I. Introduction

Chronic obstructive pulmonary disease is persistent obstruction of the airways

occurring with emphysema, chronic bronchitis, or both disorders. In the United States,

about 16 million people suffer from chronic obstructive pulmonary disease (COPD). It is

second only to heart disease as a cause of disability that forces people to stop working. It

is the fourth most common cause of death, accounting for more than 100,000 deaths per

year in the United States; the number of deaths from COPD has increased by 40% over

the last 20 years. More than 95% of all deaths from COPD occur in people older than age

55. COPD affects men more often than women and is more often fatal in men, although

there has been a recent increase in the rate of deaths in women. COPD is also more often

fatal in whites than in nonwhites and in blue-collar workers than in white-collar workers.

COPD leads to chronic airflow obstruction, which is defined as a persistent

decrease in the rate of airflow through the lungs when the person breathes out. Both

emphysema and chronic bronchitis contribute to the airflow obstruction of COPD.

Emphysema is irreversible enlargement of many of the 300 million air sacs (alveoli) that

make up the lungs and destruction of the air sac walls. Chronic bronchitis is characterized

by a cough that produces sputum for 3 months or more during 2 successive years; the

cough is not due to another lung disease.

The airflow obstruction of COPD leads to an increase in the effort required for a

person to breathe. The obstruction causes air to become trapped in the lungs, so that

the amount of air remaining in the lungs after a full exhalation is increased. The

number of capillaries in the walls of the alveoli decreases. These abnormalities impair

the exchange of oxygen and carbon dioxide between the alveoli and the blood. In the

earlier stages of COPD, oxygen levels in the blood are decreased, but carbon dioxide

levels remain normal. In the later stages, carbon dioxide levels increase and oxygen

levels fall even further. The decrease in oxygen levels in the blood stimulates the bone

marrow to send more red blood cells into the bloodstream, a condition known as

secondary polycythemia.

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Cigarette smoking is the most important cause of COPD, although only about 15

to 20% of smokers develop the disease. Pipe and cigar smokers develop COPD more

often than nonsmokers but not as often as cigarette smokers. With age, susceptible

cigarette smokers lose lung function more rapidly than nonsmokers. If a person stops

smoking, there is little improvement in lung function. However, the rate of decline of

lung function does return to that of nonsmokers when the person stops smoking, thus

delaying the progression of symptoms. COPD tends to occur more often in some

families, so there may be an inherited tendency. Working in an environment polluted by

chemical fumes or dust may increase the risk of COPD). Exposure to air pollution and to

smoke from nearby cigarette smokers (secondhand or passive smoke exposure) worsens a

person's COPD and may cause COPD. A rare cause of COPD is a hereditary condition in

which the body produces a markedly decreased amount of the protein alpha1-antitrypsin.

The main role of this protein is to prevent neutrophil elastase from damaging the alveoli.

Consequently, emphysema develops by early middle age in people with severe alpha1-

antitrypsin deficiency, especially in those who also smoke.

This case study is all about Teofilo Aviles, 75 years old from Danao City, Cebu

Province. He was admitted at Cebu Doctor’s University Hospital on June 6, 2006 and

was diagnosed with Chronic Obstructive Pulmonary Disease with exacerbation. The

student nurse chose this case since statistics show that 95% of deaths with COPD occur

in people older than age 55 and this may be a cause for alarm. Because of this, the

student nurse wants to increase her knowledge on the illness specifically aiming at its

prevention, relieving the symptoms and prevention of complications. Through this study,

the student nurse can help a patient diagnosed with this disease to improve his condition

through the implementation of proper nursing interventions.

From this case study, the student nurse expects to increase her knowledge about

Chronic Obstructive Pulmonary Diseases. With the study done, she aims to give the

utmost treatment to patients with this disease and health teachings on its prevention.

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II. Objectives

General Objectives:

After one week of student nurse-patient interaction, the student nurse will be able

to acquire knowledge, attitude and skills in the management of Chronic Obstructive

Pulmonary Disease.

Specific Objectives:

After 2 days of student nurse – patient interaction, the student nurse will be able

to:

1. establish rapport with the patient.

2. perform and present a thorough nursing assessment of the patient with COPD

using inspection, palpation, percussion and auscultation.

3. relate the effects of the disease to the functional health pattern of the patient.

4. review the normal anatomy and physiology of the respiratory system.

5. compare the classical and clinical manifestations of the actual COPD.

6. develop a comprehensive nursing care plan for the patient.

7. develop an objective with regards to how proper rehabilitation can be performed

or facilitated.

General Objectives:

After one week of student nurse-patient interaction, the patient will be able to

acquire knowledge, attitude and skills in the management of Chronic Obstructive

Pulmonary Disease.

Specific Objectives:

After 2 days of student – nurse patient interaction, the patient and family will be able

to:

1. establish a trusting relationship with the student nurse.

2. cite the factors which caused his present health condition.

3. identify the clinical signs and symptoms of COPD.

4. verbalize feelings and concerns.

5. take appropriate measures for the management of symptoms.

6. follow specific treatment regimen ordered or taught.

7. demonstrate beginning skills in pursed lip breathing for patients with COPD.

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III. Nursing Assessment

1. Personal History

1.1 Patient’s Profile

Name of Patient: Teofilo Aviles

Age: 75 years old

Sex: male

Religion: Roman Catholic

Date of Admission: June 6, 2006

Room No.: Male Medical Ward no. 1

Complaints: Dyspnea and cough

Impression/ Diagnosis: Chronic Obstructive Pulmonary Disease

(Chronic Bronchitis)

Physician: Dr. Gerardo Ypil

Dr. Julius Serrano

1.2 Family and Individual Information, Social and Health History

Mr. Teofilo Aviles is a 75 year old widow, Roman Catholic and currently residing

at National Road Dunggoan, Danao City, Cebu Province. The patient has 2 male children

and both are currently residing in the United States. His wife died at age 60 due to Lung

Cancer.

The patient used to be a smoker for more than 20 years and smokes at least 1 – 2

packs per day. The patient is known to be hypertensive for 15 years with fair compliance

of medications. His father was also hypertensive but not diabetic. The patient was also

diagnosed last march 2006 with Chronic Obstructive Pulmonary Disease and was given

Salmetrol/Seretide 250 mcg Diskus 1 puff twice a day. Mr. Aviles has been noted to have

on and off dyspnea.

About 2 weeks prior to admission, dyspnea was noted upon exertion associated

with productive cough with frothy, white phlegm. Continuing with the medication given,

no relief was noted. 3 days prior to admission, patient was seen by attending physician to

have dyspnea at rest associated with orthopnea and productive cough, thus sought

consultation again and was advised for admission.

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1.3 Level of Growth and Development

1.3.1 Normal Development at Particular Stage

NORMAL DEVELOPMENT (OLDER ADULTS OVER 65 YEARS)

Physical Development

As the person ages, a number of physical changes occur; some are visible, some

are not. In general, lean body mass is reduced and fat tissue increases until around age 60.

