HOLY ANGEL UNIVERSITY Angeles City COLLEGE OF NURSING

In partial Fulfillment of the Requirements in Related Learning Experience

A CASE STUDY ABOUT

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Submitted by: N406 (GROUP 2) ALFONSO, MARC JORDAN ANGELES, JEWELYN DAVID, JEIZREEL ESTANISLAO, JEREMY MACAPAGAL, ANDRO MACAPAGAL, LEIGH ANN OCAMPO, LOREN PASCUAL, JONNA TABERDO, FRANCHESCA LOREN YU, JESSICA KAILEEN

Submitted to: JASMINE OCAMPO RN. MAN.

AUGUST 10,2011 1

Table of Content I. INTRODUCTION II. NURSING HISTORY III. ANATOMY AND PHYSIOLOGY IV. PATHOPHYSIOLOGY V. THE PATIENT AND HIS CARE VI. NURSING CARE PLAN( PATIENT- BASED) VII. PATIENT S DAILY PROGRESS (FROM ADMISSION TO DISCHARGE VIII. DISCHARGE PLANNING IX. CONCLUSION AND RECOMMENDATION X. BIBLIOGRAPHY AND REFERENCES

I. INTRODUCTION Chronic obstructive pulmonary disease (COPD) is the overall term for a group of chronic lung conditions that obstruct the airways in your lungs. It refers

to obstruction caused by chronic bronchitis and emphysema that makes it hard for you to breathe. Coughing up mucus is often the first sign of the disease. Normally your airways branch out inside your lungs like an upside-down tree. At the end of each branch are small, balloon-like air sacs. In healthy people, both the airways and air sacs are springy and elastic. When you breathe in, each air sac fills with air like a small balloon. The balloon deflates when you exhale. In COPD, your airways and air sacs lose their shape and become floppy, like a stretched-out rubber band. In all forms of COPD, there's a blockage within the tubes and air sacs that make up your lungs, which hinders your ability to exhale. And, when you can't properly exhale, air gets trapped in your lungs and makes it difficult for you to breathe in normally. COPD is very common. Most cases occur as a result of long-term exposure to lung irritants that damage the lungs and the airways. In the majority of cases, it is caused by long-term smoking and could be prevented by not smoking or quitting smoking. However, once symptoms begin, the damage to your lungs can't be reversed, and there's no cure. Treatments focus primarily on controlling

symptoms and preventing further damage. The researchers chose this case to understand the disease afflicting millions worldwide, causing a morbid change to their lifestyle and condition. Moreover, its high prevalence makes it viable for research. Therefore, it is researchers goal to increase their knowledge and awareness of this disease, so that the researchers will be better equipped with clinical competencies in dealing with patients afflicted with the aforementioned disease condition. Statistics COPD is a major cause of death and illness worldwide, and it's the fourth-leading cause of death in the United States. 3

According to WHO over 120,000 people in the US die in a year from COPD in 2005. Smoking is the biggest risk factor for developing COPD. Female deaths from COPD have now overtaken male deaths since the year 2000. In the US in 2002, more than 61,000 females died of COPD compared to 59,000 males. Women who smoke are 13 times more likely to die of COPD than women who have never smoked. Men who smoke are 13 times as likely to die of COPD as men who have never smoked. There are more female sufferers of chronic bronchitis than male sufferers (50% more). In the Philippines, statistics show that cigarette smoking is the main cause of about 90 percent of lung cancer on men and about 70 percent in women who smoke. The more cigarettes a person smokes, the greater the risk of lung cancer and other respiratory disease like chronic obstructive pulmonary disease. More than 60,000 deaths per year of this disease according to DOH. Top 10 Leading Causes of Mortality (DOH Philippines, 2005) 1. Disease of the Heart 2. Disease of the Vascular System 3. Pneumonias 4. Cancer 5. Tuberculosis 6. Accidents 7. COPD 8. Diabetes Mellitus 9. Nephritic Syndrome 10. Other Diseases of the Respiratory System

and its short-term and long-term complications.  Recognized the nursing diagnoses and laboratory procedures in accordance to the synthesis of the disease process. PSYCHOMOTOR  Performed review of patient s chart to gather pertinent information, necessary for individualized care.  Conducted nursing history taking and assessment to aid in the comprehension of the disease condition.  Formulated significant nursing diagnoses and SOAPIEs to assist client for treatment and recuperation.  Implemented nursing interventions and evaluated the outcomes of the said actions  Applied therapeutic techniques of communication with the client and significant others. AFFECTIVE  Displayed proper knowledge, skills, and attitude in the provision of effective and efficient nursing care.  Exhibited proper ethics and positive attitude towards patient s condition, needs, and demands.

b. Socio-Economic and Cultural Factors Mr. Lung s family is composed of five members. He is an elementary and high school graduate. He pursue his college degree in Tarlac State University and graduated as a civil engineer in the year 1954. He works as a civil engineer on different

construction site. He speaks the dialect Tagalog and Kapampangan since he is a native of Pampanga.

Mr. Lung loves to eat fruits, vegetables and fruits. Also, his daughter mentioned that he is into fatty and salty foods. According to his daughter, Mr. Lung is already smoking since 16 yrs old and can consume 1 pack of cigarette everyday he also love to drink alcohol beverages. When it comes to his health practices, his daughter said that he often self medicate when she or her family has minor illnesses. He also believes in quack doctors or albularyo, but he prefers to be seen by their family doctor. Upon waking up at around 6:30 in the morning, their house maid prepares his breakfast before going to the construction site where he works. After that, he would eat together with his family at around 7 in the morning. After their breakfast he would prepare himself for work. He works as a civil engineer on a construction site. His wife is the one who prepare his food. Mr.Cardio worked from 8 in the morning till 5 in the afternoon. Upon arriving from work he usually used to watch television or rest for a while. At exactly 7 pm they take their dinner and sleeps around 10 in the evening.

b. Existing Diseases in the Family Mrs. Girlie has a family history of diabetes mellitus and hypertension from her grandmother on the maternal side and grandfather from the paternal side. Her father s eldest brother has diabetes mellitus and hypertension. The fifth and sixth siblings of her father have hypertension while the second sibling has asthma and the fourth sibling died of heart attack. Her father died on diabetes mellitus and heart attack. On the mother s side, her mother s eldest sister has asthma and fourth sibling has tuberculosis. Both her mother and her mother s third sibling have diabetes mellitus. The eldest brother of Mrs. Girlie has hypertension and her youngest sister has diabetes mellitus.

3. History of Past Illness According to Mr. Lung, he doesn t have any serious disease, but he acquired German measles, chicken fox, cough, colds during his childhood. 4. History of Present Illness Mr. Lung was admitted on July 28, 2011 with a chief complaint of difficulty of breathing. He was admitted on Angeles Medical Center with the diagnosis of COPD, emphysema and pneumonia. According to his daughter, 3 weeks ago the patient had experienced cough, difficulty of breathing, and shortness of breath before he was admitted.

a. Hereditary Diseases in the Family Paternal Side Maternal Side

GRANDPA

GRANDMA

GRANDPA

GRANDMA

ELDEST CHILD

4 CHILD

TH

ELDEST CHILD

3RD CHILD (MOTHER)

2ND CHILD

5THCHILD (FATHER)

2ND CHILD

3RD CHILD

Female Male

Asthma Heart Attack/ heart problem Hypertension Complications Brought by Old Age

ElDEST CHILD

2ND CHILD
(MR. LUNG)

3 CHILD

RD

III. Physical Assessment (IPPA-Cephalocaudal Approach)

Initial Assessment by the student nurses on July 29, 2011 Vital signs taken as follows: Blood pressure: 140/90 mmHg Temperature: 36.2 C Pulse rate: 73 bpm Respiratory rate: 28pm GCS: 15

General Appearance: Upon initial contact, the student nurses received the patient lying on his bed on ICU. The patient was wearing a hospital gown. When he was asked with questions, the patient responded slowly and at times the question is repeated in order to get a response from the patient. However, the patient is oriented with the place, time and date.

