A nurse is caring for a client who has COPD.
Nurses’ Notes
Vital Signs
Medication
Home health nurse admission note:
Client discharged from healthcare facility yesterday following a 4-day stay for exacerbation of COPD. Lives alone; alert and oriented to person, place, and time. Lung fields with scattered rhonchi throughout, cough productive for thick white sputum, dyspnea with minimal exertion.
Clubbing is noted on fingers, chest is barrel-shaped. Supplemental oxygen at 2L/min via nasal cannula.
Home Health Nurse Note 3 days following discharge from health care facility: Client sleeping in recliner with nasal canula on their lap; awakens easily and is oriented to person but disoriented to place and time.
Lung sounds with scattered rhonchi, cough productive for thick, yellow secretions. 2+pitting edema bilateral in ankles and feet.
Re-oriented client. Client states “I don’t remember if I did that breathing machine thing you told me about.”
Instructed client on oxygen use, safety, and nebulizer treatments. Elevated lower extremities.
Select the 5 findings that require follow-up.
A.
Disorientation
B.
Barrel-shaped chest
C.
Yellow sputum
D.
Nebulizer use
E.
Ankle edema SaO2 92% Clubbing of fingers
F.
Lives alone
The Correct Answer and Explanation is:
The five findings that require follow-up are:
A. Disorientation
C. Yellow sputum
E. Ankle edema
F. Lives alone
SaO2 92%
Explanation
- Disorientation (A): The client’s disorientation to place and time, especially when previously oriented, indicates a potential worsening of their condition or a new complication. This change could be due to a range of factors including hypoxia, medication side effects, or infection. Prompt follow-up is essential to assess for potential causes such as worsening COPD, side effects from medications, or new complications like a respiratory infection or cerebrovascular event.
- Yellow sputum (C): The presence of yellow sputum suggests a potential bacterial infection or worsening inflammation. This change from thick white sputum to yellow indicates a need for further evaluation to determine if an antibiotic or other treatment is required. Yellow sputum is often associated with bacterial infections, which could exacerbate COPD symptoms and require medical intervention.
- Ankle edema (E): The 2+ pitting edema in the ankles and feet can be a sign of fluid retention, which may result from congestive heart failure, a common comorbidity in clients with advanced COPD. This symptom requires follow-up to evaluate its cause and appropriate management. It’s crucial to address this as it can indicate worsening systemic issues that may affect overall health.
- Lives alone (F): Given the client’s current condition, living alone could pose risks if the client experiences further health complications or disorientation. Ensuring that the client has appropriate support, possibly arranging for a caregiver or checking the feasibility of home support services, is essential to prevent potential emergencies or worsening of their condition.
- SaO2 92%: Although not explicitly listed in the options, the SaO2 level of 92% indicates that the client’s oxygen saturation is lower than the recommended threshold of 94-98% for COPD patients. This warrants immediate follow-up as inadequate oxygenation can exacerbate symptoms and lead to further complications. Monitoring and possibly adjusting supplemental oxygen therapy may be necessary.
Findings Not Requiring Immediate Follow-Up
- Barrel-shaped chest (B): This is a characteristic feature of advanced COPD and does not typically change rapidly, so it does not require urgent follow-up unless there are other concerning symptoms.
- Nebulizer use (D): This is a standard part of COPD management and should be followed up based on the client’s understanding and adherence to the treatment plan. It is less of an immediate concern compared to the symptoms noted above.
Each of these findings should be monitored and addressed as part of a comprehensive care plan to manage the client’s COPD effectively and prevent further complications.