Bone mass decreases. Extracellular fluid remains constant, however, intracellular fluid

decreases and leads to reduced total body fluid. Thus, elders are at risk for developing

dehydration.

Integumentary

increased skin dryness

increased skin pallor

increased skin fragility

progressive wrinkling and sagging of the skin

brown “age spots” on exposed body parts

decreased perspiration

thinning and graying of scalp, pubic, and axillary hair

slower nail growth and increased thickening with ridges

Neuromuscular

Decreased speed and power of skeletal muscle contractions

Slowed reaction time

Los of height

Osteoporosis

Joint stiffness

Impaired balance

Sensory andPerceptual

Loss of visual acuity

Increased sensitivity to glare and decreased ability to adjust to darkness

Partial or complete glossy white circle around the periphery of the cornea

Progressive loss of hearing

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Decreased sense of taste, especially the sweet sensations at the tip of the tongue

Decreased sense of smell

Increased threshold for sensations of pain, touch and temperature

Pulmonary

Decreased ability to expel foreign r accumulated matter

Decreased lung expansion, less effective exhalation, reduced vital capacity, and

increased residual volume

Difficulty, short, heavy, rapid breathing (dyspnea) following intense exercise

Cardiovascular

Reduced cardiac output and stroke volume, particularly during increased activity

or unusual demands; may result in shortness of breath on exertion and pooling of

blood in the extremities

Reduced elasticity and increased rigidity of arteries

Increase in diastolic and systolic blood pressure

Orthostatic hypertension

Gastrointestinal

Delayed swallowing time

Increased tendency for indigestion

Increased tendency for constipation

Urinary

Reduced filtering ability of the kidney and impaired renal function

Less effective concentration of urine

Urinary urgency and urinary frequency

Tendency for a nocturnal frequency and retention of residual urine

Genitals

Prostate enlargement (benign) in men

Multiple changes in women (shrinkage and atrophy of the vulva, cervix, uterus,

fallopian tubes and ovaries; reduction in secretions; and changes in vaginal flora)

Cognitive development

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Changes in the cognitive structures occur as the person ages. It is believed that

progressive loss of neurons occur. In addition, blood flow in the brain decreases, the

meninges appear to thicken and brain metabolism slows. As yet, little is known about the

effect of these physical changes on the cognitive functioning of the older adult.

In older adults changes in cognitive abilities are more often a difference in speed

than inability. Over all the older adult maintains intelligence, problem solving, judgment,

creativity, and other well-practiced cognitive skills. Intellectual loss generally reflects a

disease process such as atherosclerosis, which causes the blood vessels to narrow and

diminishes perfusion of nutrients to the brain. Most older adults do not experience

cognitive impairments.

Moral development

According to Kohlberg, moral development is completed in the early adult years.

Most old people stay at Kohlberg’s conventional level of moral development and some

are at preconventional level. An older person at the preconventional level obeys rules to

avoid pain and the displeasure of others. At stage 1, a person defines good and bad in

relation to self, where as older people at stage 2 may act to meet another’s needs as well

as their own. Older adults at the conventional level follow society’s rules of conduct in

response to the expectation of others.

The value and belief patterns that are important to older adults may have little or

no significance to younger people because they developed during a time that was very

different from today. In addition, a large number of today’s elders are either foreign-born

or first-generation citizens. Cultural background, life experiences, gender, religion, and

social economic status all influence one’s values. The nurse must identify and consider

the specific values of the older client when nursing care is planned.

Spiritual development

Older adults can contemplate new religions and philosophical views and try to

understand ideas missed previously or interpreted differently. The older person also

derives a sense of worth by sharing experiences or views. In contrast, the older adult who

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has not matured spiritually may feel impoverishment or despair as the drive for economic

and professional success wanes.

Carson (1989) states that religion “ takes a new meaning for the elderly, who may

find comfort, solace, and affirmation in religious activities.” The older person knowledge

becomes wisdom, an inner resource for dealing with both positive and negative life

experiences. Many older people have strong religious convictions and continue to attend

religious meetings or services. Involvement in religion often help the older adult to

resolve issues related to the meaning of life, to adversity, or to good fortune. The “old-

old” person who cannot attend formal services often continues religious participations in

a more private manner. Many older adults watch television evangelists and some being

vulnerable to fund raising ventures, send these organizations money that they can ill

afford to spare.

According to Fowler and Keen(1985), some people enter the sixth stage of

spiritual development universalizing. People whose spiritual development reaches this

level think and act in a way that exemplifies love and justice.

1.3.2 The Ill Person at Particular Stage

In a person with COPD, a mild cough that produces clear sputum develops by

around age 45, usually when the person first gets out of bed in the morning. Cough and

sputum production persist for the next 10 years; shortness of breath may be noted with

exertion. Sometimes, shortness of breath is first noted only with a lung infection, during

which time the person coughs more and has an increased amount of sputum. The color of

the sputum changes from clear to yellow or green.

By the time the person reaches his middle to late 60s, especially with continued

smoking, shortness of breath with exertion becomes more troublesome. A lung infection

may result in severe shortness of breath even when the person is at rest and may require

hospitalization. Shortness of breath during activities of daily living, such as toileting,

washing, dressing and sexual activity may persist after the person has recovered from the

lung infection.

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About one third of people with severe COPD experience severe weight loss, in

part because shortness of breath makes eating difficult and in part because of increased

levels in the blood of a substance called tumor necrosis factor. Swelling of the legs often

develops, which may be due to cor pulmonale. People with COPD may intermittently

cough up blood, which is usually due to inflammation of the bronchi, but which always

raises the concern of lung cancer. Morning headaches may occur because breathing

decreases during sleep, which causes increased retention of carbon dioxide.

As COPD progresses, some people, especially those who have emphysema,

develop unusual breathing patterns. Some people breathe out through pursed lips. Others

find it more comfortable to stand over a table with their arms outstretched and weight on

their palms, a maneuver that improves the function of the diaphragm. Over time, many

people develop a barrel chest as the size of the lungs increases because of trapped air.

Low oxygen levels in the blood can give a blue tint to the skin (cyanosis). Clubbing of

the fingers is rare and raises the suspicion of lung cancer.

Symptoms may suddenly worsen during flare-ups of COPD. A flare-up is a

worsening of symptoms of cough, increased sputum, and shortness of breath. Sputum

color often changes from white to yellow or green. The patient had onset fever and body

aches which sometimes occur. Shortness of breath was present when the patient was at

rest.