Skin Dark complexion Dry and scaly skin Even hair distribution Slightly cold to touch Poor skin turgor 9

Short and clean nails Hair and Scalp Black hair with streaks of white Even hair distribution No infestations, lesions and inflammation noted Fine in texture No masses or tenderness noted Fine hair and slightly oily Nails Pale nail bed No brittleness or cracking Capillary refill of >3 seconds Intact surrounding tissues No lesions

Head and Face Rounded skull shape Smooth skull contour Symmetrical eyebrows Symmetrical nasolabial folds Even sides of the mouth 10

No mass, swelling or tenderness noted

Eyes General- symmetrical; absence of discharges Eyebrows- hair growth evenly distributed Eyelashes- equally distributed Eyelids- skin intact Palpebral conjunctiva- pale in color Sclera- anicteric sclerae Pupils- black in color; equal in size; PERRLA

Ears Symmetrical No lesions, masses and tenderness noted

Nose and Sinuses No deformities and tenderness noted Aligned nasal septum

Mouth and Throat Lips- pale in color 11

With three missing teeth above and four below, teeth are not properly arranged Gums- pale pink in color; no discharge or swelling Tongue- in midline; pale pink in color; moist; tongue have thin white coating Palates and uvula- pink in color; absence of swelling; uvula positioned at the midline of soft palate Throat- no soreness or inflammation Halitosis noted

Neck No stiffness, tenderness or lumps noted

Breast and axillae No pain, tenderness, swelling noted No nipple discharge No masses or lumps noted Nipples are brown in color

Chest No lumps or masses noted (+) crackles (+) wheezez With CTT 12

Abdomen Protuberant in contour Auscultated 8 BS per min (Active)

Extremities Even distribution of hair in all extremities Palpable and equal pulses

Day 1 Assessment by the student nurses on August 3, 2011 Vital signs taken as follows: Blood pressure: 160/90 mmHg Temperature: 36.6 C Pulse rate: 77 bpm Respiratory rate: 26 bpm GCS: 15

General Appearance:

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Upon initial contact, the student nurses received the patient lying on his bed on ICU. The patient was wearing a hospital gown. When he was asked with questions, the patient responded slowly and at times the question is repeated in order to get a response from the patient. However, the patient is oriented with the place, time and date.

Skin Dark complexion Dry and scaly skin Even hair distribution Slightly cold to touch Poor skin turgor Short and clean nails Hair and Scalp Black hair with streaks of white Even hair distribution No infestations, lesions and inflammation noted Fine in texture No masses or tenderness noted Fine hair and slightly oily Nails Pale nail bed No brittleness or cracking 14

Capillary refill of >3 seconds Intact surrounding tissues No lesions

Head and Face Rounded skull shape Smooth skull contour Symmetrical eyebrows Symmetrical nasolabial folds Even sides of the mouth No mass, swelling or tenderness noted

Eyes General- symmetrical; absence of discharges Eyebrows- hair growth evenly distributed Eyelashes- equally distributed Eyelids- skin intact Palpebral conjunctiva- pale in color Sclera- anicteric sclerae Pupils- black in color; equal in size; PERRLA

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Ears Symmetrical No lesions, masses and tenderness noted

Nose and Sinuses No deformities and tenderness noted Aligned nasal septum

Mouth and Throat Lips- pale in color With three missing teeth above and four below, teeth are not properly arranged Gums- pale pink in color; no discharge or swelling Tongue- in midline; pale pink in color; moist; tongue have thin white coating Palates and uvula- pink in color; absence of swelling; uvula positioned at the midline of soft palate Throat- no soreness or inflammation Halitosis noted

Neck No stiffness, tenderness or lumps noted

Breast and axillae 16

No pain, tenderness, swelling noted No nipple discharge No masses or lumps noted Nipples are brown in color

Chest No lumps or masses noted (+) crackles (+) wheezez With CTT

Abdomen Protuberant in contour Auscultated 8 BS per min (Active)

Extremities Even distribution of hair in all extremities Palpable and equal pulses

Day 1 Assessment by the student nurses on August 4, 2011 17

Vital signs taken as follows: Blood pressure: 130/90 mmHg Temperature: 36.1 C Pulse rate: 74 bpm Respiratory rate: 27 bpm GCS: 15

General Appearance: Upon initial contact, the student nurses received the patient lying on his bed on ICU. The patient was wearing a hospital gown. When he was asked with questions, the patient responded slowly and at times the question is repeated in order to get a response from the patient. However, the patient is oriented with the place, time and date.

Skin Dark complexion Dry and scaly skin Even hair distribution Slightly cold to touch Poor skin turgor Short and clean nails Hair and Scalp Black hair with streaks of white 18

Even hair distribution No infestations, lesions and inflammation noted Fine in texture No masses or tenderness noted Fine hair and slightly oily Nails Pale nail bed No brittleness or cracking Capillary refill of >3 seconds Intact surrounding tissues No lesions

Head and Face Rounded skull shape Smooth skull contour Symmetrical eyebrows Symmetrical nasolabial folds Even sides of the mouth No mass, swelling or tenderness noted

Eyes 19

General- symmetrical; absence of discharges Eyebrows- hair growth evenly distributed Eyelashes- equally distributed Eyelids- skin intact Palpebral conjunctiva- pale in color Sclera- anicteric sclerae Pupils- black in color; equal in size; PERRLA

Ears Symmetrical No lesions, masses and tenderness noted

Nose and Sinuses No deformities and tenderness noted Aligned nasal septum

Mouth and Throat Lips- pale in color With three missing teeth above and four below, teeth are not properly arranged Gums- pale pink in color; no discharge or swelling Tongue- in midline; pale pink in color; moist; tongue have thin white coating 20

Palates and uvula- pink in color; absence of swelling; uvula positioned at the midline of soft palate Throat- no soreness or inflammation Halitosis noted

Neck No stiffness, tenderness or lumps noted

Breast and axillae No pain, tenderness, swelling noted No nipple discharge No masses or lumps noted Nipples are brown in color

Chest No lumps or masses noted (+) crackles (+) wheezez With CTT

Abdomen Protuberant in contour 21

Auscultated 8 BS per min (Active)

Extremities Even distribution of hair in all extremities Palpable and equal pulses

Day 1 Assessment by the student nurses on August 5, 2011 Vital signs taken as follows: Blood pressure: 130/90 mmHg Temperature: 36.9 C Pulse rate: 79 bpm Respiratory rate: 23 bpm GCS: 15

General Appearance: Upon initial contact, the student nurses received the patient lying on his bed on ICU. The patient was wearing a hospital gown. When he was asked with questions, the patient responded slowly and at times the question is repeated in order to get a response from the patient. However, the patient is oriented with the place, time and date.

Skin 22

Dark complexion Dry and scaly skin Even hair distribution Slightly cold to touch Poor skin turgor Short and clean nails Hair and Scalp Black hair with streaks of white Even hair distribution No infestations, lesions and inflammation noted Fine in texture No masses or tenderness noted Fine hair and slightly oily Nails Pale nail bed No brittleness or cracking Capillary refill of >3 seconds Intact surrounding tissues No lesions

Head and Face 23

Rounded skull shape Smooth skull contour Symmetrical eyebrows Symmetrical nasolabial folds Even sides of the mouth No mass, swelling or tenderness noted

Eyes General- symmetrical; absence of discharges Eyebrows- hair growth evenly distributed Eyelashes- equally distributed Eyelids- skin intact Palpebral conjunctiva- pale in color Sclera- anicteric sclerae Pupils- black in color; equal in size; PERRLA

Ears Symmetrical No lesions, masses and tenderness noted

Nose and Sinuses 24

No deformities and tenderness noted Aligned nasal septum

Mouth and Throat Lips- pale in color With three missing teeth above and four below, teeth are not properly arranged Gums- pale pink in color; no discharge or swelling Tongue- in midline; pale pink in color; moist; tongue have thin white coating Palates and uvula- pink in color; absence of swelling; uvula positioned at the midline of soft palate Throat- no soreness or inflammation Halitosis noted

Neck No stiffness, tenderness or lumps noted

Breast and axillae No pain, tenderness, swelling noted No nipple discharge No masses or lumps noted Nipples are brown in color

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Chest No lumps or masses noted (+) crackles (+) wheezez With CTT

Abdomen Protuberant in contour Auscultated 8 BS per min (Active)

Extremities Even distribution of hair in all extremities Palpable and equal pulses

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g. Diagnostic and Laboratory Procedures Diagnostic/ Laboratory Procedure Hematology Complete Blood Count (CBC) y Hematocrit (HCT) Date Ordered Date Results were released DO: 08-24-10 DR: 08-25-10 To measure the concentration of RBC within the blood volume and to evaluate hydration status. 34.2 36.0 47.0% This means that the patient is anemic Normal values (units used in the hospital) Analysis and Interpretation of results

Indication or Purposes

Results

y White Blood To determine the presence Cells of an infection. (WBC)

9.27

4.6 10.6 x 10 9/L

Normal Results. This means that the patient does not manifest any infection.

10.5 y Hemoglobin (HGB) Measures the total amount of Hemoglobin in the blood. It is used as a rapid indications measurement of RBC count. 11.6 15.5 G/DL

Low Level Results. Decrease in the amount of hemoglobin will also means a decrease in the supply of oxygen in the body since it is the one responsible in transporting oxygen within the cells. As a result of this, anaerobic respiration will occur and lactic acid would be formed causing chest pain or heaviness. 27

y Lymphocyte To determine if viral infection is present. y Monocyte

2.8 19 - 40% 1.7 To determine if viral infection is present. 3 9%

This means the patient has an infection

This means the patient has an infection.

BEFORE:  Explain the procedure for obtaining the specimen.  State the specific purpose of the test  Secure patient consent for procedure.  Provide client comfort, privacy, and safety. DURING:  Provide patient comfort.  Use the correct procedure for obtaining a specimen or ensure that the client or staff followed the correct procedure.  Obtain the amount of blood needed.  Be sure to draw blood samples in a 7-ml red top tube. 28

 The time the sample was drawn and the hours elapsed since onset of chest pain. AFTER:  Provide patient comfort.  Transport the specimen to the laboratory promptly because CK activity diminishes significantly after 2 hours at room temperature.  Label specimen properly.  Be sure to handle the sample gently to prevent hemolysis.

