My case study is on a patient by the name of LaToya. LaToya is a fifty-one year-old black female. She was admitted to the medical-surgical department where I work, with a diagnosis of exacerbation of chronic obstructive pulmonary disease. She has a 66 pack-year history, meaning she smoked the equivalent of 365 packs of cigarettes for 66 years, and occasional drug and alcohol use. LaToya is divorced and lives alone in an older apartment building.
Chronic obstructive pulmonary disease (COPD) is a lung disease that limits your airflow. COPD may include chronic bronchitis, emphysema, or both. Chronic bronchitis is the production of increased mucus caused by inflammation. Bronchitis is considered chronic if you cough and produce excess mucus most days for three months in a year, two years in a row. Emphysema is a disease that damages the air sacs and/or the smallest breathing tubes in the lungs. COPD is a progressive disease that makes it hard to breathe and the symptoms will get worse over time.
Most cases of COPD occur as a result of long-term exposure to lung irritants that damage the lungs and the airways. Cigarette smoking is the leading cause of COPD. Most people who have COPD smoke or used to smoke. One of the greatest challenges for LaToya is to stop smoking. According to the Center for Disease Control (2012), the most important step a smoker can take after getting a COPD diagnosis is to quit. Not only will it make breathing easier, but it will cut down on the risk of severe exacerbations.

Health History
A health history contains both the subjective and objective data. Obtaining the subjective data is an important first step in treating the patient. The subjective data includes the history from the patient. It should include the client’s perception of their own health. The patient needs to be able to understand the questions being asked and communicate their health history. History taking allows nurses to gain a better understanding of the patient’s’ problems, and helps the nurse identify the most appropriate interventions to improve patient outcomes. (Fawcett & Rhynas, 2012).
Developmental age or stage will impact my strategy for obtaining a health history. When patients are developmentally not able to communicate their own health history, I rely on their parents or care takers to give us an accurate health history. This can also be true when interviewing an elderly adult who seeks medical care. The older adult may be forgetful or slower to respond. I may need to rely on others to fill in the gaps in the health history. The objective data is the information from physical assessment and test results.
Subjective Health History of LaToya
The first question of the illness history should be the patient’s chief complaint, followed by the history of that complaint: What brought you into the hospital today? When did you first notice these symptoms? Are there any associated symptoms? Are there any factors that make the symptoms better or worse? This information may guide me to ask additional questions. What treatments, medications, including over-the-counter medications, and vitamins are you currently taking? How is this illness affecting your activities of daily living, dressing, cooking, chores around the house, and shopping? This question may give me clues about the patient’s ability to care for themselves, and the need to ask additional questions. I would ask the patient to discuss your overall general health, including past illnesses and hospitalizations. Also, are you allergic to anything? Do you have a regular physician for routine exams and follow-up? Do you follow the recommendations of a provider? If no, what prevents it?
Psychosocial and Spiritual assessments include assessing the patient’s belief system to oneself, others, and a higher spirit. It includes variables that influence one’s lifestyle and mental health. Do you have religious and spiritual preferences? Who would we contact in case of an emergency? What is your living arrangement? What is your occupation? Do you have a hobby? What kinds of leisure activities do you enjoy? Any cultural or spiritual concerns regarding your care that you would like to tell me about?
Next, I should assess LaToya’s usage of cigarettes, alcohol, and drugs. Getting a complete smoking history is a critical part of the subjective assessment process. A good history helps me to understand what function or role smoking plays in the life of LaToya, and forms the basis for developing a solid plan to help her quit. I asked LaToya to tell me about your smoking: How did you start? How old were you? What functions or purpose does smoking play in your life? How much do you smoke? Has your smoking patterns changed recently? If so, can you tell me why? Tell me about your past quitting attempts: How many times have you tried to quit? What, and when was your longest quit attempt? What worked then to help you keep from smoking? What caused you to relapse? What do you need to do differently the next time? What needs to change now in order for you to decide to quit in the near future? How can I help you?
Next, I review with LaToya her perceptions, beliefs, and understanding of the health hazards of smoking and COPD. I asked LaToya her thoughts are about smoking and her connection between smoking and her current condition. I allowed LaToya to talk and express her feelings regarding cigarette smoking and her diagnosis of COPD. I remained at the bedside, actively listening to LaToya and encouraging her to tell me more. I continued to actively listen and use therapeutic touch when appropriate to let LaToya know that I do care about how she is feeling, and that I want to help. LaToya’s personal reasons to quit smoking will serve as important motivators during the quitting process, especially during difficult times, when confronted with triggers or cravings. LaToya may start to make connection between what she has verbalized, and what she is feeling. It is important for me to know if Latoya is using other drugs, such as alcohol or cocaine. This may also impact her ability to quit cigarette smoking. Assessing substance use is important to determine if LaToya needs any type of drug or alcohol intervention.