2. Diagnostic Results

Complete Blood Count: June 6, 2006

Diagnostic Test Normal Value Result Significance

hemoglobin

hematocrit

WBC count

neutrophil

14.0 – 17.5 g/dl

41.5 – 50.4 %

4.4 – 11.0 x 10^9/ul

40 – 70 %

6.0 g/dl

32.8 %

17.8 x 10^9/ul

89 %

Anemia

Anemia

Acute infections,

emphysema, MI

Acute infections,

acute MI, COPD

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lymphocyte

monocyte

RBC

MCH

MCV

MCHC

Platelet

20 – 40 %

0 – 8 %

4.5 – 5.9 10^12/L

27.5-33.2 pg

80 – 96 fL

33.4 – 35.5 %

150 – 45010^9/L

9 %

2 %

2.64 x 10^12/L

22.72

68.18

22.72

150-450

decreased w/ the use

of corticosteroids

Normal

Anemia

hypochromic RBC’s

microcytic RBC’s

Hemoglobin

deficiency

Normal

Urinalysis June 6, 2006

Diagnostic Test Normal Value Result Significance

color

appearance

pH

specific gravity

protein

glucose

ketones

blood

leucocyte

nitrite

bilirubin

urobilinogen

RBC/ hpf

WBC hpf

pale to dark color

clear/slightly cloudy

4.6-8.0

1.001-1.030

negative

negative

negative

negative

negative

negative

negative

0.2 EU/dl

2-3

4-5

yellow

slightly cloudy

6.0

1.011

+2

negative

negative

negative

trace

negative

negative

0.2 EU/dl

0-2

1-5

normal

normal

normal

normal

nephropathy

normal

normal

normal

bacteriuria

normal

normal

normal

normal

normal

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3. Present Profile of Functional Health Patterns

3.1 Health Perception/ Health Management Pattern

The patient describes his health as usually good. At this time, he feels weak and has

a difficulty in breathing. He weighs 134 lbs. To keep healthy and prevent disorders, he

has been taking vitamins like Pharmaton and Enervon C. The patient is now suffering

from a chronic obstructive disease and is experiencing dyspnea upon exertion and even at

rest. He has also been diabetic and hypertensive for 15 years now. 2 weeks before

admission, patient has been experiencing dyspnea and productive cough with whitish

phlegm. Patient was given Cefexine 200 mg BID with good compliance. However,

patient persisted to have cough and dyspnea, thus sough admission.

3.2 Nutritional – Metabolic Pattern

The patient does not eat much since he has to take special precaution with regards

to his diet. He is now on a soft diet, 1800 KCalories, 2 grams sodium chloride, low

potassium, low purine, low phosphate, 40 grams protein, low cholesterol, low saturated

fat, divided in 3 meals and 2 snacks with no fruit and no juices. His fluid intake is also

limited to 800 cc per day.

3.4 Activity/ Exercise Pattern

The patient is too weak to perform any exercise at the moment. He is not

ambulatory and is even having a difficult time turning his body from one side to another.

The doctor has ordered that he has to change position every 2 hours to prevent bed sores.

He is able to raise his hand and foot but only to atleast an angle of 15 degrees.

3.5 Cognitive/ Perceptual Pattern

The patient has a deficit in visual perception but is not wearing his eye glasses at

the moment. He does not complain of vertigo and is able to read and write.

3.6 Rest/ Sleep Pattern

The patient only has a maximum of atleast 2 hours of sleep now a day. He usually

wakes up once in a while and just stares blankly. He is also easily awakened whenever

someone would enter his room.

3.7 Self-perception Pattern

The patient is concerned about his health and wants to recover as soon as

possible. He also verbalized that he misses going to the beach and also drinking coffee.

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3.8 Role Relationship Pattern

The patient speaks in vernacular. Speech is sometimes slurred but relevant. The

patient does not use any gestures in speaking since his extremities are weak.

The patient lives together with his 2 sons at Danao City. When he has problems,

he turns to his neighbor, who has been his friend for 20 years now. His 2 sons are already

married and are now residing in the United States, while his other 2 sons are still single

and living in the same house.

3.9 Sexuality-Reproductive Pattern

The patient is already a widow since his wife died at age 60 due to lung cancer.

Since then, he did not re-marry and had no sexual contact.

3.10 Value-Belief System

The patient finds strength from his family. He used to attend mass every Sunday

together with his 2 sons but now he only prays at night and asks God’s guidance and

healing power.

4. Pathophysiology and Rationale

4.1 Normal Anatomy and Physiology of Organ/ System Affected

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The lung is the essential organ of respiration in air-breathing vertebrates. Its

principal function is to transport oxygen from the atmosphere into the bloodstream, and

to excrete carbon dioxide from the bloodstream into the atmosphere. This it accomplishes

with the mosaic of specialized cells that form millions of tiny, exceptionally thin-walled

air sacs where gas exchange takes place. Lungs also have nonrespiratory functions.

Respiratory function

Energy production from aerobic respiration often requires oxygen and produces

carbon dioxide as a by-product, creating a need for an efficient means of oxygen delivery

to cells and carbon dioxide excretion from cells. In smaller organisms, such as single-

celled bacteria, this process of gas exchange can take place entirely by simple diffusion.

In larger organisms, this is not possible; only a small proportion of cells are close enough

to the surface for oxygen from the atmosphere to enter them through diffusion. Two

major adaptations made it possible for organisms to attain great multicellularity: an

efficient circulatory system that conveyed gases to and from the deepest tissues in the

body, and a large, internalised respiratory system that centralized the task of obtaining

oxygen from the atmosphere and bringing it into the body, whence it could rapidly be

distributed to all tissues via the circulatory system.

In air-breathing vertebrates, respiration occurs in a series of steps. Air is brought

into the animal via the airways — in reptiles, birds and mammals this often consists of

the nose; the pharynx; the larynx; the trachea; the bronchi and bronchioles; and the

terminal branches of the respiratory tree. The lungs of mammals are a rich lattice of

alveoli, which provide an enormous surface area for gas exchange. A network of fine

capillaries allows transport of blood over the surface of alveoli. Oxygen from the air

inside the alveoli diffuses into the bloodstream, and carbon dioxide diffuses from the

blood to the alveoli, both across thin alveolar membranes. The drawing and expulsion of

air is driven by muscular action; in early tetrapods, air was driven into the lungs by the

pharyngeal muscles, whereas in reptiles, birds and mammals a more complicated

musculoskeletal system is used. In the mammal, a large muscle, the diaphragm (in

addition to the internal intercostal muscles), drive ventilation by periodically altering the

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intra-thoracic volume and pressure; by increasing volume and thus decreasing pressure,

air flows into the airways down a pressure gradient, and by reducing volume and

increasing pressure, the reverse occurs. During normal breathing, expiration is passive

and no muscles are contracted.. (the diaphragm relaxes).

Nonrespiratory functions

In addition to respiratory functions such as gas exchange and regulation of hydrogen ion

concentration, the lungs also:

influence the concentration of biologically active substances and drugs used in

medicine in arterial blood

filter out small blood clots formed in veins

serve as a physical layer of soft, shock-absorbent protection for the heart, which

the lungs flank and nearly enclose.

The environment of the lung is very moist, which makes it a hospitable environment

for bacteria. Many respiratory illnesses are the result of bacterial or viral infection of the

lungs.

Breathing is largely driven by the muscular diaphragm at the bottom of the thorax.