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Diagnostic/ Laboratory Procedure

Indication or Purposes

Date Ordered Date Results were released

Results

Normal values (units used in the hospital)

Analysis and Interpretation of results

Chest X - ray

For viewing of lungs and heart. To see if there is any obstruction or to see the clearance of the lungs.

DO: July 28, 2011 DP: July 29, 2011

The initial chest radiography when compared with that taken on 11- 6812 shows a homogeneous density in the left hemothorax. The right lung is clear.

Both left and right lung and heart should be clear.

Homogeneous density in the left hemothorax, may be: 1. pneumonia with collaboration. 2. new growth. Concominant left sided pleural effusion cannot be entirely ruled out

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Nursing Responsibilities: A. Before the procedure: o Check the physicians order. o Explain the procedure to the patient. o Instruct the patient to drink plenty of fluids to have clearer view of the abdominal organs. B. During the procedure: o Provide privacy to the patient. C. After the procedure: o Actual X-ray interpretation is the responsibility of the radiologist and primary physician. The nurse may be the first health care professional to review the X-ray for gross abnormalities.

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Diagnostic and Laboratory Procedure Procedure Date ordered Indication and purpose

Results and date

Normal values

Analysis and interpretation

Blood Chemistry

July 29 2011

BUN

to measure of the amount of nitrogen in the blood in the form of urea, and a measurement of renal function. to evaluate the kidney function

66.6

(7 -21 mg/dl) The result is above normal range

Creatinine is used to help diagnose the cause of recurrent kidney stones and to monitor people with gout for stone formation.

5.62

(0.5 1.69 mg/dl

The result is above normal range

Uric acid (MALE)

9.58

(3.5- 8.5 mg/dl )

The result is above normal range

Phosporus

to help diagnose and/or monitor treatment of various

1.78

(0.81 1.61 mmo/l

The result is above normal range

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conditions that cause calcium and phosphorus imbalances.

to evaluate kidney function

27

( 35- 60 g/l

The result is within normal range

Albumin

to evaluate fluid and electrolyte status. It plays an important role in muscle contractions

5. 0

( 3.6 5.0 mmo/l 0

The result is within normal range

**Blood Chemistry BEFORE:  Explain the procedure for obtaining the specimen.

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 State the specific purpose of the test  Secure patient consent for procedure.  Provide client comfort, privacy, and safety. DURING:  Provide patient comfort.  Use the correct procedure for obtaining a specimen or ensure that the client or staff followed the correct procedure.  Obtain the amount of blood needed.  Be sure to draw blood samples in a 7-ml red top tube.  The time the sample was drawn and the hours elapsed since onset of chest pain. AFTER:  Provide patient comfort.  Transport the specimen to the laboratory promptly because CK activity diminishes significantly after 2 hours at room temperature.  Label specimen properly.  Be sure to handle the sample gently to prevent hemolysis.

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Procedure

Date ordered

Indication and purpose

Results and date

Normal values

Analysis and interpretation

Ck mb

To determine if you have had a heart attack and whether certain clot-dissolving drugs are working if you have chest pain or other signs and symptoms of a heart attack

15 u/l

( less than 16 u/l)

The result is within normal range

BEFORE:  Explain the procedure for obtaining the specimen.  State the specific purpose of the test  Secure patient consent for procedure.  Provide client comfort, privacy, and safety. DURING:  Provide patient comfort.  Use the correct procedure for obtaining a specimen or ensure that the client or staff followed the correct procedure.  Obtain the amount of blood needed.  Be sure to draw blood samples in a 7-ml red top tube. 35

 The time the sample was drawn and the hours elapsed since onset of chest pain. AFTER:  Provide patient comfort.  Transport the specimen to the laboratory promptly because CK activity diminishes significantly after 2 hours at room temperature.  Label specimen properly.  Be sure to handle the sample gently to prevent hemolysis.

36

Procedure

Date ordered

Indication and purpose

Results and Normal values date ( 4.5 6.3 % ) (HbAIC) 5. 8 %

Analysis and interpretation The result is within normal range

July 29, 2011 Hemoglobin

Procedure Blood chemistry

Date ordered JULY 28 2011

Indication and purpose

Results and date Normal values 5.5 (3.6 5.0 mmol)

Analysis and interpretation

to evaluate the kidney function

Creatinine to evaluate fluid and electrolyte status. It plays an important role in muscle contractions (7.35- 7.45)

ABG:

PH:

to measure of the acidity of the blood, reflecting the number of hydrogen ions present.

(35-45 mmhg)

pCo2 7. 37 37

(22-26meq/ l)

( +-2 meq/l) pO2: Measure the amount of carbon dioxide gas dissolved in the blood. measures the effectiveness of the lungs in pulling oxygen into the blood stream from the atmosphere. 20.3 an accumulation of metabolically-produced acids, the body attempts to neutralize those acids to maintain a constant acidbase balance. measures the percent of hemoglobin which is fully combined with oxygen 97 %)

36.9

B.E:

O2 sat

FIO2:

RR: .

4.2

PH: : 99.6

38

pCo2:

to measure of the acidity of the blood, reflecting the number of hydrogen ions present.

70 % (7.35- 7.45) 30 (35-45 mmhg) 97 %)

O2 sat: HCO3: B.E: FIO2: RR

Measure the amount of carbon dioxide gas dissolved in the blood.

7. 37

( +-2 meq/l) measures the percent of hemoglobin which is fully combined with oxygen 41. 3

an accumulation of metabolically-produced acids, the body attempts to neutralize those acids to maintain a constant acidbase balance.

94.7 23.3 1.9 40 % 18

**Blood Chemistry BEFORE: 39

 Explain the procedure for obtaining the specimen.  State the specific purpose of the test  Secure patient consent for procedure.  Provide client comfort, privacy, and safety. DURING:  Provide patient comfort.  Use the correct procedure for obtaining a specimen or ensure that the client or staff followed the correct procedure.  Obtain the amount of blood needed.  Be sure to draw blood samples in a 7-ml red top tube.  The time the sample was drawn and the hours elapsed since onset of chest pain. AFTER:  Provide patient comfort.  Transport the specimen to the laboratory promptly because CK activity diminishes significantly after 2 hours at room temperature.  Label specimen properly.  Be sure to handle the sample gently to prevent hemolysis.

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III. ANATOMY AND PHYSIOLOGY

The Respiratory System is crucial to every human being. Without it, we would cease to live outside of the womb. Let us begin by taking a look at the structure of the respiratory system and how vital it is to life.

During inhalation or exhalation air is pulled towards or away from the lungs, by several cavities, tubes, and openings. The organs of the respiratory system make sure that oxygen enters our bodies and carbon dioxide leaves our bodies. The respiratory tract is the path of air from the nose to the lungs. It is divided into two sections: Upper Respiratory Tract and the Lower Respiratory Tract.

Upper Respiratory Tract

The upper respiratory tract consists of the nose and the pharynx. Its primary function is to receive the air from the external environment and filter, warm, and humidify it before it reaches the delicate lungs where gas exchange will occur.

Air enters through the nostrils of the nose and is partially filtered by the nose hairs, then flows into the nasal cavity. The nasal cavity is lined with epithelial tissue, containing blood vessels, which help warm the air; and secrete mucous, which further filters the air. The endothelial lining of the nasal cavity also contains tiny hair-like projections, called cilia. The cilia serve to transport dust and other foreign particles, trapped in mucous, to the back of the 41

nasal cavity and to the pharynx. There the mucus is either coughed out, or swallowed and digested by powerful stomach acids. After passing through the nasal cavity, the air flows down the pharynx to the larynx.

Lower Respiratory Tract

The lower respiratory tract starts with the larynx, and includes the trachea, the two bronchi that branch from the trachea, and the lungs themselves. This is where gas exchange actually takes place.

Larynx. The larynx (plural larynges), colloquially known as the voice box, is an organ in our neck involved in protection of the trachea and sound production. The larynx houses the vocal cords, and is situated just below where the tract of the pharynx splits into the trachea and the esophagus. The larynx contains two important structures: the epiglottis and the vocal cords.

The epiglottis is a flap of cartilage located at the opening to the larynx. During swallowing, the larynx (at the epiglottis and at the glottis) closes to prevent swallowed material from entering the lungs; the larynx is also pulled upwards to assist this process. Stimulation of the larynx by ingested matter produces a strong cough reflex to protect the lungs. Note: choking occurs when the epiglottis fails to cover the trachea, and food becomes lodged in our windpipe.

The vocal cords consist of two folds of connective tissue that stretch and vibrate when air passes through them, causing vocalization. The length the vocal cords are stretched determines what pitch the sound will have. The strength of expiration from the lungs also contributes to the loudness of the sound. Our ability to have some voluntary control over the respiratory system

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enables us to sing and to speak. In order for the larynx to function and produce sound, we need air. That is why we can't talk when we're swallowing.

