NRNP 6566 Week 11 Integrated Case Study Example

Integrated Admission Case Study: A COPD Exacerbation in a 66-Year-Old With Type 2 Diabetes, From Competing Scripts to a Plan With Evidence Inside

Student Name

College of Nursing, Walden University

NRNP 6566: Advanced Care of Adults in Acute Settings I

Instructor Name

Month Day, Year

Integrated Admission Case Study: A COPD Exacerbation in a 66-Year-Old With Type 2 Diabetes, From Competing Scripts to a Plan With Evidence Inside

Compact Presentation

The patient, drawn as a composite, supervised a textile mill until retiring; she is 66, with chronic obstructive pulmonary disease, a post-bronchodilator FEV1 of 44% predicted on testing last year, and type 2 diabetes managed on metformin plus a DPP-4 inhibitor, last A1c 7.4%. Her maintenance inhaler is a once-daily dual long-acting bronchodilator, and albuterol as needed. Two exacerbations in the past year, one treated in hospital.

Present illness: 3 days of a runny nose and sore throat, caught from her granddaughter, followed by 2 days of worsening breathlessness, cough, and sputum that changed from white to thick green and increased in amount. She now becomes breathless walking to the bathroom and has used her albuterol 8 to 10 times a day. No chest pain, no hemoptysis, no leg swelling, no orthopnea, no fever above 37.9 C.

Examination: respiratory rate 28; heart rate 108; blood pressure 142/84; oxygen saturation 86% on room air; temperature 37.8 C. Speaking in phrases; using accessory muscles; pursed-lip breathing. Diffuse expiratory wheezes, prolonged expiration, no focal crackles or bronchial breathing. Equal breath sounds and chest expansion. No jugular venous distension, no edema, calves soft and nontender.

Admission data: arterial blood gas on 2 liters by nasal cannula, pH 7.31, PaCO2 58 mm Hg, PaO2 62 mm Hg, bicarbonate 29 mmol/L. White cell count 12.4 x 10^9/L. Glucose 196 mg/dL. BNP 64 pg/mL. Troponin within normal limits. ECG: sinus tachycardia, no ischemic change. Chest radiograph: hyperinflation, no consolidation, no pneumothorax, no edema. Respiratory viral panel: rhinovirus positive.

Competing Illness Scripts

COPD exacerbation: an upper respiratory infection followed by increased dyspnea, sputum volume, and sputum purulence, with diffuse wheeze and hypercapnic acidosis on a background of severe airflow limitation. This script fits every finding.

Pneumonia: fever, leukocytosis, and purulent sputum fit, but there is no focal crackle or bronchial breathing and no consolidation on the radiograph. Not supported.

Pulmonary embolism: tachycardia and hypoxemia fit, but the onset was gradual after a viral illness, there is no pleuritic pain, hemoptysis, or leg sign, and wheeze with sputum change gives an alternative diagnosis more likely than embolism. Not the leading script, though an exacerbation that fails to respond would reopen it.

Heart failure: tachycardia and breathlessness fit, but there is no orthopnea, no raised neck veins, no edema, a normal BNP, and no edema on the radiograph. Not supported.

Pneumothorax: sudden breathlessness in severe COPD should always raise it, but her decline was gradual, breath sounds are equal, and the radiograph shows none. Not supported.

Working Diagnosis and Trigger

Acute exacerbation of COPD with acute-on-chronic hypercapnic respiratory failure and mild respiratory acidosis, triggered by rhinovirus infection, with increased sputum purulence suggesting bacterial involvement. Her elevated bicarbonate indicates chronic carbon dioxide retention; the pH of 7.31 shows an acute rise on top of it.

Management With Evidence Inside

Bronchodilation: nebulized short-acting beta-agonist and short-acting muscarinic antagonist every 4 hours and as needed, delivered by compressed air rather than oxygen to avoid driving up her carbon dioxide; her long-acting combination resumes once she can use the inhaler effectively.