Contraction of the diaphragm vertically expands the cavity in which the lung is enclosed.

Relaxation of the diaphragm has the opposite effect. The rib cage itself is also able to

expand and contract to some degree, through the action of other respiratory and accessory

resipratory muscles. As a result, air is sucked into or expelled out of the lungs, always

moving down its pressure gradient.

Air enters through the oral and nasal cavities; it flows through the larynx and into the

trachea, which branches out into bronchi. In humans, it is the two main bronchi

(produced by the bifurcation of the trachea) that enter the roots of the lungs. The bronchi

continue to divide within the lung, and after multiple generations of divisions, give rise to

bronchioles. Eventually the bronchial tree ends in alveolar sacs, composed of alveoli.

Alveoli are essentially tiny sacs in close contact with blood filled capillaries. Here

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oxygen from the air diffuses into the blood, where it is carried by hemoglobin, and

carried via pulmonary veins towards the heart.

Deoxygenated blood from the heart travels via the pulmonary artery to the lungs for

oxidation.

The lungs are located inside the thoracic cavity, protected by the bony structure of the

rib cage. Each is enclosed by a double-layered sac called pleura. The inner layer of the

sac (visceral pleura) adheres tightly to the lung and the outer layer (parietal pleura) is

attached to the inner wall of the thoracic cavity. The two layers are separated by a thin

space called the pleural cavity that is filled with pleural fluid; this allows the inner and

outer layers to slide over each other, and prevents them from being separated easily. The

left lung is smaller than the right one, to provide room for the heart.

The lungs are attached to the heart and trachea through structures that are called the

"roots of the lungs." The roots of the lungs are the bronchi, pulmonary vessels, bronchial

vessels, lymphatic vessels, and nerves. These structures enter and leave at the hilus of the

lung.

The lungs are divided into lobes by the horizontal and oblique fissures. The right lung

has three lobes and the left lung has two. A unique feature of the left lung is the cardiac

notch, which helps create the lingula (Latin for "tongue") of the left lung.

The lungs are connected to the upper airway by the trachea and bronchi. The trachea

runs down the neck and divides into left and right bronchi behind the sternal angle ( at the

level of the fourth thoracic vertebra T4). The right main bronchus is shorter, wider and

runs more vertically than the left. For this reason, it is more common to aspirate foreign

objects into the right lung.

The right bronchus gives rise to the superior lobe bronchus before entering the hilum

and dividing into the middle and inferior lobe bronchi. The left bronchus enters the hilum

and gives rise to the superior and inferior lobe bronchi.

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The bronchi enter the lung and branch out to form the bronchial tree. The bronchi

divide into smaller bronchioles, which terminate into alveoli. An alveolus is composed of

respiratory tissue and is the site of gas exchange in the lung. The inner walls of the

alveoli are covered in surfactant, a fluid which reduces the surface tension of the alveoli,

allowing them to expand and recoil with inspiration and expiration and preventing them

from collapsing.

The blood supply to the lungs is from two sources: the pulmonary vessels and the

bronchial vessels. The bronchial vessels support the nonrespiratory tissue and the

pulmonary vessels provide support to the respiratory tissue.

The pulmonary arteries carry deoxygenated blood, which has returned to the heart

from the systemic venous system, to the lungs to be reoxygenated. The pulmonary veins

carry oxygenated blood back to the heart to go to the systemic arterial system. The right

and left pulmonary arteries arise from the pulmonary trunk and carry deoxygenated blood

to their respective lungs. The pulmonary veins, two on each side, carry oxygenated blood

to the left atrium of the heart.

The bronchial arteries that supply the nonrespiratory tissue of the lung arise from

different sources. The left bronchial arteries come off of the thoracic aorta, however, the

right bronchial artery has a variable source.

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4.2 Schematic Diagram

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Predisposing Factors:- increasing age (older than

40 years)- male gender- alpha 1 antitrypsin

deficiency

Precipitating Factors:- smoking - occupational exposure to

inhaled chemicals- pollution- lower economic status- work environment

CHRONIC BRONCHITIS- inflammation of airways

- irritation of the lung tissues

- increase in goblet cells

- increase in mucous glands

- reduce numbers of ciliated cells

Signs and symptoms:

- Productive cough, with progression over time to intermittent dyspnea- Frequent and recurrent pulmonary infections- Progressive cardiac/respiratory failure over time, with edema - Frequent cough and expectoration - Use of accessory muscles of respiration - Coarse rhonchi and wheezing heard on auscultation.

Pharmacologic:- corticosteroids- beta agonists- anti-cholinergic

agents- antibiotics

Nursing Management:- good nutrition for patient- encourage exercise programs- advise patient to quit smoking- environmental changes

4.3 Disease Process and its Effects on Different Organ/ System

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of

death in this country. Patients typically have symptoms of both chronic bronchitis and

emphysema, but the classic triad also includes asthma. Most of the time COPD is

secondary to tobacco abuse, although cystic fibrosis, alpha-1 antitrypsin deficiency,

bronchiectasis, and some rare forms of bullous lung diseases may be causes as well.

Patients with COPD are susceptible to many insults that can lead rapidly to an

acute deterioration superimposed on chronic disease. Quick and accurate recognition of

these patients along with aggressive and prompt intervention may be the only action that

prevents frank respiratory failure.

Pathophysiology: COPD is a mixture of 3 separate disease processes that together form

the complete clinical and pathophysiological picture. These processes are chronic

bronchitis, emphysema and, to a lesser extent, asthma. Each case of COPD is unique in

the blend of processes; however, 2 main types of the disease are recognized.

Chronic bronchitis

In this type, chronic bronchitis plays the major role. Chronic bronchitis is defined

by excessive mucus production with airway obstruction and notable hyperplasia of

mucus-producing glands.

Damage to the endothelium impairs the mucociliary response that clears bacteria

and mucus. Inflammation and secretions provide the obstructive component of chronic

bronchitis. In contrast to emphysema, chronic bronchitis is associated with a relatively

undamaged pulmonary capillary bed. Emphysema is present to a variable degree but

usually is centrilobular rather than panlobular. The body responds by decreasing

ventilation and increasing cardiac output. This V/Q mismatch results in rapid circulation

in a poorly ventilated lung, leading to hypoxemia and polycythemia.

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Eventually, hypercapnia and respiratory acidosis develop, leading to pulmonary

artery vasoconstriction and cor pulmonale. With the ensuing hypoxemia, polycythemia,

and increased CO2 retention, these patients have signs of right heart failure and are

known as "blue bloaters."

What causes COPD?

Smoking is responsible for COPD in our country. Although not all cigarette

smokers will develop COPD, it is estimated that 15% will. Smokers with COPD have

higher death rates than nonsmokers with COPD. They also have more frequent

respiratory symptoms (coughing, shortness of breath, etc.) and more deterioration in lung

function than non-smokers.

