W. Cary Edwards School of Nursing Course Reflection Details The

Case Study ISBAR Handover: Chronic Obstructive Pulmonary Disease Introduction-David Nazzal a 62-year-old male with no known allergies (NKA) Situation- David presented to the Emergency Department at 2200 hrs. Upon assessment he was sitting in a tripod position and found to have a barrel chest. David presents with fever, sore throat, productive cough, yellow phlegm and dyspnoea. Background- David tested positive for COVID-19 three days ago through a rapid antigen test. Wife Linda indicated symptoms had progressively worsened with no relieving factors noted. David had similar episode a year ago with an acute exacerbation of chronic obstructive pulmonary disease (COPD) requiring hospitalisation. David has an increasing amount of purulent mucus which appears as yellow phlegm. He self-medicated with a Ventolin inhaler prior to admission but this had not resolved his symptoms Past Medical History- COPD, hypertension, hyperlipidaemia. He was a previous smoker for 30 years however he quit when he was diagnosed with COPD 10 years ago. Current Regular Medications taken: – Ipratropium (Atrovent) via nebulizer once a day- Salbutamol (Ventolin) puffer PRN- Lipitor 40mg daily- Not up to date on his annual pneumococcal and influenza vaccinations A to G Assessment Airway- Patent, own Breathing- RR-30 b/min, SPO2 78% on room air, Increased Shortness Of Breath (SOB) Auscultation: Diminished breath sounds bilaterally, with wheezing and crackles in the lung bases. Using accessory muscles of respiration ++. Circulation- Heart Rate (HR) Regular- 128 b/min-Sinus tachycardia. BP- 168/85 mmHg. Capillary Refill Time 3 sec, peripherally cool, heart sounds dual no murmur. Disability- GCS-14/15 E4V4M6, confused and distressed + Exposure- Febrile, skin intact, IV cannula right cubital fossa Abdo: bowel sounds present in all four quadrants with a soft, nontender abdomen Fluid- IVF fluids in progress TKVO, Nil by mouth Glucose- BSL- 5.8 mmol/L Imaging: Chest X-ray showing hyperinflated lungs with increased interstitial markings consistent with COPD exacerbation. Lab tests • CBC Result Reference Range Haemoglobin 153 g/L 120-140 g/L White blood cells 15.0×10^9/L 4.0-11.0×10^9/L Neutrophils 11.0×10^9/L 2.0-7.5×10^9/L Platelets 200×10^9/L 150-400×10^9/L C Reactive Protein (CRP) 25 mg/L <3mg/L • 2- COVID-19 PCR Test: Positive • ABG on room air (at 2200hrs) Result Reference Range pH 7.30 7.35-7.45 PaO2 55 mmHg 80-100 mmHg PaCO2 60 mmHg 35-45 mmHg HCO3- 28 mmol/L 22-26 mmol/L SpO2 78% (88-92% COPD) BE -4 mmol/L -2 to +2 mmol/L Clinical Impression: Infective Exacerbation of COPD COVID 19 +ve Recommendations • Continuous monitoring of vital signs- Transfer to High Dependency Unit • COVID-19 Management: Isolate the patient in a negative pressure room, implement infection control precautions, and monitor for progression of COVID-19 symptoms• Controlled oxygen therapy -Continuous pulse oximetry, to keep O2 between 88% to 92% • Sit patient in high fowlers position• 4/24 ABGs• Salbutamol (Ventolin) nebuliser 2/24 • Ipratroprium (Atrovent) via nebuliser 6/24• Prednisolone (40-50 mg daily) • 12- lead ECG 6th hourly • Blood troponin • Sputum culture • IV Azithromycin (Zithromax) 500 mg on day 1 ,followed by 250 mg once daily for the next four days.• 300 mg nirmatrelvir with ritonavir 100 mg taken together orally every 12 hours for 5 days.• Pulmonary function tests Spirometry when patient is stable Question 1 ( Explain the pathophysiology leading to all the clinical manifestations with which David Nazzal presents. Use the information from the deranged vital signs shown in the A to G assessment and the ISBAR handover. You must critically analyse the available evidence-based literature to support your response and provide intext in-text references Question 2 I.​Select 1 (one) intervention, from 2 (two) of three categories listed in the table below. II.​Provide rationales for each of the interventions listedfor Mr Nazzal in the categories that you have selected. You must critically analyse the available evidence-based literature to support your response and provide intext in-text references Category 1 Non-pharmacological interventions Category 2 Pharmacological interventions Category 3 Diagnostic interventions 1 Administer controlled oxygen therapy to maintain O2 saturation between 88% and 92%. 2 Position the patient in a high Fowler's position. 3 Perform continuous monitoring of vital signs. 1. Salbutamol, Ipratropium, and Prednisolone 2. Azithromycin 3. Nirmatrelvir and Ritonavir 1. 4th hrly ABGs 2. Sputum culture 3. Pulmonary function test- Spirometry 4. Blood Troponin level

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