Oxygen: titrate to a saturation of 88 to 92%. In a cluster randomized trial of patients with a COPD exacerbation treated by paramedics, titrated oxygen, compared with high-flow oxygen, reduced mortality in patients with confirmed COPD from 9% to 2% (Austin et al., 2010). The lower target is not a compromise; it is a treatment.

Ventilatory support: bilevel noninvasive ventilation started now, because she has a respiratory acidosis with a pH of 7.31 despite initial therapy. In a multicenter trial on general respiratory wards, early noninvasive ventilation for mild to moderate acidosis reduced the need for intubation from 27% to 15% and in-hospital mortality from 20% to 10% (Plant et al., 2000). Repeat blood gas at 1 hour; if pH falls or she tires, intensive care review.

Anti-inflammatory therapy: prednisone 40 mg daily for 5 days. In the REDUCE trial, 5 days of 40 mg prednisone was noninferior to 14 days for time to the next exacerbation over 180 days, with less total steroid exposure (Leuppi et al., 2013).

The infection question: she has all three cardinal symptoms, increased dyspnea, sputum volume, and sputum purulence. In a randomized crossover trial of exacerbations defined by these symptoms, antibiotics increased the success rate from 55% to 68% and halved the rate of deterioration (Anthonisen et al., 1987). A positive rhinovirus test does not exclude bacterial involvement. Oral amoxicillin-clavulanate for 5 days; no pneumonia on imaging, so no broader coverage.

Glycemic effect of therapy: prednisone will raise her glucose, mainly in the afternoon and evening. Metformin continued while her kidney function is normal; add intermediate-acting insulin with the morning prednisone dose, dosed by weight and adjusted daily, and correction insulin before meals; glucose checks before meals and at bedtime; taper the insulin as the steroid ends to avoid hypoglycemia after day 5.

Prophylaxis: subcutaneous heparin for venous thromboembolism; she is in bed on noninvasive ventilation and has an acute respiratory illness.

Monitoring and the day-3 checkpoint: she should be off noninvasive ventilation, with pH normal, speaking in sentences, and using albuterol no more than every 4 hours. Before discharge: inhaler technique checked, pulmonary rehabilitation referral, and vaccination status reviewed.

Evidence Against Judgment

The evidence does not settle every decision in this plan. The oxygen target rests on a prehospital trial, and its application in hospital is an extrapolation, though the physiology is the same. The antibiotic trial predates current viral testing, so it cannot say whether a patient with a positive rhinovirus test and purulent sputum benefits as much as its participants did; the decision here is a judgment weighted by her severe airflow limitation and previous hospital admission. The glycemic plan has no trial behind the specific insulin regimen; it follows the known timing of prednisone's effect on glucose and is adjusted daily rather than fixed. Where the evidence is direct, the plan follows it; where it is indirect, the note says so, so that the next clinician knows which choices are open to revision.

References

Anthonisen, N. R., Manfreda, J., Warren, C. P., Hershfield, E. S., Harding, G. K., & Nelson, N. A. (1987). Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Annals of Internal Medicine, 106(2), 196-204. https://doi.org/10.7326/0003-4819-106-2-196

Austin, M. A., Wills, K. E., Blizzard, L., Walters, E. H., & Wood-Baker, R. (2010). Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: Randomised controlled trial. BMJ, 341, Article c5462. https://doi.org/10.1136/bmj.c5462

Leuppi, J. D., Schuetz, P., Bingisser, R., Bodmer, M., Briel, M., Drescher, T., Duerring, U., Henzen, C., Leibbrandt, Y., Maier, S., Miedinger, D., Müller, B., Scherr, A., Schindler, C., Stoeckli, R., Viatte, S., von Garnier, C., Tamm, M., & Rutishauser, J. (2013). Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: The REDUCE randomized clinical trial. JAMA, 309(21), 2223-2231. https://doi.org/10.1001/jama.2013.5023

Plant, P. K., Owen, J. L., & Elliott, M. W. (2000). Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: A multicentre randomised controlled trial. The Lancet, 355(9219), 1931-1935. https://doi.org/10.1016/S0140-6736(00)02323-0