Effects of passive smoking or "second-hand smoke" on the lungs are not well-

known; however, evidence suggests that respiratory infections and symptoms are more

common in children who live in households where adults smoke.

Cigarette smoking damages the lungs in many ways. For example, the irritating

effect of cigarette smoke attracts cells to the lungs that promote inflammation. Cigarette

smoke also stimulates these inflammatory cells to release elastase, an enzyme that breaks

down the elastic fibers in lung tissue.

Air pollution can cause problems for persons with lung disease, but it is unclear

whether air pollution contributes to the development of COPD. Some occupational

pollutants such as cadmium and silica do increase the risk of COPD. Persons at risk for

this type of occupational pollution include coal miners, construction workers, metal

workers, cotton workers, etc. (Most of this risk is associated with cigarette smoking and

these occupations, an issue not well controlled for. These occupations are more often

associated with interstitial lung diseases, especially the pneumoconoses) Nevertheless,

the adverse effects of smoking cigarettes on lung function is far greater than occupational

exposure.

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Another well-established cause of COPD is a deficiency of alpha-1 antitrypsin

(AAT). AAT deficiency is a rare genetic (inherited) disorder that accounts for less than

1% of the COPD in the United States.

As discussed previously, normal function of the lung is dependent on elastic

fibers surrounding the airways and in the alveolar walls. Elastic fibers are composed of a

protein called elastin. An enzyme called elastase that is found even in normal lungs (and

is increased in cigarette smokers) can break down the elastin and damage the airways and

alveoli. Another protein called alpha-1 antitrypsin (AAT) (produced by the liver and

released into the blood) is present in normal lungs and can block the damaging effects of

elastase on elastin.

The manufacture of AAT by the liver is controlled by genes which are contained

in DNA-containing chromosomes that are inherited. Each person has two AAT genes,

one inherited from each parent. Individuals who inherit two defective AAT genes (one

from each parent) have either low amounts of AAT in the blood or AAT that does not

function properly. The reduced action of AAT in these individuals allows the destruction

of tissue in the lungs by elastase to continue unopposed. This causes emphysema by age

30 or 40. Cigarette smoking accelerates the destruction and results in an even earlier

onset of COPD.

Individuals with one normal and one defective AAT gene have AAT levels that

are lower than normal but higher than individuals with two defective genes. These

individuals are not believed to have an increased risk of developing COPD if they do not

smoke cigarettes; however, their risk of COPD probably is higher than normal if they

smoke.

What are the symptoms of COPD?

Typically, after smoking 20 or more cigarettes a day for more than twenty years,

patients with COPD develop a chronic cough, shortness of breath (dyspnea) and frequent

respiratory infections.

2

In patients affected predominantly by emphysema, shortness of breath may be the

major symptom. Dyspnea usually is most noticeable during increased physical activity,

but as emphysema progresses, dyspnea occurs at rest.

In patients with chronic bronchitis as well as bronchiectasis, chronic cough and

sputum production are the major symptoms. The sputum is usually clear and thick.

Periodic chest infections can cause fever, dyspnea, coughing, production of purulent

(cloudy and discolored) sputum and wheezing. (Wheezing is a high pitched noise

produced in the lungs during exhalation when mucous, bronchospasm, or loss of lung

elasticity obstructs airways.) Infections occur more frequently as bronchitis and

bronchiectasis progress.

In advanced COPD, patients may develop cyanosis (bluish discoloration of the

lips and nail beds) due to a lack of oxygen in blood. They also may develop morning

headaches due to an inability to remove carbon dioxide from the blood. Weight loss

occurs in some patients, primarily (other possibility is reduced intake of food) because of

the additional energy that is required just to breathe. In advanced COPD, small blood

vessels in the lungs are destroyed, and this blocks the flow of blood through the lungs. As

a result, the heart must pump with increased force and pressure to get blood to flow

through the lungs. (The elevated pressure in the blood vessels of the lungs is called

pulmonary hypertension.) If the heart cannot manage the additional work, heart failure

results and leads to swelling of the feet and ankles.

Patients with COPD may cough up blood (hemoptysis). Usually hemoptysis is

due to damage to the inner lining of the airways and the airways' blood vessels; however,

occasionally, hemoptysis may signal the development of lung cancer.

How is COPD diagnosed?

COPD usually is first diagnosed on the basis of a medical history which discloses

many of the symptoms of COPD and a physical examination which discloses signs of

COPD. Other tests to diagnose COPD include chest x-ray, computerized tomography (CT

2

or CAT scan) of the chest, tests of lung function (pulmonary function tests) and the

measurement of oxygen and carbon dioxide levels in the blood.

COPD is suspected in chronic smokers who develop shortness of breath with or

without exertion, chronic persistent cough with sputum production, and frequent

infections of the lungs such as bronchitis or pneumonia. Sometimes COPD is first

diagnosed after a patient develops a respiratory illness necessitating hospitalization.

Some physical findings of COPD include enlarged chest cavity, wheezing, faint and

distant breathing sounds when listening to the chest by stethoscope.

In patients affected predominantly with emphysema, the chest x-ray may show an

enlarged chest cavity and decreased lung markings reflecting destruction of lung tissue

and enlargement of air-spaces. In patients with predominantly chronic bronchitis, the

chest x-ray may show increased lung markings which represent the thickened, inflamed

and scarred airways. Computerized tomography (CT or CAT scan) of the chest is a

specialized x-ray that can accurately demonstrate the abnormal lung tissue and airways in

COPD. Chest x-rays and CT scans of the chest also are useful in excluding lung

infections (pneumonia) and cancers. CT scan of the chest usually is not necessary for the

routine diagnosis and management of COPD.

The most commonly used pulmonary function test is spirometry, a test which

quantitates the amount of airway obstruction. During spirometry, the patient takes a full

breath and then exhales fast and forcefully into a tube connected to a machine that

measures the volume of expired air. The FEV1 (the volume of air expired in 1 second) is

a reliable and useful measure of airflow obstruction; the lower the FEV1, the greater the

airway obstruction. The FEV1 can be determined again after treatment with

bronchodilators. Improvement in FEV1 after bronchodilator treatment means that airway

obstruction is reversible. Demonstrating improvement in FEV1 also helps doctors select

the proper bronchodilators for patients. Measurements of FEV1 can be repeated over time

to determine how rapidly airway obstruction is progressing.

2

Spirometry also can measure the maximal volume of air that can be inhaled and

exhaled with each breath. This maximal volume is called the forced vital capacity or FVC

By comparing the FEV1 with FVC, airway obstruction can be even more accurately

quantified than FEV1. The normal ratio of FEV1/FVC is 70%, but it is reduced in

patients with COPD.

