Case study - Chronic obstructive pulmonary disease (COPD): Nursing

Nurse Seema works on a medical-surgical unit and is caring for Richard, a 75-year-old male with a history of smoking, who was admitted for an acute exacerbation of chronic obstructive pulmonary disease, or COPD. After settling Richard in his room, Nurse Seema goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Richard’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes. 

First, Nurse Seema recognizes important cues including Richard’s vital signs, which are temperature 99.6 F or 37.5 C, heart rate 98 beats per minute, respirations 28 breaths per minute, blood pressure 142/90 mmHg, and oxygen saturation 85 percent on room air. When asked about pain, Richard reports a current pain level of 0 out of 10. Upon assessment, Nurse Seema notes that Richard’s respirations are labored, he has expiratory wheezing, and he’s leaning over in a tripod position. 

Next, Nurse Seema analyzes these cues.  She reviews the electronic health record, or EHR, and notes Richard’s arterial blood gas, or ABG, shows a low PaO2, indicating hypoxemia. She also recognizes COPD causes airway inflammation, leading to obstructed airflow out of the lungs, causing CO2 retention, making gas exchange difficult. Nurse Seema knows that Richard’s hypoxemia, wheezing, and tripod positioning indicate he’s experiencing impaired respiratory function and needs effective respiratory management. 

Now, using the information she’s gathered, Nurse Seema chooses a priority hypothesis of impaired gas exchange. 

Then, she generates solutions to address Richard’s impaired gas exchange that will include pharmacologic and nonpharmacologic interventions. She establishes an expected outcome that after intervening, Richard will maintain an oxygenation saturation between 89 to 92 percent on 2 liters nasal cannula within one hour.   

Nurse Seema then takes action to implement these solutions. She places Richard on continuous pulse oximetry monitoring and applies 2 liters of oxygen using a nasal cannula.