Review Chest X-ray – COPD Nursing Care in ER

by Rhonda Lawes, PhD, RN

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    00:01 Okay, what time is it? You look at the clock on the wall and it is 10:15. Good.

    00:06 So how long has it been since the last time that you titrated or increased the oxygen? 15 minutes. Now remember, you should have this written down in your notes somehow.

    00:17 You've got the time of when you need to keep checking the oxygenation for sure to see if you need to titrate.

    00:23 You're always keeping an eye on the pulse ox, of course, but every 15 minutes you're gonna consider if you need to titrate or not.

    00:30 So the pulse ox is 90%. Okay, you look at the order.

    00:35 That's just there as in we just made it. So what do you do? Well, within the range of 90-93, what do you do? Well, you continue to monitor the patient but you maintain them on 4 liters for now.

    00:49 Now, why all of a sudden did she magically go up to 90? Well remember what we've done since she's been here.

    00:56 We have been titrating the oxygen and we gave her that albuterol, that breathing treatments so we're probably seeing the benefit of that albuterol, the bronchodilator and that's why we've managed to bump her sat up just a little bit but we know we got to keep a close eye on that because she's really at risk for that to drop back down.

    01:15 Okay, chest x-ray results are back. Now look at the results.

    01:19 Here's what's written on the report.

    01:21 Chest x-ray revealed enlarged lungs and flattened diaphragm consistent with the diagnosis of COPD.

    01:29 Okay, what's up with that? Why are the lungs enlarged? Well, based on your knowledge of COPD, you know that as patient with this disease has chronic hyperinflation particularly with emphysema, right? Because those alveolar walls get all blown up.

    01:46 They have chronic hyperinflation because of the air trapping that comes along with COPD so now you've got this tissue that's getting bigger and bigger and the patient ends up being barrel-chested.

    01:57 Normally you and I are just as wide as you are deep and that's what causes that appearance of being barrel-chested.

    02:04 So is that consistent with the COPD results on the chest x-ray? Yeah, it is because it says you have enlarged lungs and why is the diaphragm flattened? Because of the enlarged lungs.

    02:17 So that lines up with what we would see that also lets us know her disease process is kinda advanced.

    02:22 Now you'll also see consolidation in the right lower lobe.

    02:27 Ah, yeah, she had that respiratory infection.

    02:31 Clearly she got some nasty things going on in that right lower lobe.

    02:36 You wanna go back and really listen again closely with the lung sounds.

    02:40 Do you notice anything different on the right lower lobe than you do on the left? That would be critically important after you get results like this.

    02:48 Okay, the health care provider now has written another order.

    02:52 So the health care provider saw the chest x-ray results and they order Levofloxacin 750 mg IV or PO q 24 hours.

    03:02 Why? Okay, you know this but let me to break it down.

    03:07 First of all, what is Levofloxacin? Now the dosage, I'm gonna let you know that's an appropriate dose.

    03:14 That's what something you would always check.

    03:16 Remember, I was gonna give you the clue that it is okay.

    03:18 Now IV or PO, that's kind of odd, isn't it? Well, this particular antibiotic, yes. It's effective IV or PO.

    03:28 That's what's super cool about this antibiotic.

    03:31 Pretty broad spectrum but it's a common one that we would order.

    03:34 But why is the physician ordering this specific one? Because the consolidation on the right side in the chest x-ray plus the patient's other symptoms is indicative of pneumonia.

    03:49 So she's likely got a pneumonia going.

    03:51 Levofloxacin is an appropriate empiric antibiotic.

    03:55 Now that's a cool word, isn't it? Empiric.

    03:57 I want you to underline that. In pharmacology, we always teach that empiric means it's an educated guess.

    04:04 That means that based on knowing the community and knowing the types of bugs that we likely see patients come in with in our community that develop pneumonia, we're gonna give an antibiotic that will kill that most likely.

    04:17 So that's what empiric means.

    04:19 I don't know for sure what exact bug you have but I'm gonna give you my best educated guess based on what we see in the community, that's how I select the antibiotic. That's what the health care provider would do.

    04:31 She has community-acquired pneumonia because she came into the hospital with it.

    04:37 We didn't give it to her after she came in the hospital.

    04:40 She has a community-acquired so it developed outside of the hospital.

    04:45 Now, what are you supposed to make sure has been done before you give this antibiotic? Cool. Culture and sensitivity. We need that sputum.

    04:57 So if she can, it would be great if she can cough it up on her own otherwise you're gonna have to suction her to get it and that's just uncomfortable for the patient.

    05:05 So hopefully, we can help her and assist her in giving us that sputum specimen for the culture and sensitivity that'll help us narrow down the correct antibiotic for her and we're gonna make sure that we get that before.

    05:19 We get the culture and sensitivity sample before we give the antibiotic.

    About the Lecture

    The lecture Review Chest X-ray – COPD Nursing Care in ER by Rhonda Lawes, PhD, RN is from the course Respiratory Case Study: Nursing Care of COPD Patient.

    Included Quiz Questions

    1. Obtain sputum cultures
    2. Perform a nasal swab to test for influenza
    3. Draw the second set of arterial blood gases (ABGs)
    4. Increase oxygen administration to the client
    1. If done after administration, it will alter the sensitivity of the bacteria in the lungs
    2. If done after administration, it will change the type of bacteria in the lungs
    3. If done after administration, it will alter the second set of arterial blood gases (ABGs)
    4. If done after administration, the client will likely develop a superbug
    1. Clients with COPD have chronic hyperinflation due to air trapping in the alveoli
    2. This client likely has a tumor on the lungs
    3. Clients with COPD chronically retain too much oxygen
    4. The client likely has additional fluid in the pleural space
    1. Emphysema
    2. Acute left-sided heart failure
    3. Chronic sleep apnea
    4. Influenza virus
    1. A barrel chest
    2. Lower extremity pitting edema
    3. Light sputum
    4. Abdominal distention
    1. Flattening of the diaphragm
    2. Swelling of the diaphragm
    3. Enlarged thoracic surface of the diaphragm
    4. Fluid accumulation surrounding the diaphragm
    1. Levofloxacin
    2. Clindamycin
    3. Ceftrixone
    4. Vancomycin

    Author of lecture Review Chest X-ray – COPD Nursing Care in ER

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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