Oxygen and carbon dioxide levels can be measured in samples of blood obtained

from an artery, but this requires inserting a needle into an artery. A less invasive method

to measure oxygen levels in the blood is called pulse oximetry. Pulse oximetry works on

the principle that the degree of redness of hemoglobin (the protein in blood that carries

oxygen) is proportional to the amount of oxygen, that is, the more oxygen there is in

blood, the redder the blood. A probe (oximeter) is placed around a fingertip. On one side

of the finger the probe shines a light. Some of the light is transmitted through the

fingertip, and the transmitted light is measured on the opposite side of the finger by the

probe. Depending on the redness of the blood within the fingertip (that is, the amount of

oxygen in the blood) more or less light is transmitted through the fingertip. Thus, by

measuring the amount of light transmitted, it is possible to determine the amount of

oxygen in the blood.

Complications:

Some complications that must be anticipated in COPD treatment include the

following:

o Incidence of pneumothorax due to bleb formation is relatively high;

consider pneumothorax in all patients with COPD who have increased

shortness of breath.

o In patients who require long-term steroid use, the possibility of adrenal

crisis is very real; at a minimum, patients with steroid-dependent COPD

should receive stress dosing in the event of an exacerbation or any other

stressor.

2

o Infection (common)

o Cor pulmonale

o Secondary polycythemia

o Bullous lung disease

o Acute or chronic respiratory failure

o Pulmonary hypertension

o Malnutrition

2

4.4 Comparative Chart of Classical and Clinical manifestations

CLASSICAL SYMPTOM CLINICAL SYMPTOM RATIONALE

COUGH Manifested

- the patient has been

coughing for 2 weeks now

Cough results from the

irritation of the mucous

membranes anywhere in the

respiratory tract.

Medical Surgical Nursing

by Brunner and Suddarth

p.472

SPUTUM PRODUCTION Manifested

- the patient has a whitish

sputum

Sputum production is the

reaction of the lungs to any

constantly recurring irritant.

Medical Surgical Nursing

by Brunner and Suddarth p.

473

DYSPNEA Manifested

- the patient has a

respiratory rate of 30

breaths per minute and has

dyspnea at rest

Dyspnea occurs due to the

obstruction of airflow in the

narrowed lumen resulting

from the inflammatory

process.

Medical surgical nursing by

Brunner and Suddarth

p.569-571

BARREL CHEST

THORAX

CONFIGURATION

Manifested Barrel chest occurs as a

result of over inflation of

the lungs. There is an

increase anteroposterior

diameter of the thorax.

Medical surgical nursing by

Brunner and Suddarth p.476

WHEEZING Manifested Wheezing is often the major

2

- crackles with slight

wheezing was herd upon

ausculation

finding in a patient with

bronchoconstriction or

airway narrowing. Medical

surgical nursing by Brunner

and Suddarth p.474

WEIGHT LOSS Manifested

- the patient currently

weighs 134 lbs. and

weighed 155 lbs. before

Weight loss occurs in some

patients (other possibility is

reduced food intake)

because of the additional

energy that is required just

to breathe.

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CYANOSIS Not manifested The bluish discoloration of

the lips and nail beds is due

to the lack of oxygen in the

blood.

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MORNING HEADACHES Not manifested Occurs when there is

inability to remove carbon

dioxide from the blood.

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SWELLING OF FEET

AND ANKLES

Not manifested Swelling is due to the

additional workload of the

heart resulting to failure.

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2

Nursing Intervention

1. Care Guide of Patient with Disease Condition

Treatment for COPD is based on the patient's general medical condition and

severity of the disease. Options usually include a combination of the following

treatments. Proper treatment of COPD can result in improvements in exercise capacity,

activity levels, quality of life, less hospitalization, and longer survival.

Stop smoking

By far, the most important and effective treatment for COPD is smoking

cessation, which results in improvement in lung function during the first year after

quitting and a return to a normal rate of change in lung function thereafter. The

benefits of quitting smoking apply regardless of age, amount smoked or severity of

COPD. Quitting smoking also reduces the risk of sudden cardiac death, heart attacks,

strokes and lung cancer. People with COPD live longer and have a better quality of

life if they stop smoking.

Despite the best efforts to stop smoking, many patients do not succeed in

quitting. Many doctors are reluctant to prescribe treatment for patients with COPD

who continue to smoke. That is unwarranted. There is good evidence that

bronchodilators and inhaled corticosteroids are as beneficial for smokers as for

nonsmokers.

Medications

1. Short-acting bronchodilators, both beta agonists and anticholinergics, are the

mainstay of therapy for COPD.

2. Long-acting bronchodilators are indicated for moderate to severe COPD.

Currently two beta agonists are available. A long-acting anticholinergic is

under consideration for approval by the U.S. Food and Drug Administration.

3. Inhaled corticosteroids are recommended for patients with moderate to severe

COPD with frequent exacerbations (incidents which worsen symptoms).

2

4. Systemic corticosteroids (IV or pills) are beneficial for treatment of severe

exacerbations.

5. Antibiotics may be beneficial for treatment of exacerbations.

6. Theophylline in low doses may reduce frequency of exacerbations in patients

who tolerate it (it has many side effects).

Home oxygen therapy

Supplemental oxygen is prescribed to correct hypoxemia (low blood

oxygen) to improve the physical and mental functioning of patients. Several

studies have shown greater long-term survival in patients with severe COPD who

received oxygen therapy.

Pulmonary rehabilitation

For those who have difficulty completing daily tasks, pulmonary

rehabilitation may be very beneficial. The program can improve exercise capacity,

reduce the hospitalization rate and improve overall quality of life for patients. It is

conducted by a multidisciplinary team of specialists, including pulmonary

physicians, respiratory therapists, physical therapists, occupational therapists and

dietitians with expertise in the care of people with chronic pulmonary diseases.

The comprehensive evaluation, educational and exercise components are covered

on an outpatient or inpatient basis.

Surgery

Bullectomy- removing a part of the lung which is damaged.

Lung Volume Reduction Surgery- parts of the lung are removed to stop

the lung from overly increasing in size. This procedure has limited

effectiveness and is not widely used.

Lung Transplantation- replacing a damaged lung or lungs with healthy

donor lungs.

2

2. Actual patient care

2.1 Physical assessment

Body part I P P A

Skin

Head

Hair

Scalp

Face

Eyebrows

Pupils

Iris

Muscle Function

Fair complexion with red blotches on right arm

normoce-phalic, no irregularities

gray hair, without parasites

absence of dandruff & parasites

symmetrical facial features

hair evenly distributed, aligned together

Pupils Equally Round Reactive To Light & Accommodation, papillary high reflexes, equal reactions of both sides

black

followed moving objects

Senile, warm to touch

no lumps or masses noted

no lumps or mass noted

warm to touch

smooth

2

Lashes

Upper & Lower Lids

Sclera

Conjunctiva

Lacrimal ducts

Cornea

Visual Acuity

Nose

Frontal & Maxillary Sinuses

Lips

Gums

Teeth

Hard Palate

Soft Palate

Uvula

properly

short,curves outward

lids are color brown, closes symmetrically

white

pale palpebral

no discharges

corneal light reflexes equal on both sides

can read clearly at near or far distance, without eyeglasses

not obstructed,

no occlusion when transillumina-tion was done

dark brown, dry

blackish gums

no teeth left but uses dentures

pink

pink

straight & hanging

not painful

not painful

smooth

soft

hard & stable

hard

soft, gag reflex present

not painful

3

Tonsils

Ears

Neck

Lymph Nodes

Trachea

Lungs

Heart

Chest

Abdomen

Spleen

Genitalia

Upper Extremities

non-visible

no occlusion, symmetrical on both sides, upper auricle in line with outer contour of eye, hearing is clear

same as normal skin tone

Tachypnea: 30 breaths per minute

barrel shape

no suture present, flat

Male, with Condom Catheter

weak muscle strength but

no lumps/mass

not palpable

located at midline, no masses

smooth, warm to touch, no pain

not palpable

Radial pulse: 76bpm

tympanic sound

(+)Crackles with slight wheezing in the apex of the lungs(left side)