Further subjective assessments that I have explored included: What medications are you presently taking? Have you ever been hospitalized before, if so why? Have you had any recent weight changes? How many hours of sleep do you get each night? How many pillows do you require to sleep? Do you normally get short of breath walking up the stairs? How many stairs can you climb before you get short of breath? Depending on her answers I may need to ask for further clarification and investigation.
Objective Health History of LaToya
The objective data is information about the patient that can be measured. It includes findings on my physical exam, and any results of tests that were performed. After obtaining the subjective history, it will now help guide me through the physical exam by giving me clues on what body system assessments are more complex for LaToya. In addition, knowing that LaToya is short of breath, I know that I will need to alter her position for adequate ventilation during the exam. Furthermore, I may need to do a mini-database, examining the areas that are most appropriate until LaToya’s respiratory distress is resolved.
I knocked on the door, walked in, and introduced myself. I washed my hands and I made sure LaToya was comfortable. Then, I began the examination. As I start my head to toe assessment, I noticed Latoya’s body position, her facial expressions, mood, and her level of consciousness. First, I took her vital signs, while we talked, allowing me to begin assessing the neurological system and establishing rapport with Latoya. The four primary techniques of the physical assessment are inspection, palpation, percussion, and auscultation. The inspection begins during the subjective history, taking with the general survey of the patient. It includes the general appearance, behavior, hygiene, mental status, vital signs, height, and weight of the patient. During the subjective history phase, I also started setting my priorities of LaToya’s physical assessment. Her immediate priorities include breathing problems. According to Jarvis (2012), the highest priorities are airway, breathing, cardiac, and vital sign concerns. I also started to address her secondary concerns, which include medical intervention and safety concerns. And lastly, I focus on lower priority concerns; knowledge deficits, diet, self-care deficits, and inactivity.
Assessment always begins with inspection, so I inspected the posterior and anterior chest. First, I noted the shape, configuration, and symmetry of the thoracic cage, including the anteroposterior ratio, looking for a barrel chest. With LaToya facing me, I noted the rate and depth of respiration and the rhythm of respirations, looking at whether the patient's breathing is regular, irregular, labored, non-labored, symmetric, and whether or not she is using accessory muscles. If the respirations are irregular, I would note if the respirations are Kussmaul, Cheyne-Stokes, agonal, or if she has periods of apnea. I assessed her skin color, skin condition, and evaluated for cyanosis and pursed lips while breathing. I know that in dark-skin persons, I need to assess the conjunctivae, oral membranes, and nail beds when evaluating for cyanosis. I also took notice of Latoya’s body position, facial expression, and level of consciousness.
Palpation is the second assessment technique, starting with light touch to assess pulses, noting edema, capillary refill, identifying tender areas. During palpation of the chest, I checked for any lumps, masses, or tenderness. The third assessment technique is percussion. Percussion is an assessment technique which produces sounds by the examiner tapping on the patient's chest wall. I note the sound produced over the lung fields including amplitude, pitch, quality, and duration of the sound. I will also estimate the diaphragmatic excursion by noting the difference in the level of dullness on percussion with inspiration and expiration - normal is 5-6cm, but may be decreased with hyper-inflated lungs of COPD. (Elsherif & Noble, 2011).
Finally, auscultation of breath sounds is the last step in the lung assessment. After I warm my stethoscope diaphragm in my hands, I asked LaToya to breathe quietly and deeply through her opened mouth. I started at the base of the lungs to prevent overexertion of the patient. It is important to compare lung fields symmetrically, comparing the right with the left. I listened and compared each side for at least one full breath during inspiration and expiration, comparing lung fields from left to right. I also listened before and after a nebulizer treatment to note differences. I noted abnormal or adventitious breath sounds.