1. Trachea 2. Bronchi 3. Lungs

As air moves along the respiratory tract it is warmed, moistened and filtered.

Functions:

1. BREATHING or ventilation 2. EXTERNAL RESPIRATION, which is the exchange of gases (oxygen and carbon dioxide) between inhaled air and the blood. 3. INTERNAL RESPIRATION, which is the exchange of gases between the blood and tissue fluids. 4. CELLULAR RESPIRATION

Breathing and Lung Mechanics

Ventilation is the exchange of air between the external environment and the alveoli. Air moves by bulk flow from an area of high pressure to low pressure. Air will move in or out of the lungs depending on the pressure in the alveoli. The body changes the pressure in the alveoli by changing the volume of the lungs. As

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volume increases pressure decreases and as volume decreases pressure increases. There are two phases of ventilation; inspiration and expiration. During each phase the body changes the lung dimensions to produce a flow of air either in or out of the lungs.

The body is able to change the dimensions of the lungs because of the relationship of the lungs to the thoracic wall. Each lung is completely enclosed in a sac called the pleural sac. Two structures contribute to the formation of this sac. The parietal pleura is attached to the thoracic wall where as the visceral pleura is attached to the lung itself. In-between these two membranes is a thin layer of intrapleural fluid. The intrapleural fluid completely surrounds the lungs and lubricates the two surfaces so that they can slide across each other. Changing the pressure of this fluid also allows the lungs and the thoracic wall to move together during normal breathing. Much the way two glass slides with water in-between them are difficult to pull apart, such is the relationship of the lungs to the thoracic wall.

The rhythm of ventilation is also controlled by the "Respiratory Center" which is located largely in the medulla oblongata of the brain stem. This is part of the autonomic system and as such is not controlled voluntarily (one can increase or decrease breathing rate voluntarily, but that involves a different part of the brain). While resting, the respiratory center sends out action potentials that travel along the phrenic nerves into the diaphragm and the external intercostal muscles of the rib cage, causing inhalation. Relaxed exhalation occurs between impulses when the muscles relax. Normal adults have a breathing rate of 12-20 respirations per minute.

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The Pathway of Air

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When one breathes air in at sea level, the inhalation is composed of different gases. These gases and their quantities are Oxygen which makes up 21%, Nitrogen which is 78%, Carbon Dioxide with 0.04% and others with significantly smaller portions.

In the process of breathing, air enters into the nasal cavity through the nostrils and is filtered by coarse hairs (vibrissae) and mucous that are found there. The vibrissae filter macroparticles, which are particles of large size. Dust, pollen, smoke, and fine particles are trapped in the mucous that lines the nasal cavities (hollow spaces within the bones of the skull that warm, moisten, and filter the air). There are three bony projections inside the nasal cavity. The superior, middle, and inferior nasal conchae. Air passes between these conchae via the nasal meatuses.

Air then travels past the nasopharynx, oropharynx, and laryngopharynx, which are the three portions that make up the pharynx. The pharynx is a funnel-shaped tube that connects our nasal and oral cavities to the larynx. The tonsils which are part of the lymphatic system, form a ring at the connection of the oral cavity and the pharynx. Here, they protect against foreign invasion of antigens. Therefore the respiratory tract aids the immune system through this protection. Then the air travels through the larynx. The larynx closes at the epiglottis to prevent the passage of food or drink as a protection to our trachea and lungs. The larynx is also our

45

voicebox; it contains vocal cords, in which it produces sound. Sound is produced from the vibration of the vocal cords when air passes through them.

The trachea, which is also known as our windpipe, has ciliated cells and mucous secreting cells lining it, and is held open by C-shaped cartilage rings. One of its functions is similar to the larynx and nasal cavity, by way of protection from dust and other particles. The dust will adhere to the sticky mucous and the cilia helps propel it back up the trachea, to where it is either swallowed or coughed up. The mucociliary escalator extends from the top of the trachea all the way down to the bronchioles, which we will discuss later. Through the trachea, the air is now able to pass into the bronchi.

Inspiration

Inspiration is initiated by contraction of the diaphragm and in some cases the intercostals muscles when they receive nervous impulses. During normal quiet breathing, the phrenic nerves stimulate the

diaphragm to contract and move downward into the abdomen. This downward movement of the diaphragm enlarges the thorax. When necessary, the intercostal muscles also increase the thorax by contacting and drawing the ribs upward and outward.

46

As the diaphragm contracts inferiorly and thoracic muscles pull the chest wall outwardly, the volume of the thoracic cavity increases. The lungs are held to the thoracic wall by negative pressure in the pleural cavity, a very thin space filled with a few milliliters of lubricating pleural fluid. The negative pressure in the pleural cavity is enough to hold the lungs open in spite of the inherent elasticity of the tissue. Hence, as the thoracic cavity increases in volume the lungs are pulled from all sides to expand, causing a drop in the pressure (a partial vacuum) within the lung itself (but note that this negative pressure is still not as great as the negative pressure within the pleural cavity--otherwise the lungs would pull away from the chest wall). Assuming the airway is open, air from the external environment then follows its pressure gradient down and expands the alveoli of the lungs, where gas exchange with the blood takes place. As long as pressure within the alveoli is lower than atmospheric pressure air will continue to move inwardly, but as soon as the pressure is stabilized air movement stops.

Expiration

During quiet breathing, expiration is normally a passive process and does not require muscles to work (rather it is the result of the muscles relaxing). When the lungs are stretched and expanded, stretch receptors within the alveoli send inhibitory nerve impulses to the medulla oblongata, causing it to stop sending signals to the rib cage and diaphragm to contract. The muscles of respiration and the lungs themselves are elastic, so when the diaphragm and intercostal muscles relax there is an elastic recoil, which creates a positive pressure (pressure in the lungs becomes greater than atmospheric pressure), and air moves out of the lungs by flowing down its pressure gradient.

47

Although the respiratory system is primarily under involuntary control, and regulated by the medulla oblongata, we have some voluntary control over it also. This is due to the higher brain function of the cerebral cortex.

When under physical or emotional stress, more frequent and deep breathing is needed, and both inspiration and expiration will work as active processes. Additional muscles in the rib cage forcefully contract and push air quickly out of the lungs. In addition to deeper breathing, when coughing or sneezing we exhale forcibly. Our abdominal muscles will contract suddenly (when there is an urge to cough or sneeze), raising the abdominal pressure. The rapid increase in pressure pushes the relaxed diaphragm up against the pleural cavity. This causes air to be forced out of the lungs.

Another function of the respiratory system is to sing and to speak. By exerting conscious control over our breathing and regulating flow of air across the vocal cords we are able to create and modify sounds.

External Respiration

External respiration is the exchange of gas between the air in the alveoli and the blood within the pulmonary capillaries. A normal rate of respiration is 12-25 breaths per minute. In external respiration, gases diffuse in either direction across the walls of the alveoli. Oxygen diffuses from the air into the blood and carbon dioxide diffuses out of the blood into the air. Most of the carbon dioxide is carried to the lungs in plasma as bicarbonate ions (HCO3-). When blood enters the pulmonary capillaries, the bicarbonate ions and hydrogen ions are converted to carbonic acid (H2CO3) and then back into carbon dioxide (CO2) and water. This chemical

48

reaction also uses up hydrogen ions. The removal of these ions gives the blood a more neutral pH, allowing hemoglobin to bind up more oxygen. De-oxygenated blood "blue blood" coming from the pulmonary arteries, generaly has an oxygen partial pressure (pp) of 40 mmHg and CO pp of 45 mmHg. Oxygenated blood leaving the lungs via the pulmonary veins has a O2 pp of 100 mmHg and CO pp of 40 mmHg. It should be noted that alveolar O2 pp is 105 mmHg, and not 100 mmHg. The reason why pulmonary venous return blood has a lower than expected O2 pp can be explained by "Ventilation Perfusion Mismatch".

Internal Respiration

Cellular respiration also known as Internal Respiration is the process by which the chemical energy of "food" molecules is released and partially captured in the form of ATP. Carbohydrates, fats, and proteins can all be used as fuels in cellular respiration, but glucose is most commonly used as an example to examine the reactions and pathways involved.

IV. PATHOPHYSIOLOGY a. Book Based i. Schematic Diagram

49

ii. Synthesis of the condition 1. Definition of the disease Chronic obstructive disease, also known as COPD and chronic obstructive lung disease chronic airway limitation is a collective term used to refer to several lung disorders that affect the movement of the air into and out of the lungs. The diseases included in COPD are chronic obstructive bronchitis,

50

emphysema, asthma. Although these diseases may be presented in pure form, they most commonly exist with overlapping clinical manifestations. The disease can occur as a result of increased airway resistance secondary to bronchial mucosal edema or smooth muscle contraction. The disease can also result of decreased elastic recoil of the lung, as seen in emphysema. Emphysema, one of the diseases included in COPD, is a disorder in which the alveolar walls are destroyed. Because of this destruction, there is permanent distention of the alveolar spaces, and obstruction results from this destruction. This obstruction is what differentiates emphysema from chronic bronchitis, in which there is obstruction due to excessive mucus production. There are three main forms of emphysema, and these include the centriacinar (centrilobular) form, the panacinar form, and the paraseptal form. The most common of these forms is the centriacinar form in which there is destruction in the bronchioles, usually in the upper lung regions. In this type, the inflammation begins in the bronchioles then spreads peripherally; the alveolar sacs usually remain intact. This is the type of emphysema usually seen in smokers. The panacinar form of emphysema destroys the entire alveolus and most commonly involves the lower portions of the lungs. This is the form of the disease found in individuals who have alpha1-antitrypsin deficiency. Focal panacinar emphysema may also be seen in conjunction with the centricinar form at the base of the lungs. The last type of emphysema is the paraseptal form with involved the distal airway structures, alveolar ducts, and alveolar sacs. This process is focused around the septa of the lungs or pleura resulting in isolated blebs along the lungs periphery.