Normal & Regular Rhythm:76 bpm

Bowel sounds= 3-5 gurgling sounds ( normal intervals)

BP: 160/90mmhg

3

Lower Extremities

able to give resistance, with IV infusing well at left arm D5. 3%NaCl@10 gtts/min.

not able to walk, needs assistance

weak muscle tone

3

3

3

3

3

3

3

2.3 DTR

3

DRUG/ DOSE/ FREQ/ROUTE

CLASSIFICATION/ MECHANISM

INDICATIONS/ CONTRAINDICATIONS/ ADVERSE REACTIONS

PRINCIPLES OF CARE

TREATMENT EVALUATION

COMBIVENT1 neb every 6 hours(10am-4pm-10pm)

Anti-asthmatic preparation- Bronchodilators- relaxes bronchial vascular smooth muscles by stimulatory B2 receptors

Indications:- bronchospasmContraindications:- hypersensitivityAdverse reactions:- fine tremors- palpitations- headache

1. Perform oral inhalation correctly2. Wash inhaler in warm soapy water at least once a week

a. monitor vital signsb. position patient properly in Semi Fowler’s positionc. encourage deep breathing exercises

Patient was placed in a Semi Fowler’s position and was able to do deep breathing.

SERETIDE DISKUS 250 mcg1 puff BID(8am – 6pm)

Anti-asthmatic- Beta 2 selective adrenergic agent- long acting agonist that binds to beta 2 receptors in the lungs, causing bronchodilation, also inhibits release of inflammatory mediators in the lungs, blocking swelling and inflammation

Indications:- prevention and

maintenance therapy of bronchospasm in patients with COPD

Contraindications: - acute airway

obstructionAdverse reactions:- headache, tremor,

tachycardia

1. instruct patient in the proper use if diskus

2. monitor use of inhaler

a. monitor I and O

b. monitor vital signs

c. gargle with water after use

d. moderate high back rest

Patient was placed on a moderate high back rest and was able to gargle with water.

FELODIPINE(PLENDIL ER)5 mg 1 tablet OD(8am)

Anti-hypertensive- leads to arterial and coronary vasodilation and decreased peripheral vascular resistance

Indications:- essential

hypertensionContraindication:- hypersensitivityAdverse reactions:- dizziness, light-headedness, peripheral edema, flushing, rash

1. have patient swallow whole tablet2. administer drug without regard to meals

a. monitor vital signsb. hold medication if bp is equal or less than 90/60

Patient was able to swallow the whole tablet and BP dropped from 150/90 to 130/80.

2.5. Health teaching plan

4

OBJECTIVES CONTENTS METHO-

DOLOGY

EVALUA-

TION

General objectives:

After one week of

student nurse-client

interaction, the

client will be able to

acquire knowledge,

attitude and skills in

the care of patients

with chronic

obstructive

pulmonary disease.

Specific objectives:

After 30-45 minutes

of student nurse-

client interaction,

the client will be

able to:

1. discuss why he

should quit smoking Quitting smoking makes a

difference right away in the way you

feel. You can taste and smell food

better. Your breath smells better. Your

cough goes away. These benefits

happen for men and women of all ages,

even those who are older. They happen

for healthy people as well as those who

already have a disease or condition

caused by smoking.

Even more importantly, in the long

Informal

discussion

4

2. enumerate the

steps in quitting

run, quitting smoking cuts the risk of

lung cancer, many other cancers, heart

disease, stroke, and other lung or

breathing (respiratory) diseases (e.g.,

bronchitis, pneumonia, and

emphysema). Moreover, ex-smokers

have better health than current

smokers. For example, ex-smokers

have fewer days of illness, fewer

health complaints, and less bronchitis

and pneumonia than current smokers.

Finally, quitting smoking saves

money.It appears that the price of

cigarettes will continue to rise in

coming years, as will the financial

rewards of quitting.

Getting Ready to Quit

Set a date for quitting. If possible, plan to have a friend quit smoking with you.

Notice when and why you smoke. Try to find the things in your daily life that you often do while smoking (such as drinking your morning cup of coffee or driving a car).

Change your smoking routines: Keep your cigarettes in a different place. Smoke with your other hand. Don't do anything else when you are smoking. Think about how you feel when you smoke.

Smoke only in certain places,

Informal

discussion

4

3. list ways on how

to improve appetite

4. explain the

such as outdoors. When you want a cigarette,

wait a few minutes. Try to think of something to do instead of smoking. For example, you might chew gum or drink a glass of water.

Buy one pack of cigarettes at a time. Switch to a brand of cigarettes that you don't like.

General guidelines

Talk to your doctor.

Sometimes, poor appetite is due

to depression, which can be

treated. Your appetite is likely

to improve after depression is

treated.

Avoid non-nutritious beverages

such as black coffee and tea.

Try to eat more protein and fat,

and less simple sugars.

Eat small, frequent meals and

snacks.

Walk or participate in light

activity to stimulate your

appetite.

Keep food visible and within

easy reach.

Improve your circulation and help the body better use oxygen

Improve your COPD symptoms

Build energy levels so you can

Informal

discussion

Informal

4

benefits of doing

exercise

4. show positive

response on

exercising by

knowing how often

exercise should be

done

do more activities without

becoming tired or short of

breath

Strengthen your heart and

cardiovascular system

Increase endurance

Lower blood pressure

Improve muscle tone and

strength; improve balance and

joint flexibility

Strengthen bones

Help reduce body fat and help

you reach a healthy weight

Help reduce stress, tension,

anxiety, and depression

Boost self-image and self-

esteem; make you look fit and

feel healthy

Improve sleep

Make you feel more relaxed

and rested

The frequency of an exercise program

is how often you exercise. In general,

to achieve maximum benefits, you

should gradually work up to an

exercise session lasting 20 to 30

minutes, at least three to four times a

discussion

Informal

discussion

4

5. demonstrate ways

on how to perform

pursed lip breathing

week. Exercising every other day will

help you keep a regular exercise

schedule.

Pursed lip breathing is one of the

simplest ways to control shortness of

breath. It provides a quick and easy

way to slow your pace of breathing,

making each breath more effective.