LaToya’s physical assessment abnormal findings are related to the respiratory function. On my initial assessment on the day shift, LaToya denied pain. She stated that she missed her three cats and asked if a nursing assistant to take her outside for a cigarette. She complained that her “cough is tiring at times” and described her cough as “productive with yellow flem.” I noted that she remains dyspneic at rest, and as well as on exertion. Her vital signs were; T 99.4F (37.4C); P78 regular rate and rhythm; R 26 regular and shallow; BP 136/94 LA; SaO2 95% on 4 liters of oxygen by nasal cannula. LaToya rated her pain as 0/10. Upon inspection of LaToya, I noticed her sitting on side of bed with elbows on the over side table, in the tripod position. Cyanosis was absent, but she was using accessory muscles to breath. Auscultation of LaToya’s left lung base revealed a wheeze or ronchi sound, and the right lung base revealed coarse crackles. I also needed to reevaluate after a respiratory treatment to assess its effectiveness. S1 and S2 was regular rate and rhythm, no extra sounds were noted. Palpation of the radial pulse found 2+ and symmetric, and dorsalis pedis is 1+ and symmetric. Probably a normal finding since both lower extremities have equal, palpable pulses, no edema, and assessment can be based on her age and smoking history. Skin was cool and flaking on the lower legs and feet. No edema was noted.
Using the nursing process, I identify LaToya’s dyspnea as my highest priority. It is the
“ABCs plus V” or immediate priority for Latoya at this time. Since LaToya’s oxygenation is adequate, I review orders for current medications and respiratory treatments, which I can initiate to improve her breathing. I also explained to LaToya to limit her activity to reserve her energy for breathing. Before I left LaToya, I asked her, “Do you have any questions? Is there anything that you need?” I checked to see the call bell is within reach, the bed was in a low position with the top 2 rails elevated. I reminded Latoya to call for help before attempting to get out of bed by herself, reminding her that I and the nurses are here to help.

Risk Factors, Health Promotion, and Primary Prevention Strategies
Risk Factors
The one most significant risk factor for COPD is long-term cigarette smoking. Between
80% and 90% of COPD cases are caused by cigarette smoking. Secondhand cigarette smoke for persons who lives with one or more smokers for decades is another risk factor. Age is also a risk factor, COPD develops slowly over years and most people are at least 40 years old when they notice symptoms. Another risk factor is long-term exposure to chemical fumes, vapors and dusts such as in an occupational hazard that can irritate and inflame your lungs. Less common risk factors for COPD include a history of frequent childhood lung infections, which increases your risk of scarring of lung tissue and reduces their elasticity. Furthermore, a rare genetic disorder known as alpha-1-antitrypsin deficiency is the source of a few cases of COPD. Persons with this form of COPD have a hereditary deficiency of a blood component.
Health Promotion and Prevention Strategies
LaToya needs to stop smoking immediately. It is not too late to reduce the exacerbations of the COPD, and improve her overall health. Most people need some help to quit smoking successfully. According to the American Lung Association, the most effective way to quit smoking is with a structured cessation program and a medication such as a patch, a lozenge, or prescription medication.
Medication is crucial to control the symptoms and to manage LaToya’s COPD. It is imperative to teach LaToya to take her medications as prescribed by her doctor. LaToya will most likely be prescribed long-acting maintenance medicines to help reduce inflammation and ease constriction in her airway, and short-acting bronchodilators to help relieve sudden COPD symptoms. LaToya needs medication teaching that includes name of medication, indication, dose, frequency, dosage, instructions on how to use inhalers, target symptoms that medication is treating including the expectation that should occur after taking the medication, and any special instructions such as taking before meals or taking at bedtime. I taught and reviewed potential side effects and other interactions that can occur, including combining medication with herbal remedies, and possible hindrance from other prescription medications and over-the-counter medications.
Metered dose inhalers (MDIs) are used to deliver bronchodilators. An MDI is a pressurized canister containing a medication that is released when the canister is compressed. A standard amount of medication is released with each compression of the MDI. To maximize the delivery of the medications to the airways, the patient has to learn to coordinate inhalation with each compression. I, along with Respiratory Therapist, teach LaToya the correct usage of a MDI. Wrong use of the MDI will place the medication in the mouth instead of in the airways. LaToya demonstrated delivery of the MDI consistently prior to discharge.
Nutritional Support and education are important strategies to maintain optimal health. Latoya has an increased risk for under nutrition due to her limited functional ability and shortness of breath. I made it clear to LaToya that choosing a low fat, low sodium diet with fresh fruit and vegetables is advantageous. I also explained to LaToya that too much salt may cause her to retain excess water, making breathing more difficult. Additionally, I instructed LaToya not to eat large, “heavy” meals to avoid getting short of breath while eating or just after. Furthermore, if Latoya’s breathing is uncomfortable after eating or she has a difficult time eating enough calories, eating 5 or 6 small meals may be ideal strategy for her to maintain optimal nutrition.
