Discussion Week #3: COPD COPD is defined by the Global Initiative for Chronic Obstructive Lung disease (COLD) as a common preventable and treatable disease that is characterized as persistent respiratory symptoms and airflow limitation. This limitation is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases, such as cigarette smoking (Kennedy-Malone et al., 2019).       What additional subjective information will you be asking of the patient?  Because COPD is a complex, chronic disease, patients require a comprehensive assessment of their symptoms. As the healthcare provider, I would ask him detailed questions regarding symptoms of dyspnea, cough, sputum production, lower respiratory infections, chest tightness, and fatigue. In the collection of data regarding history of present illness (HPI) I’d have the patient explain the onset, location/radiation, duration, characteristics, aggravating and alleviating factors, timing and severity of his symptoms. I would question what medications he is currently using. I’d ask him about any weight loss or anorexia pulmonary cachexia, which are commonly associated with severe COPD (Kennedy-Malone et al., 2019). It’s important to collect information from the patient regarding his past medical history, family history, history of exacerbations, and impact of symptoms on his activities of daily living and socioeconomic impact.  What additional objective findings would you be examining the patient for?  My objective assessment would begin with evaluation of all his vital signs including pulse oximetry and respiratory rate. Physical assessment would include inspection for ruddy or cyanotic skin color, increased anteroposterior diameter of the thorax, use of accessory muscles, and clubbing of nail beds (Cash & Glass, 2020). With auscultation I would assess his cough, lung sounds for prolonged expiration, wheezing or crackles, and decreased heart and breath sounds. Percussion may reveal hyperresonance. Thorough assessment of the cardiovascular system is imperative as it attempts to compensate for the restricted diaphragmatic movement caused by hyperinflation (Kennedy-Malone et al., 2019). I would assess for tachycardia, gallop rhythm, cor pulmonale, jugular venous distension, and peripheral edema.   What are the differential diagnoses that you are considering?  The first differential I would rule out is that of bronchiectasis considering the patient reports coughing up blood. Other differentials would include asthma, carcinoma of the lung, interstitial lung disease, and tuberculosis (Hollier, 2018).   What radiological examinations or additional diagnostic studies would you order? What additional laboratory tests might you consider ordering?  According to Hollier (2018), the gold standard for diagnosis of COPD is spirometry with bronchodilation. An FEV1/FVC ratio of < 70% constitutes diagnosis in symptomatic patients. Additional testing would include a chest x-ray, sputum testing, CBC (to rule out anemia since our patient complains of dyspnea), ECG, and a PPD. If his pulse oximetry is < 92%, I would check an arterial blood gas. What treatment and specific information about the prescription will you give this patient?  My treatment plan for this COPD patient would begin with continued encouragement for smoking cessation as well as removing exposure to any known respiratory irritants. According to Hollier (2018), most exacerbations of COPD are due to viral infections, including the common cold, so strict hand hygiene and vaccinations (influenza and pneumococcal conjugate) are recommended. Healthy lifestyle habits, exercise training, and proper nutrition are important for nonpharmacological management. Before beginning or modifying the patient’s pharmacological management, I would ascertain information on his current treatment regimen adherence and correct inhaler technique. I would instruct him to discontinue his cough medicine as antitussives are not recommended for the COPD patient. I would use the GOLD guidelines and base his treatment on the algorithm according to his FEV1 and exacerbation history.   Based on the diagnostic studies and sputum testing, if infection is suspected the patient would begin antibiotic treatment. For COPD exacerbation, the patient will be prescribed short-acting bronchodilators (SABDs) and short-term use of oral corticosteroids. Tiotropium, a long acting anticholinergic/antimuscarinic, is used for maintenance to decrease symptoms of dyspnea and reduce exacerbations. What are the potential complications from the treatment ordered?  Beta-2 Agonists-Short Acting (SABAs) selectively stimulate beta-2 adrenergic receptors in the lungs for bronchodilation (Hollier, 2018). The patient should be educated that it may increase heart rate, irritability, blood pressure and QTc interval, as well as lower potassium levels. Complications associated with steroid use include water retention, edema, increased blood pressure, and increased blood glucose levels. Additionally, oral steroids can lower the patient’s immune system. Tiotropium is contraindicated in atropine allergy and requires monitoring of GI/GU obstruction or narrow-angled glaucoma. The patient will be advised to discontinue its use if paradoxical bronchospasms occur. Will you be looking for a consult?  Collaborative management of the COPD patient is advised for optimal health outcomes. I would have the patient consult a pulmonologist based on the diagnostic study results, severity of symptoms, or if suboptimal response to therapies is noted. Hemoptysis is not uncommon in severe COPD patients and discovering its source is important if it persists. A pulmonologist can order further testing, such as a bronchoscopy to help treat some cases of bleeding. An evaluation can also be made for oxygen therapy if applicable (Kennedy-Malone et al., 2019).     References Cash, J. C., & Glass, C. A. (2019). Adult-gerontology practice guidelines. Springer Publishing Company, Llc. Hollier, A. (2018). Clinical guidelines in primary care (3rd ed.). Advanced Practice Education Associates. Kennedy-Malone, L., Lori Martin Plank, & Evelyn Groenke Duffy. (2019). Advanced practice nursing in the care of older adults (2nd ed.). F.A. Davis Company.