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Mr. Jake Dogson is a 62 year old male with a history of chronic obstructive pulmonary disease (COPD), hypertension, and hyperlipidemia. He was a previous smoker for forty years; he quit when he was diagnosed with COPD 10 years ago. His home medications include ipratroprium via nebulizer once a day, albuterol quick-relief inhaler, metoprolol, lisinopril, hydrochlorothiazide, and atorvastatin. He is up to date on his annual pneumococcal and influenza vaccinations, recommended for individuals with COPD (Holmes & Scullion, 2015). Family history for Mr. Dogson includes his father dying of a heart attack at age 72.
Jake Dogson was at home watching the food network learning a recipe to surprise his wife for his anniversary dinner. He had been at work the whole day, repairing arcade machines at the local theme park. His wife was teaching her water aerobics class at the gym. Mr. Dogson prepared the ingredients and began to cook his meal. While cooking, he left the kitchen for a moment and mistakenly left a towel on one of the over burners, which soon caught fire. He attempted to smother the fire with his apron which also caught fire. Smoke soon swarmed around him, forcing him to leave his home, running outside in a panic. A neighbor witnessed the scene and called 911. The fire department arrived at 18:00 to find him lying on the lawn with shallow breathing, wheezing, and a respiratory rate of 33, heart rate 116, blood pressure 140/90, and oxygen saturation at 88%. They transported him to St. Medical Hospital in Tuscaloosa, Alabama.
On arrival to the emergency department, nurses immediately took Mr. Dogson’s vitals (Appendix B). Upon assessment, Mr. Dogson was found to have barrel chest, bilateral wheezes, dyspnea, moderate intercostal retractions, cough with yellow-brown sputum, and hoarseness. Neurologically, Mr. Dogson was alert and oriented to person, place, time, and situation. He had S1S2 heart sounds and he presented with tachycardia and hypertension. Capillary refill was 3 seconds. He had bowel sounds in all four quadrants with a soft, nontender abdomen. The physician orders included oxygen to keep O2 above 90%, continuous pulse oximetry, STAT chest x-ray, basic metabolic panel, ABGs STAT, vitals every 30 minutes, albuterol 2.5 mg inhaled via nebulizer, a continuous EKG due to tachycardia and hypertension, and pulmonary function tests. The x-ray revealed lung hyperinflation and a flattened diaphragm due to his COPD. Arterial blood gases are listed in Appendix B. ECG revealed sinus tachycardia without signs of right ventricular hypertrophy or ischemia. Labs revealed increased hematocrit, BUN of 22, Creatinine 1.21, and elevated PaCO2 and carboxylhemoglobin from smoke inhalation (Demling, 2008). All other laboratory findings were within normal range. Pulmonary function tests revealed an FEV1/PVC ration of 0.55 which is indicative of airway obstruction (Cornforth, 2012). He was diagnosed with acute COPD exacerbation from smoke inhalation due to assessment and lab findings.
He was kept overnight for observation based on the continued symptoms, dyspnea and low oxygen saturation in the ER. The respiratory therapist administered two albuterol treatments in the ED. However, upon 05:00 assessment, Mr. Dogson showed dyspnea, increased wheezes, cyanosis of the lips, agitation, and confusion. His oxygen saturation was 77 and his respiratory rate increased to 36/minute. The nurse immediately began ventilating the patient with a bag valve mask at 15L/min and called a rapid response. The rapid response team intubated Mr. Dogson and transported him to the ICU at 06:30. He had an 18 gauge IV placed in his right upper arm with normal saline running at 75 ml/hour and a Foley catheter inserted.
In the ICU, physician orders included vitals every 30 minutes, ABGs every 4 hours, a chest x-ray to confirm tube placement, a CT scan to evaluate for hypoxic brain injury, a bronchoscopy to visualize the small airways, intake and output record, and a lactate level for to evaluate for lactic acidosis (Medscape 2017). Medication orders included albuterol, ipratroprium bromide, and methylprednisolone for bronchodilation and COPD management; famotidine for prevention of gastric reflux; lovenox for prevention of deep vein thrombosis; and labetalol and enalapril for hypertension (Medscape 2017).
By 14:00 on the first day in the ICU, Mr. Dogson’s vitals stabilized (Appendix A) however his ABGs still showed respiratory acidosis (Appendix B). Nursing care for the day included suctioning and oral care every 2 hours to prevent aspiration, sequential compression device applied to the legs, turning every two hours for skin precautions, and hourly assessment. Upon assessment the first day, Mr. Dogson consistently showed restlessness, bilateral faint wheezes, and diminished lower lobes due to COPD and airway injury (Dewar, et al. 2016).
ABGs following intubation showed improvement the next morning, and Mr. Dogson was no longer in respiratory acidosis. Therefore during rounds the physician decided to wean Mr. Dogson off the ventilator on synchronized intermittent mandatory ventilation (SIMV) and titrate sedation down. Upon spontaneous breathing trial (SBT) Mr. Dogson was found to be protecting his airway, he had an intact cough and gag reflex, he had decreased wheezing on auscultation and overall better lung sounds as he was responding well to the bronchodilators, steroid, and oxygen therapy.
The following day he was transferred to the med-surg unit. The nurse put him on an oxygen trial and was able to maintain an oxygen saturation of 90% on 2L nasal cannula (85% without oxygen therapy). Assessment findings were alert and oriented to person, place, time and situation, heart sounds S1S2 normal sinus rhythm, capillary refill 3 seconds, lung sounds clear with distant sounds in the lower lobes, and integument warm and dry. Mr. Dogson was discharged the next day with a prescription for home oxygen therapy.
During his stay at the hospital discharge planning, beginning on admission, case management aided Mr. and Mrs. Dogson with housing, support groups, grief counseling, and financial issues. The case manager ordered a home oxygen for Mr. Dogson, and requested an evaluation for and dispensing of a lightweight portable oxygen system and conserving device. He also received education regarding the use of his prescribed medications, encouraged a physical activity regimen, and prevention of future exacerbations of COPD.
Case management assisted in finding temporary housing at Mrs. Dogson’s sisters home after assisting in filing a claim with the Dogson’s homeowner’s insurance company. Case management also assisted in finding a local food bank near Mrs. Dogson’s sisters house to cope with living expenses and set up deliveries to the home once a week. Financial issues were important to consider as Mr. Dogson is a theme park worker and does not make much money and his wife only works part-time.
The case manager also provided Mr. Dogson with contact information for COPD support group one mile away from the home, as well as grief counseling for Mr. and Mrs. Dogson for loss of home, important documents, family photos, and personal belongings.
References
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