low fluid intake: lack of fluids in the body leads to tachycardia,
hypotension, dehydration, constipation and disturbed body temperature. This problem could be
solved by giving the patient excessive fluids per oral or nasogastric tube, administrate
intravenous fluids such as saline and ringer, take vegetables and fruits rich in fluids, reduce
patient’s effort and set in calm and cold places(Swearingen and Wright, 2019) and the patient
received all these procedures.
Constipation related to poor nutrition and immobility: A prolonged period of constipation
causes pain in the lower abdomen, hemorrhoids and difficulty in expelling it, so it should be
avoided and treated it by fed the patient with fiber like fruits and vegetables, increase fluid
intake, doing exercises, avoid alcohol and caffeine, use lubricant or stool softeners and laxatives
(Snyder and Sump, 2023). The patient did not move or do exercises because he was unconscious,
and the patient’s diet was changed to the diet appropriate for his condition.
Impaired skin integrity is related to immobility and poor nutrition: When the integrity of the skin
is weakened, this exposes the patient to some risks, such as bed sores, infection, and dehydration
and the patient already suffers from bed sores grade one. Therefore, it is necessary to provide the
patient with healthy diet consist fruits, vegetables and healthy fats, Excessive fluid should be
increased, keep skin dry, using moisturizers and lotions, turn the patient from side to side each
two hours, keep the bed sheets clean and tidy, put water prof sheet under places that sweat a lot
and massage to increase blood circulation (Swearingen and Wright, 2019) but keeping the
patient’s skin dry all the time was difficult, as the patient’s temperature was high and there was
sweat.
Risk for infection related to connections and invasive lines: One of the most common causes of
infection is the contacts that the patient comes into contact with urinary catheter, endotracheal
tube, central venous catheter and cannulas. Therefore, some measures must be taken to reduce
the chances of infection occurring to the patient like doing cannula care, central venous catheter
care, urinary catheter care, endotracheal tube care, changing gauze when fell up with blood or
secretions, use aseptic technic and perform hand washing and wear sterile gloves, give the
patient antibiotic with doctor order as a protection from infection (Snyder and Sump, 2023) and
trying to raise patient’s immunity through healthy diet, minerals and vitamins and the patient
receives all of these.

Impaired oral mucous membrane (mouth ulcer) related to pressure of ETT evidenced by,
mouth sores, ruptured mouth blister, tissue scraping, swelling and redness. The objective to that
the patient maintains an intact mucus membrane with the absence of sores, lesions, ulceration
and bleeding. Nursing intervention, 1) assess the cause of impaired oral mucus membranes like
infection, malnutrition or ETT insertion, assessment provides baseline data to plan further
interventions 2) provide medication and oral hygiene with a soft toothbrush and frequent rinsing
mouth with saline to feel the mouth ulcer. 3) topical anaesthetic for 2 mins and rinse with
lidocaine 2% to relieve pain 4) apply topical emollients like 0.1% triamcinolone to smooth the
mouth ulcer and provide comfort 5) Apply amlexanox topical agent over the ulcerated area with
the finger after oral hygiene to treat ulcers and improve healing. 6) administer NSAIDS like
ibuprofen or as prescribed to treat mouth inflammation and relieve pain. The goal has been
accomplished as the patient’s oral mucus membranes improved as evidenced by the redness and
the swelling has disappeared (Doenges et al. 2019).

Ethical aspect:
Every patient in intensive care has rights and responsibilities. Even if the patient is unconscious,
he has rights with the medical staff present, especially the nurses, because they are responsible
for his care (Keatings and Pamela, 2019). Full care must be provided to the patient, his customs,
traditions, and religious and worldly beliefs must be respected, and the patient’s rights must be
respected, including:
• Justice: The nurse must be fair in dealing with patients and also in providing care and not
neglect my patients at the expense of other patients or be lazy in performing her duty. She must
take all necessary measures for the patient’s recovery, and there will be no bias towards specific
patients (Burkhardt and Nathaniel, 2020).

• Maintaining the patient’s privacy is one of the especially important things that helps build
a strong relationship between the patient and the nurse. Maintaining privacy includes the
patient’s secrets and some personal matters, even his body while caring for him and bed bath.

• Explaining the procedures to the patient is also one of the patient’s rights over the nurse,
even if the patient is unconscious. This does not mean that he does not hear, he is just unable to
respond to the call, but he hears.

Summary
References
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