Patient Case Assessment: Acute Exacerbation of COPD

72-year-old client enters the emergency room and reports shortness of
breath. The client has a two pack per day smoking history for 50 years.
The paint tales she clin waf dreat had progres a worse dover
Has a history of hypertension and hyperlipidemia.
• Admitting Diagnosis: Shortness of breath, acute exacerbation, COPD. 1200
• Vital signs
• B/P: 173/92
• Pulse: 123
Respirations: 39
: Ox saluten: 85% on room air
• Pain: 0/10

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Patient Case Assessment: Acute Exacerbation of COPD

Patient Information:

• Age: 72 years old
• Chief Complaint: Shortness of breath
• History:
  • 50-year history of smoking (2 packs per day)
  • Hypertension
  • Hyperlipidemia
• Admitting Diagnosis: Acute exacerbation of COPD

Vital Signs:

• Blood Pressure (BP): 173/92 mmHg (Elevated – Hypertension)
• Pulse (HR): 123 bpm (Tachycardia)
• Respiratory Rate: 39 breaths per minute (Severely increased – Respiratory distress)
• Oxygen Saturation (SpO₂): 85% on room air (Indicates hypoxia)
• Pain Level: 0/10

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Clinical Impression & Initial Management Considerations:

1. Severe Respiratory Distress
   • Rapid breathing, tachycardia, and low oxygen saturation indicate acute respiratory compromise.
   • Likely acute COPD exacerbation, possibly triggered by infection, allergens, or continued smoking.
2. Intervention Priorities:
   • Oxygen Therapy: Administer low-flow oxygen (e.g., nasal cannula 1-2 L/min) to prevent CO₂ retention.
   • Nebulized Bronchodilators: Short-acting beta-agonist (e.g., albuterol) and/or anticholinergic (e.g., ipratropium).
   • Corticosteroids: IV or oral prednisone to reduce inflammation.
   • Monitoring: Continuous SpO₂, respiratory rate, and ABG (arterial blood gases) to assess CO₂ retention.
   • Chest X-ray & Labs: Rule out pneumonia or other complications.
   • Smoking Cessation Counseling: Long-term management plan to reduce further COPD progression.

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