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Chronic bronchitis is a chronic inflammation of the bronchi (medium-size airways) in the lungs. It is generally considered one of the two forms of chronic obstructive pulmonary disease (COPD). It is defined clinically as a persistent cough that produces sputum (phlegm) and mucus, for at least three months in two consecutive years

2. Predisposing and precipitating factors Predisposing Factors: 1. Alpha1-Antitrypsin Hereditary Deficiency is an autosomal codominant genetic disorder caused by defective production of alpha 1-antitrypsin (A1AT), leading to decreased A1AT activity in the blood and lungs, and deposition of excessive abnormal A1AT protein in liver cells. There are several forms and degrees of deficiency. Severe A1AT deficiency causes panacinar emphysema and/or COPD in adult life in many people with the condition (especially if they are exposed to cigarette smoke), as well as various liver diseases in a minority of children and adults, and occasionally more unusual problems. It is treated by avoidance of damaging inhalants, by intravenous infusions of the A1AT protein, by transplantation of the liver or lungs, and by a variety of other measures, but it usually produces some degree of disability and reduced life expectancy. A deficiency in alpha1antitrypsin causes a change in the elactase of the lungs, causing destruction in the alveolar septa, as the elastic recoil of the lungs is reduced. 2. Age is a risk factor in COPD, because with age comes the natural deterioration of lung function. Precipitating Factors: 1. Smoking: Tobacco smoking causes 80% to 90% of COPD cases. Chemicals found in tobacco smoke stimulate inflammation in the lungs, leading to destruction of the alveoli and narrowing of the airways. While smoking is related to most COPD cases, only 15% to 20% of smokers develop the disease.

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2. Passive Smoking: Passive smoking, also known as second hand smoke, is a risk factor for getting COPD because many of the chemicals exhaled by smokers still contain the same compounds. These chemical compounds, similar to the effects of the chemicals in first hand smoke, also stimulate inflammation of the lungs leading to the narrowing of the airways. 3. Occupational Exposure: Constant exposure to certain chemicals or pollutants in the work place, such as silica dust, lung irritants, vapors, and fumes, cause the inflammation of the lungs. The constant inflammation leads to the destruction of the septa, causing COPD. 4. Ambient Air Pollution: Besides being carcinogenic, air pollution, especially smoke from vehicles and burning garbage can cause the irritation of the lungs. This irritation leads to inflammation, which in time may cause damage to the lung s alveoli. 3. Pathologic changes Pathologic changes in chronic obstructive pulmonary disease (COPD) occur in the large (central) airways, the small (peripheral) bronchioles, and the lung parenchyma. Most cases of COPD are the result of exposure to noxious stimuli, most often cigarette smoke. The normal inflammatory response is amplified in persons prone to COPD development. The pathogenic mechanisms are not clear but are most likely diverse. Increased numbers of activated polymorphonuclear leukocytes and macrophages release elastases in a manner that cannot be counteracted effectively by antiproteases, resulting in lung destruction. The primary offender has been found to be human leukocyte elastase, with synergistic roles suggested for proteinase-3 and macrophage-derived matrix metalloproteinases (MMPs), cysteine proteinases, and a plasminogen activator. Additionally, increased oxidative stress caused by free radicals in cigarette smoke, the oxidants released by phagocytes, and polymorphonuclear leukocytes all may lead to apoptosis or necrosis of exposed cells. Accelerated aging and autoimmune mechanisms have also been proposed as having roles in the pathogenesis of COPD. 4. Sign and symptoms with rationale

53

1. Cough

When the lungs are experiencing difficulty with gas exchange or breathing, it is a

normal mechanism for the body to cough as a means for the lungs to be cleared even though there may or may not be blockages in the airway. With chronic bronchitis, a cough may also result as a mechanism against retained secretions, as there is a heightened or increased amount of secretions produced in chronic bronchitis as a reaction from respiratory irritants such as smoke and pollution. 2. Barrel Chest Barrel chest is the enlargement or and increase in the anteroposterior

diameter of the chest. In COPD, there is the distension of the lungs, caused by the trapping of air. The trapping of the air is caused by a decrease in airway caliber or diameter within the airway passages. 3. Pink Puffer Line/ Pink Puffer Syndrome The pink puffer line is a sign which helps in

distinguishing the difference between patients with emphysema and patients with chronic bronchitis. This line is a result from the pattern of breathing the client uses while with the disease. A patient with emphysema is often seen using a tripod position, so that they may be able to inhale and exhale easily. Because of the positioning, with the upper anterior chest wall facing the floor, blood begins to rush to the site due to the pull of gravity. The line is also the result of the use of accessory muscles for breathing. 4. Respiratory acidosis: Respiratory acidosis is a result of the trapping of the air within the alveolus during expiration. Since the air which is meant to be exhaled is trapped, there is the reabsorption of pCO2 in the blood (more than 45mmHg). 5. Leukocytosis: In chronic bronchitis, there is a constant excessive production of mucous in the lungs. Due to the large amount of mucous being produced, not all of the phlegm is being expectorated, meaning that some of the mucous produced is left in the lungs. Because of this, the secretions retained become a medium for bacterial growth causing infection. Due to the infection, the number of WBC becomes increased.

54

6. Dyspnea: Dyspnea, or difficulty of breathing, is a result of the air obstruction caused by the distention of the damaged alveoli. There is difficulty in the passage of air throughout the lungs as the caliber of the air passage ways become smaller in size or narrowed. 7. Orthopnea: This is again also due to the narrowing of air passage ways. When the client lies down on their back, more weight or pressure is pushed unto the chest due to gravity. Because of this, the passage ways of air become more compressed or narrowed, further complicating and compromising the breathing of a patient with COPD. 8. Use of Accessory Muscles: Since the client has difficulty inhaling and even more difficulty expiring, the client must use extra force to push the air outside of the lungs. This extra force comes from the surrounding muscles, such as the trapezius or shoulder muscle, the sternum, and the intercoastal spaces. 9. Tripod position: The tripod position is a form that all patients with emphysema assume to help facilitate better breathing. This position includes the client sitting while leaning forward, the arms supporting the weight of the shoulders either with placement on the knees or leaning on a chair placed in front of them. This position is ideal for patients with emphysema because it allows air to be more fully expired as there is compression of force placed on the lung fields. It is also due to this position that clients with emphysema also have a pink band across their chest, due to tension. 10. Dependent Edema: This is edema of the extremities which is affected by gravity. Edema occurs as a result of either constant hypertension (due to the increase in pulmonary vascular resistance) or due to the congestion of blood to the peripheral tissues causing damage to the vessels in the extremities. Dependent edema usually subsides if the patient assumes a position where the weight of gravity does not fully pull on the affected area, such as in the case of lying flat. 11. Anorexia: Anorexia, or the loss of appetite, occurs as a result of GI congestion.

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12. GI Distress - include cramping, nausea, bloating, vomiting, and diarrhea. This is also a result of GI congestion and also due to ischemia of the gastrointestinal organs from oxygen rich blood. 13. Weight Loss- A decrease in body weight for patients with COPD is due to loss of appetite which is further caused by GI congestion. 14. Restlessness Restlessness is the inability to sit still or relax. This is due to a decrease of cerebral perfusion of oxygenated blood causing hypoxia or ischemia. 15. Clubbing of Fingernails Clubbing of fingers is the characteristic used to describe fingernails which are 180 degrees or more in angle. This is due to a decrease of perfusion of oxygenated blood causing hypoxia or ischemia. 16. Irritability Irritability is defined as an excessive response to stimuli. This is due to a decrease of cerebral perfusion of oxygenated blood causing hypoxia or ischemia.