Regular exercise is beneficial for LaToya even with COPD. Regular exercise will increase her energy level, improve her circulation, reduce symptoms, and increase her endurance. I encouraged Latoya to talk to her doctor about how much physical activity and what kinds of activities are best for her. These might be stretching exercises, an aerobic exercise like walking, or exercise aimed at strengthening her muscles. As indicated, I consulted with discharge planning to check if LaToya is a candidate for Pulmonary Rehabilitation or Physical Therapy at home as well as the visiting nurse, upon discharge.
If upon discharge, oxygen therapy at home is required, LaToya will require teaching of oxygen therapy function in treating her COPD. Teaching includes rational that oxygen therapy will increase LaToya’s circulating oxygen content in her blood. This therapy will improve LaToya’s overall health and additionally, make physical activity easier. It will not only improve exercise endurance, but also improve sleep quality and improve her mental function. Additionally, I emphasized that she understands that oxygen is a flammable gas and compressed oxygen can catch on fire. She cannot allow anyone to smoke in her apartment. She needs to avoid smokers and other flames when in public.
Oxygen therapy education includes LaToya’s needs to recognize that she cannot use anything flammable while she is using oxygen, this includes cleaning fluids, gasoline, paint thinner, or aerosol sprays. LaToya needs to comprehend that the oxygen container has to stay at least 5 feet away from open flames such as heaters, candles, gas stoves, or hot water heaters. She needs to avoid alcohol and sedatives, which can slow her breathing. LaToya will need to put signs on all the doors of her apartment to let visitors and emergency workers know that oxygen is in use. Keeping a fire extinguisher and a phone close by in case of a fire is very important, as well as having working smoke detectors. Furthermore, LaToya needs to know that there are some mild side effects to oxygen therapy, including a reduced sense of smell and taste as well as cosmetic concerns related to the cords that attach to her face.
I educated LaToya on some additional health maintenance skills. I reminded LaToya to avoid respiratory irritants. I caution LaToya to stay out of extremely hot or cold weather and to avoid aggravating bronchial obstruction. I also warn her to avoid persons with respiratory infections, and crowds or areas with poor ventilation. Teaching LaToya how to recognize evidence of respiratory infection is vital. I taught her to report to her doctor immediately symptoms such as chest pain, changes in description of sputum (amount, color and consistency), expectorating larger amounts of sputum, increasing coughing and wheezing, increasing of shortness of breath. We also discussed why it is so important to have current vaccinations. I explained to LaToya that having her influenza and pneumococcal vaccines will protect her from conditions that she is greatly at risk for, and avoid a potentially severe illness.
With the decline of extended families and the increased mobility of other family members, support systems within families are diminished. I encouraged LaToya to stay involved with others. I encouraged Latoya to stay in touch with a member of her religious affiliation, and I urged her to give progress reports to a Church Deacon or significant church member who can update the congregation. I also stressed to LaToya to keep in contact with family and friends. As the nurse, I reinforced to LaToya to advocate for herself. I explained that she can do things, such as, writing down questions about her treatment and bringing her questions to the appointment, or by encouraging her to bring a supportive person with her to her medical appointments when possible. Finally, I remind LaToya to lean on family and friends for support.
Conclusion
The goals of COPD treatment are to prevent further deterioration in lung function, alleviate symptoms, and to improve activities of daily living which will increase the overall quality of life. The treatment strategies for LaToya include quitting smoking, taking medications as prescribed, oxygen supplementation as ordered, follow up care with primary and pulmonary specialist as indicated. To achieve these goals, I educated LaToya on the effects of smoking and to avoid smoking and other pollutants to improve her difficulty of breathing. We discussed sign and symptoms on when to seek a physician’s care immediately, before she has even more difficulty breathing. Diet and exercise will help minimize the effects of the COPD and improve overall health. Furthermore, I discussed with LaToya what she can do to improve her own health, such as, joining a smoking cessation program and in combination with some type of pharmacologic agent; LaToya can quit smoking and dramatically improve her health and breathing. Other health maintenance techniques that we discussed to improve LaToya’s health are keeping up-to- date vaccinations, a recommendation for pulmonary rehabilitation, and maintain personal support systems.
According to Healthy People 2020 (2012), goals for patients with COPD include: 1) to reduce activity limitations, 2) reduce deaths, 3) reduce hospitalizations, and 4) reduce emergency room visits. Upon evaluation, if LaToya meets the objectives of her COPD treatment, LaToya should exceed the aims initiated by Healthy People 2020.