Pursed lip breathing technique

1. Relax your neck and shoulder

muscles.

2. Breathe in (inhale) slowly through

your nose for two counts, keeping your

mouth closed. Don't take a deep breath;

a normal breath will do. It may help to

count to yourself: inhale, one, two.

3. Pucker or "purse" your lips as if you

were going to whistle or gently flicker

the flame of a candle.

4. Breathe out (exhale) slowly and

gently through your pursed lips while

counting to four. It may help to count

to yourself: exhale, one, two, three,

four.

Demonstr

ation and

return

demonstra

tion

4

2.6 SOAPIE Charting

June 20, 2006

Name of Patient: Mr. Aviles, Teofilo

Room/ Ward No.: MM1

Age: 75 y.o.

Chief Complaint(s): dyspnea, cough

SOAPIE # 1

S – “ init bitaw ni siya. Gi hilantan man siya ganina sad ” as verbalized by significant

other.

O – received patient, febrile, awake, conscious, coherent, cooperative with IV infusing

well at left arm D5 .3%NaCl 1 liter at 10 drops/ minute. Patient’s skin is warm to touch,

skin is flushed, poor skin turgor, with vital signs of BP: 180/80mmhg ; T: 37.7 ˚ ; P: 80

beats per minute ; RR: 28 breaths per minute.

A – Altered thermoregulation: hyperthermia related to upper respiratory tract infection

P – patient will be able to decrease body temperature from 37.7 ˚ to a normal range of

36.4-37.5 ˚

I – monitored vital signs; noted shaking, chills or profuse diaphoresis; modified

environment through turning off the ceiling fan; provided extra blanket ; advised to wear

light clothing ; rendered tepid sponge bath; encouraged bed rest ; performed nebulization

as prescribed and administered analgesic as prescribed.

E – patient manifested a decrease in body temperature from 37.7˚ to 37.2˚

4

June 21, 2006

Name of Patient: Mr. Aviles, Teofilo

Room/ Ward No.: MM1

Age: 75 y.o.

Chief Complaint(s): dyspnea, cough

SOAPIE # 2

S – “ maglisud mana siya ug ginhawa, murag maghangak lang pirmi” as verbalized by

patients significant other.

O - received patient, afebrile, awake, conscious, coherent, cooperative with IV infusing

well at left arm D5 .3%NaCl 1 liter at 10 drops/ minute. Patient is experiencing a

productive cough with thick, whitish phlegm. There is presence of crackles with slight

wheezing heard upon auscultation. The patient also uses accessory muscle for breathing

and has vital signs of BP: 140/80mmhg ; T: 37.3 ˚ ; P: 80 beats per minute ; RR: 30

breaths per minute.

A – Ineffective airway clearance: dyspnea related to increased production of tenacious

secretions

P – patient will be able to have improved airway as evidences by a decrease of

respiratory rate from 30 breaths per minute to a range within normal of 16-20 breaths per

minute.

I – monitored vital signs ; taught client to maintain adequate hydration by drinking 8-10

glasses of fluid per day; taught effective coughing techniques; performed chest

physiotherapy; performed nebulization as prescribed; due medications given.

E – the patient had a decrease in respiratory rate from 30 breaths per minute to 27 breaths

per minute.

4

V. Evaluation and Recommendation

Prognosis

The prognosis for people with mild COPD is favorable, little worse than the

prognosis for smokers without COPD; continued smoking, however, virtually assures that

symptoms will worsen. With moderate and severe airway obstruction, the prognosis

becomes progressively worse. People with an FEV1 between 35% and 50% of normal are

still only slightly more likely to die within 10 years than a normal person. However,

about 30% of people with more severe airway obstruction die in 1 year; 95% die in 10

years. Death may result from respiratory failure, pneumonia, pneumothorax, heart rhythm

abnormalities (arrhythmias), or blockage of the arteries leading to the lungs (pulmonary

embolism). People with COPD have a risk of lung cancer beyond that due to their use of

cigarettes.

The patient has quit smoking for more than 2 years now and is sticking to his

treatment program. His symptoms have improved considering he is on an oxygen

therapy. With regards to his nutrition, he is still on a struggle since he only eats atleast 2 –

3 tablespoons of the food served. Considering also his old age, it makes his prognosis

poor.

Prognosis

The goals of COPD treatment are to prevent further deterioration in lung

function, to alleviate symptoms, to improve performance of daily activities and quality of

life.Below are listed recommendations for the patient :

1) Quit cigarette smoking

Set a date for quitting. If possible, plan to have a friend quit smoking with you.

Notice when and why you smoke. Try to find the things in your daily life that you

often do while smoking (such as drinking your morning cup of coffee or driving a

car).

4

Change your smoking routines: Keep your cigarettes in a different place. Smoke

with your other hand. Don't do anything else when you are smoking. Think about

how you feel when you smoke.

Smoke only in certain places, such as outdoors.

When you want a cigarette, wait a few minutes. Try to think of something to do

instead of smoking. For example, you might chew gum or drink a glass of water.

Buy one pack of cigarettes at a time. Switch to a brand of cigarettes that you don't

like.

2) Taking medications to dilate airways (bronchodilators) and decrease airway

inflammation

3) Vaccinating against influenza and pneumonia

4) Regular oxygen supplementation

4

VI. Evaluation and Implication of this Case Study to:

NURSING PRACTICE

This case study of a patient with Chronic obstructive pulmonary disease will

enable the student nurse to accomplish a well prepared Nursing Care Plan to patients with

such disease. With its outcome, it may serve as a guide or reference in providing care to

patients with the said disease. This will help in the development of nursing measures in

the clinical setting.

NURSING EDUCATION

This case study will serve as a reference guide to students who are interested in

the diseases of the lungs and who, later on when they become nurses. This will enable

them to increase their knowledge, attitude and skills in giving care to patients with

Chronic obstructive pulmonary disease.

NURSING RESEARCH

There have been several researches with regards to nursing that might not have

gotten the support that it needs for justification. Hopefully, this will be another one of the

most reliable sources as remedy to the support of the researcher’s study. This will also

serve as a difficult but nevertheless an interesting topic for research and studies.

5

BIBLIOGRAPHY

Brunner and Suddarth; Medical Surgical Nursing; 10th edition; Lippincott

Williams and Wilkins; copyright 2004

Black and Hawks; Medical Surgical Nursing; 6th edition; W.B Saunders

Company; copyright 2001

Long, Phipps, Woods; Medical Surgical Nursing Concepts and Clinical Practice;

2nd edition; The C.V Mosby Company; copyright 1983

Patrick, Woods; Medical Surgical Nursing; 2nd edition; J.B Lippincott Company

copyright 1991

Potter and Perry; Fundamentals of Nursing; 5th edition; The C.V Mosby

Company; copyright 2001

Robbins; by Pathologic basis of disease; 5th edition; Rodale Press; copyright 1994

www.google .com

www.medlineplus.com

www.medicinenet.com

5