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B. CLIENT CENTERED Predisposing Factors y 77 y/o Hgb: 10.5; Hct: 34.2; RBC: 3.66; Neutro: 95.2; lympho: 2.8; mono: 1.7

Precipitating Factors y Smoking y Ambient air pollution

Mucosal Inflammation

Homogeneous density in the left hemithorax

Mucosal Edema Hypertrophy of bronchial mucus Narrowing of bronchial lumen y RR= 30 bpm Decrease ventilation ABG (7-28-11) y PO2: 258.1mmhg y O2 sat:

Muscle Contraction Bronchial smooth muscle cell hyperactivity Bronchospasm

Increase mucus secretion Squamous cell metaplasia Accumulation of secretion

Obstruction of airflow Impaired gas exchange

Air trapping ABG (7-28-11) y Pco2: 36.9

Hypoxemia

Hypercapnia Vasoconstrictio n of blood vessel

Respiratory acidosis Bp= 200/90

57

Pulmonary

Synthesis of the Disease (Client-Centred) Predisposing Factors 1. Age : Mr. Lung is 77 years old. With age comes the natural deterioration of the lung function. Precipitating Factors 1. Smoking: Chemicals found in tobacco smoke stimulate inflammation in the lungs, leading to destruction of the alveoli and narrowing of the airways. The client has a total of 36 pack years, and has been smoking since he was 12. He stopped smoking in 1987 when he was diagnosed with pulmonary tuberculosis. 2. Ambient Air Pollution: Besides being carcinogenic, air pollution, especially smoke from vehicles and burning garbage can cause the irritation of the lungs. This irritation leads to inflammation, which in time may cause damage to the lungs alveoli. Signs & Symptoms with Rationale & Dates assessed 1. Barrel Chest Barrel chest is the enlargement or and increase in the anteroposterior diameter of the chest. In COPD, there is the distension of the lungs, caused by the trapping of air. The trapping of the air is caused by a decrease in airway caliber or diameter within the airway passages. 2. Expiratory wheezesis a continuous, coarse, whistling sound produced in the

respiratory airways during breathing. For wheezes to occur, some part of the respiratory tree must be narrowed or obstructed, or airflow velocity within the respiratory tree must be heightened. 3. Shallow Breathing - This is again also due to the narrowing of air passage ways. When the client lies down on their back, more weight or pressure is pushed unto the chest due to gravity. Because of this, the passage ways of air become more compressed or narrowed, further complicating and compromising the breathing of a patient with COPD. 4. Use of Accessory Muscles - Since the client has difficulty inhaling and even more difficulty expiring, the client must use extra force to push the air outside of the lungs. This extra force

58

comes from the surrounding muscles, such as the trapezius or shoulder muscle, the sternum, and the intercoastal spaces. 5. Leukonychia Striata These are the white horizontal lines occurring on the nail plate typically caused by decreased perfusion of oxygenated blood to the nails, injury, or liver damage.

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V. THE PATIENT AND HIS CARE i. IVF Date Ordered, Medical General Description Management Purpose Date Changed or D/C to Treatment Indications/ Date Performed, Client s Response

It is a slightly hypertonic solution that minimizes Intravenous Fluid glyconeogenesis and promotes (IVF) of anabolism in patient s who D5.3 NACl can t receive sufficient oral caloric intake.

It is used frequently in The patient did intravenous drips (IVs) for patients who cannot take fluids orally and have developed or are dehydration due in danger of developing to the IVF given to dehydration. him. D.O.: 07-28-11 not manifest any D.P: 07-28-11 sign of

A nebulizer is a device used to Nebulization administer medication to (1 neb q 4 ) people in the form of a mist inhaled into the lungs. respiratory diseases. It is commonly used in treating

D.O.: 07-28-11 The patient did D.P.:07-28-11 not experience asthma attack.

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Nursing Responsibilities a.1. IVF before: 1. 2. 3. During: 1. 2. 3. 4. 5. After: 1. 2. 3. 4. 5. 6. Adjust rate of flow of fluids appropriate to needs of patient as prescribed. Monitor IVF flow and patient s response. Monitor patient for evidence of local IV R/T complications, such as pain, swelling & tenderness. Check for the presence of air in tubing. If there is, remove it immediately. Isotonic solutions expand the intravascular compartment, monitor patient s fluid overload. Record all procedures done. Check IV level. Check for the patency of the tubing. Check if the IVF is infusing well. Select a suitable vein for vernipuncture. Practice aseptic technique. Verify the doctor s order. Explain the procedure to the patient. Obtain the necessary materials. Acquaint the SO & patient the requirements needed for IV infusion.

a.2. Nebulization 61

before: 1. 2. 3. 4. Verify doctor s order. Obtain necessary materials for the procedure. Verify the dosage of the medication to be given. Inform the SO of the procedure to be done.

During: 1. 2. Verify the patients name before giving the nebulization. Ensure that the medication is inhaled by the patient.

After: 1. 2. Encourage the SO to do bronchial tapping to aid in loosening secretions. Record all procedures done.

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ii.Drugs

Date Ordered, Date Route, dosage and Drug Name Started, Date Changed, frequency or Discontinued Furosemide is a potent diuretic (water pill) that is used to eliminate water and salt from the body. In the kidneys, salt (composed of sodium and chloride), water, and other small molecules normally are filtered out of Generic Name: Furosemide DO: 07-28-11 the blood and into the tubules of the DS: 07-28-11 20mg IV stat Brand Name: Lasix chloride and water that is filtered out of the blood is reabsorbed into the blood before the filtered fluid becomes urine and is eliminated from the body. kidney. The filtered fluid ultimately becomes urine. Most of the sodium, frequent urination. Patient had Mechanism of action to the Medication Client s Response

Generic Name:

25/125 BID 2 puffs

Patient did not 63

Salmeterl and Fluticasone Propionate

DO: 07-28-11 DS: 07-28-11

Seretide contains salmeterol and fluticasone propionate Salmeterol is a selective long-acting (12 hrs)
2-

complain of dyspnea.

adrenoceptor agonist with a long side Brand Name: Seretide chain which binds to the exo-site of the receptor.It offer more effective protection against histamine-induced bronchoconstriction and produce a longer duration of bronchodilation,. Fluticasone propionate given by inhalation at recommended doses has a potent glucocorticoid antiinflammatory action within the lungs.

 Anti-inflammatory Generic Name: DO: 07-28-11 Hydrocortisone DS: 07-28-11 . Brand Name: Hydrocortone, Cortef 250 stat / 100mg q 8 Decreases inflammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses immune response; stimulates bone marrow; and influences protein, fat and There was no new formation of tophi noted.

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carbohydrate metabolism. omeprazole is a selective and irreversible proton pump inhibitor. The patient did Omeprazole suppresses gastric acid Generic Name: Omeprozole DO: 07-28-11 secretion by specific inhibition of the DS: 07-28-11 40mg IV OD hydrogen potassium adenosinetriphosphatase (H +, K +Brand Name: ATPase) enzyme system found at the omepron secretory surface of parietal cells . prevented risk of ulcerations. stomachache and not complain

A synthetic fluoroquinolone The patient did Generic Name: Levofloxin DO: 07-28-11 DS: 07-28-11 500mg IV OD (fluoroquinolones) antibacterial agent not manifest any that inhibits the supercoiling activity sign of infection of bacterial DNA gyrase, halting DNA such as fever. Brand Name: Levox Antithrombotic the antithrombotic DO: 07-28-11 Generic Name: Fondaparin Sodium Brand Name: DS: 07-28-11 2.5ml OD SQ activity of fondaparinux is the result of antithrombin III [ATIII]-mediated selective inhibition of Factor Xa. By selectively binding to ATIII, 65 The patient was decrease the risk of having thrombosis replication. [PubChem]

Arixtra

fondaparinux potentiates the innate neutralization of Factor Xa by ATIII. Neutralization of Factor Xa interrupts the blood coagulation cascade and thus inhibits thrombin formation and thrombus development. Diazepam is an anti-anxiety medication in the benzodiazepine family, the same family that includes alprazolam (Xanax), clonazepam (Klonopin), lorazepam (Ativan), flurazepam (Dalmane), and others.

Generic Name: DO: 07-28-11 Diazepam DS: 07-28-11 Brand Name: the brain. GABA is a neurotransmitter Valium (a chemical that nerve cells use to communicate with each other) that inhibits activity in the brain. It is believed that excessive activity in the brain may lead to anxiety or other 66 5mg stat IV act by enhancing the effects of gamma-aminobutyric acid (GABA) in not experience any seizure. Diazepam and other benzodiazepines The patient did

psychiatric disorders. Ceftazidime is in a group of drugs called cephalosporin (SEF a low spor in) antibiotics. It works by fighting bacteria in your body. Ceftazidime injection is used to treat Generic Name: Ceftazidime DO: 07-28-11 DS: 07-28-11 IV many kinds of bacterial infections, including severe or life-threatening forms. Brand Name: Tazidime Ceftazidime may also be used for other purposes not listed in this medication guide.

The patient did not manifest any sign of infection such as fever.

b.1. Nursing Responsibilities Furosemide BEFORE: >Check doctor s order for the time, dosage and route of the drug. >Explain the purpose of the drug to be administered. 67

>Perform skin testing before administration. DURING: >Verify patient s identification/name. >Observe sterile technique during administration. >Slowly push the medication to lessen pain. AFTER: >Educate SO about the possible side effects. >Tell SO to make the patient take all of the drugs as prescribed, even after he feels better. >Record the medication given. >Observe for signs and symptoms of adverse or allergic reactions.

Seretide BEFORE: >Check the doctor s order before drug administration. >Check the drug label three times and its expiration date. >Explain the importance and purpose of the medication. >Advocate and be guided by the 10 R s of drug administration. DURING: >Adhere to standard precautions. AFTER: >Monitor the patient s vital signs especially the respiratory rate. 68

>Monitor the patient s response to medication and assess for any adverse reaction. >Record and document all procedures done.

Hydrocortisone: BEFORE: >Check doctor s order for the time, dosage and route of the drug. >Explain the purpose of the drug to be administered. DURING: >Verify patient s identification/name. AFTER: >Monitor glucose levels. >Record medication given.

Omeprozole: BEFORE: >Check doctor s order for the time, dosage and route of the drug. >Explain the purpose of the drug to be administered. DURING: >Verify patient s identification/name. >Assess patient for abdominal pain. AFTER: 69

>Note presence of blood in emesis, stool or gastric aspirate. >Record the medication given. Levox: BEFORE: >Check doctor s order for the time, dosage and route of the drug. >Explain the purpose of the drug to be administered. >Perform skin testing before administration.

DURING: >Verify patient s identification/name. >Observe sterile technique during administration. >Slowly push the medication to lessen pain. AFTER: >Educate SO about the possible side effects. >Tell SO to make the patient take all of the drugs as prescribed, even after he feels better. >Record the medication given. >Observe for signs and symptoms of adverse or allergic reactions. Arixtra: BEFORE: >Check doctor s order for the time, dosage and route of the drug. >Explain the purpose of the drug to be administered. 70

DURING: >Verify patient s identification/name. AFTER: >Monitor patient for he may develop respiratory depression. >Record medication given. Diazepam: BEFORE: >Check for the doctor s order. >Explain procedure and importance to the client.

DURING: >Make sure that the patient will take the medication on time. AFTER: >Observe for side effects. >Tell the SO to immediately report any signs of adverse effect. Tazidime: BEFORE: >Check doctor s order for the time, dosage and route of the drug. >Explain the purpose of the drug to be administered. >Perform skin testing before administration. DURING: 71

>Verify patient s identification/name. >Observe sterile technique during administration. >Slowly push the medication to lessen pain. AFTER: >Educate SO about the possible side effects. >Tell SO to make the patient take all of the drugs as prescribed, even after he feels better. >Record the medication given. >Observe for signs and symptoms of adverse or allergic reactions.

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iii.Diet

Type of Diet

General Description

Indications/Purpose Date ordered. Date started, date changed or D/C

Client s Response

Nursing

and Reaction to the Responsibilities diet Prior to, During, and Initiation of the diet

Low fat, low salt diet

A diet wherein foods that are

To limit the total amount of fat and

07/28/11

Patient followed the dietary regimen.

Prior > Verify doctor s order. Discuss importance of the diet.  Cite examples of food under diet ordered. Ask patient s SO of the food preference that may be  73

taken should be low salt to reduce blood in fat and salt. pressure.

  included in their list. During > Assist px for comfortable position. >Identify the patient. Verify the meal served in the tray. After > Monitor how much meal and fluids were taken.  Monitor px s reaction and compliance with diet.  Instruct SO to increase fruit juices 74

and milk in diet for nourishment

75

VI. NURSING CARE PLAN (PATIENT BASED) 1. Ineffective airway clearance Cues S: O: > faint breath sounds with expiratory wheezes >increased RR (30 bpm) Nursing Diagnosis Ineffective Airway Clearance related to inflammation and formation of connective tissues in the alveoli secondary to emphysema as evidenced by faint breath sounds with expiratory wheezes and tachypnea. Scientific Explanation Through the formation of connective tissues in the alveoli, air that comes inside cannot completely penetrate and flow out causing inadequate air that comes and out of the lungs. Objectives After 2 hours of nursing interventions, the patient will be able to have improved airway clearance as evidenced by effective coughing technique and a patent airway. Nursing Interventions 1. Monitor lung sounds every 4-8 hours and before and after coughing episodes. 2. Teach the client to maintain adequate hydration by drinking 8 to 10 glasses of fluids each day and increasing the humidity of the ambient air. 3. Teach and supervise effective coughing techniques. Rationale Rhonchi present in the large airways may impair patency. Hydration helps to reduce secretions. Evaluation

Proper coughing techniques conserve energy, reduce airway collapse and lessen client s frustration. 76

4. Reassess the condition of the oral mucous membranes and perform or offer oral care every 2 hours.

Thick secretions line the mouth when the client coughs; oral care removes them.

77

2. Impaired Gas Exchange Nursing Cues Diagnosis S> O: >tachypneic (30 bpm) > prolonged expiratory phase with grunting >hyperresonant lungs >becomes short of breath after an activity Impaired Gas exchange related to ventilation perfusion imbalance secondary to inflammation and loss of elasticity of the lung alveoli as evidenced by tachypnea, prolonged expiratory phase with grunting, and hyperresonant lungs.

Scientific Explanation In emphysema, there is destruction of the connective tissue responsible for much of the elastic recoil of the lung resulting to shortness of breath.

Objectives After 2 hours of nursing interventions, the client will be able to maintain adequate gas exchange.

Nursing Interventions 1. Regularly monitor the client s respiratory rate and pulse oximetry, ABG results, and manifestations of hypoxia or hypercapnia. Report significant changes or lack of response promptly. 2. Administer low flow oxygen therapy (1 to 3 L/min or 24 % to 31% Flo2) as needed via nasal prongs or a highflow venture mask.

Rationale Prompt recognition of deteriorating respiratory function can reduced potentially lethal outcomes.

Evaluation

Oxygen corrects existing hypoxemia. Excessive increases in o2 (55% to 70% Flow) may diminish respiratory drive and increases carbon dioxide retention further. Environmental 78

3. During episodes, open doors and curtains and limit the number of people and unnecessary equipment in the room. Provide a fan if the client perceives a benefit from the moving air. 4. Encourage the use of breathing retraining and relaxation technique.

changes may lessen the client s perception of suffocation.

A feeling of self control and success in facilitating breathing helps reduced anxiety. Over sedation may cause respiratory depression.

5. Give sedatives and tranquilizers with extreme caution, nonpharnaceutical method of anxiety are useful.

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3. Activity intolerance Nursing Cues Diagnosis S: Kaagad kung papagal, makanita naman keng emphysema ewari? O: > RR increases after an activity > walks, regular paced, but becomes short of breath. Activity intolerance related to imbalance between oxygen supply and demand secondary to emphysema and possible unstable angina as evidenced by reports of easy fatigability and becomes short of breath after a strenuous activity.

Scientific Explanation Insufficient physiological or psychological energy to endure or complete required or desired daily activities which could be related to any discomfort that the patient feels.

Objectives After 4 hours of nursing intervention, the patient will identify negative factors affecting activity tolerance and eliminate or reduce their effects when possible.

Nursing Interventions 1. Evaluate client s actual and perceived limitations in light of usual status

Rationale Provides comparative baseline and provides information about needed interventions regarding quality of life.

Evaluation

2. Ascertain ability to stand and move about and degree of assistance or necessary use of equipment 3. Adjust activities to patient s own capability 4. Teach methods to increase activity levels gradually and plan care with balanced rest periods. 5. Provide positive atmosphere and

To determine current status and needs associated with participation in needed or desired activities. To prevent overexertion

To conserve energy and reduce fatigue

Helps to minimize frustration and 80

diversional activities.

rechannel energy

6. Teach client with the use of assistive devices 7. Promote comfort measures 8. Assist client in learning appropriate safety measures

To protect client from injury

To enhance ability to participate in activities To prevent injury

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4. Ineffective Breathing Pattern Nursing Scientific Cues Diagnosis Explanation S: Ineffective When a Breathing stimulant O: Pattern related trigger such as >With rapid and to bronchoinhalation of shallow spasm and an allergen or respirations inflammation of irritant occurs, (30bpm) the alveoli an acute or secondary to early response >Uses accessory emphysema as develops in the muscles to aid in evidenced by hyperreactive breathing barrel chest, airways >hyperinflated tachypnea, and predisposed to chest prolonged bronchospasm >prolonged expiratory . Sensitized expiratory phase phase. mast cells in the bronchial mucosa release inflammatory mediators such as histamine, prostaglandins and leukotrienes. These mediators stimulate

Objectives The client will be able to establish an effective respiratory pattern so as to provide adequate ventilation as manifested by stabilizing respiratory rate, decreasing chest tightness, slight to no nasal flaring and decreasing usage of accessory muscles

Nursing Interventions 1. Frequently reassess respiratory rate, pattern, and breath sounds. Note manifestations of ineffective breathing. 2. Monitor vital signs and laboratory results.

Rationale Early identification of ineffective respirations allows timely initiation of interventions.

Evaluation

Tachypnea, tachycardia, an elevated blood pressure, and increasing hypoxemia and hypercapnia are signs of compromised respiratory status. This conserves energy and reduces fatigue. Scheduled rest is important to prevent fatigue.

3. Assist with self-care activities. 4. Provide rest periods between scheduled activities and treatments. 5. Place in Fowler s, High Fowler s or orthopneic (with head

These positions reduce the work of breathing and increases lung 82

parasympathet ic receptors and bronchial smooth muscle to produce bronchoconstri ction.

and arms supported on the overbed table) position to facilitate breathing and lung expansion. 6. Teach and assist to use techniques to control breathing pattern: a. Pursed-lip breathing b. Abdominal breathing c. Relaxation technique including visualization, meditation and others.

expansion, especially the basilar areas.

Pursed- lip breathing helps keep airways open by maintaining positive pressure, and abdominal breathing improves lung expansion. Relaxation techniques reduce anxiety and its effect on the respiratory rate.

7. Administer 2 liters per minute of oxygen as ordered.

Supplemental oxygen reduces hypoxemia.

8. Administer nebulizer treatments as ordered.

Adrenergic stimulants affect receptors on smooth muscle cells of the respiratory tract, causing smooth muscle relaxation and bronchodilation.

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9. Administer antiinflammatory agents as ordered.

These are used to suppress airway inflammation and reduce asthma symptoms. It blocks late response to inhaled allergens and reduce bronchial hyperresponsiveness.

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VII. PATIENT S DAILY PROGRESS (FROM ADMISSION TO DISCHARGE)

PATIENT S DAILY PROGRESS IN THE HOSPITAL (from Admission to Discharge)

CRITERIA NURSING PROBLEMS 1. Ineffective airway clearance related to and formation of connective tissue in the alveoli secondary to emphysema as evidenced by faint breath sounds with expiratory wheezes and tachypnea.

ADMISSION (07-28-11)

7-2911

8-3-11

8-4-11

8-5-11

DISCHARGE (08-06-11 )

2. Impaired Gas exchange related to ventilation perfusion imbalance secondary to inflammation and loss of elasticity of the lung alveoli as evidenced by tachypnea, prolonged expiratory phase with grunting, and hyperresonant lungs. Activity 85

intolerance related to imbalance between oxygen supply and demand secondary to emphysema and possible unstable angina as evidenced by reports of easy fatigability and becomes short of breath after a strenuous activity. 4. Ineffective Breathing Pattern related to broncho-spasm and inflammation of the alveoli secondary to emphysema as evidenced by barrel chest, tachypnea, and prolonged expiratory phase. VITAL SIGNS Temperature(C)

Pulse rate

Respiratory rate

9-12 9 10 11 12 9-12 9 10 11 12 9-12 9 10 11 12

36

36.6

36. 6

36.1

36.9

36.3C

76

77

77

74

79

71

30

26

26

27

23

24

86

Blood pressure

9-12 9 10 11 12

200/90

160/9 0

160/90

130/9 0

130/90

130/90

DIAGNOSTIC PROCEDURES / LABORATORY EXAMS 1. ABG 2. Hemoglobin A1C 3. CK-MB 6. CBC 7. Chest xray 8. BUN 9. CREA 10. HBAIC MEDICAL MGMT. IVF S D5 0.3 NaCl + 2 vials NaHCO3 x 40 cc / hr D5 0.3 NaCl + 2 vials NaHCO3 x 40 cc / hr D5 0.3 NaCl + 2 vials NaHCO3 x 40 cc / hr DRUGS 1. Furosemide 2. Hydrocortisone 3.Seretide 4. Omepron 5. Levox 6. Arixtra 7. Diazepam 8. Tazedine DIET Low fat, Low salt Soft diet SURGICAL MANAGEMENT 87

VIII. DISCHARGE PLANNING 1. General condition of client upon discharge Upon discharge the patient is able to move with nurse assistance, an aid of a device or a relative. He has normal vital signs with a temperature of 36.3 C, pulse rate of 71 beats/min, respiration rate of 24 breaths/min and a blood pressure of 130/90mmHg. On the last rounds of his attending physician said that he can perform ADL s and he needs to have adequate rest for faster recovery.

Medications: Furosemide 40mg ,three times a day Seretide 25mcg inhaler, two puffs, two times a day. Hydrocortisone 20mg, once a day Omeprozole 20mg, once a day

Exercise: y Mild exercise can increased oxygen utilization and re-train muscle to help improve the tissue. y Encouraged the patient to pursed-lip breathing to prolong exhalation and increase airway pressure during expiration, thus reducing the amount of trapped air and the amount of airway resistance. y Instructed the patient to Inhale through the nose while slowly counting to 3 then blow it slowly and evenly against pursed lips while tightening the abdominal muscles. 88

y y

Activities, as long as tolerated. Instructed the patient to do outdoor walking to increase the strength of respiratory muscles.

Treatment: Postural drainage. This helps to remove secretions from the airways. The patient lies in a position that allows gravity to aid in draining different parts of the lung. This is often done after the patient inhales an aerosol medication. The basic position involves the patient lying on the bed with his chest and head over the side and the forearms resting on the floor. Chest percussion. This technique involves lightly clapping the back and chest, and may help to loosen thick secretions. Coughing and deep breathing. These techniques may aid the patient in bringing up secretions. Nebulization therapy. Health Teachings: y y Instructed patient and SO for smoking cessation. Instruct the family to avoid air pollutants such as smoke, dust or aerosol sprays which may initiate brochospasm. y Encouraged patient to increase fluid intake, drinking for at least 8 glasses of water a day.

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Instructed patient in energy conservation techniques, such as pacing activities throughout the day, interspersed with adequate rest periods, and alternating high-energy, lo-energy tasks.

y y OPD:

Advised patient pursed-lip technique during activities. Encouraged patient to maintain a regular and consistent bedtime routine.

The patient was instructed to come back to the hospital for a follow-up check up with the physician. Diet: y y Recommended patient small frequent meals high in protein. Advised patient to avoid gas-producing foods, such as beans and cabbage. y Eat slowly and chewed food thoroughly to avoid becoming breathless while eating and to prevent choking. y Limit salty food, consuming too much can cause the body to retain water and make breathing become difficulty. y Eat food with contains Vitamin C for development and maintenance of the blood vessels and scar tissues.

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IX. CONCLUSION AND RECOMMENDATION Emphysema is a chronic obstructive pulmonary disease (COPD). It is often caused by exposure to toxic chemicals, including long-term exposure to tobacco smoke or cigarette smoking. The lungs become damaged because of reactions to irritants entering the airways and alveoli. Cigarette smoking is the major cause of emphysema, accounting for more than 80 percent of all cases. Emphysema occurs most often in people older than age 40 who have smoked for many years. Long-term exposure to secondhand smoke may also play a role. Smoking stresses the natural antioxidant defense system of the lung, allowing free radicals to damage tissue down to the cellular level. When cigarette smoke is inhaled, 80 to 90 per cent remains in the lungs and causes irritation, increased mucus production and damage to the deep parts of the lungs. Eventually mucus and tar clog up the air tubes, causing chronic bronchitis and emphysema. Among other causes of emphysema are industrial pollutants, aerosol sprays, non-tobacco smoke, internal-combustion engine exhaust, and physiological atrophy associated with old age (senile emphysema). Emphysema is characterized by loss of elasticity (increased pulmonary compliance) of the lung tissue caused by destruction of structures feeding the alveoli, owing to the action of alpha 1 antitrypsin deficiency. This causes the small airways to collapse during forced exhalation, as alveolar collapsibility has decreased. As a result, airflow is impeded and air becomes trapped in the lungs, in the same way as other obstructive lung diseases. Symptoms include shortness of breath on exertion, and an expanded chest. However, the constriction of air passages isn't always immediately deadly, and treatment is available. 91

Emphysema is often the result of smoke that has triggered the immune system to produce more harmful enzymes. Although these harmful enzymes are normally prevented from causing any significant damage by a protective protein, smoking reduces the protein s protective effect. Even if someone has plenty of the protein in their system, smoking generates certain substances that keep the protective protein from doing its job. COPD, particularly emphysema could be a fatal problem. Therefore, as student nurses, we should be equipped with the right knowledge and information in order for us to increase the awareness of our patients suffering from such condition. We are involved in learning what type of nursing interventions we are to apply to this type of patient. Beyond understanding the relevant health issue, this case study also explored other factors that can enhance our knowledge in the field of our nursing practice. The support and skill of a student nurse are essential especially during these times. If the patient and other persons involved will do their part and we will do ours, somehow, both of us are trying to reach a goal.

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X. BIBLIOGRAPHY AND REFERENCES y Black and Hawks. Medical Surgical Nursing. 7th edition. y y y y http://emedicine.medscape.com/article/297664-overview#a0104 http://copd.about.com/od/copdbasics/a/copdpathophysiology.htm http://ezinearticles.com/?Pathophysiology-of-COPD&id=408861 http://www.medicinenet.com/chronic_obstructive_pulmonary_disease_copd/article.ht m y y y y http://en.wikipedia.org/wiki/Chronic_obstructive_pulmonary_disease MIMS Drug Handbook Year 2011 Edition http://www.scribd.com/doc/20622925/angina-pectoris-pathophysiology#archive http://www.who.int/whosis/mort/profiles/mort_wpro_phl_philippines.pdf

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