TABLE OF CONTENTS I. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II. NURSING HISTORY a. Personal History a. Demographic Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. Socio-economic and Cultural Factors. . . . . . . . . . . . . . . . . . . . b.

Family-Health Illness History . . . . . . . . . . . . . . . . . . . . . . . . . . . . c. History of Past Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. History of Present Illness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e. Genogram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PHYSICAL ASSESSMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DIAGNOSTIC AND LABORATORY PROCEDURES. . . . . . . . .

1-4

5 5-6 6 6-7 7 8 9-12 13-26

III. IV.
V.

THE PATIENT AND HIS ILLNESS a. Anatomy and Physiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27-31 b. Pathophysiology i. Book-Based. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32-36 ii. Patient-Based . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37-40 THE PATIENT AND HIS CARE a. Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i. Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii. Diet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii. Activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. Surgical Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41-42 43-52 53-54 55 56-58

VI.

VII. VIII. IX.

NURSING CARE PLAN. . . . . ACTUAL SOAPIE(s) . . . . . . . DISCHARGE PLANNING. . . REFERENCES.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59-68 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69-70 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71-72

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

1|COPD CASE STUDY.

INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible. This newest definition COPD, provided by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), is a broad description that better explains this disorder and its signs and symptoms (GOLD, World Health Organization [WHO] & National Heart, Lung and Blood Institute [NHLBI], 2004). Although previous definitions have include emphysema and chronic bronchitis under the umbrella classification of COPD, this was often confusing because most patient with COPD present with over lapping signs and symptoms of these two distinct disease processes. COPD may include diseases that cause airflow obstruction (e.g., Emphysema, chronic bronchitis) or any combination of these disorders. Other diseases as cystic fibrosis, bronchiectasis, and asthma that were previously classified as types of chronic obstructive lung disease are now classified as chronic pulmonary disorders. However, asthma is now considered as a separate disorder and is classified as an abnormal airway condition characterized primarily by reversible inflammation. COPD can co-exist with asthma. Both of these diseases have the same major symptoms; however, symptoms are generally more variable in asthma than in COPD. Currently, COPD is the fourth leading cause of mortality and the 12th leading cause of disability. However, by the year 2020 it is estimated that COPD will be the third leading cause of death and the firth leading cause of disability (Sin, McAlister, Man. Et al., 2003). People with COPD commonly become symptomatic during the middle adult years, and the incidence of the disease increases with age.

2|COPD CASE STUDY.

In 2008, 13.1 million U.S. adults (aged 18 and over) were estimated to have COPD. Chronic Obstructive Pulmonary Disease (COPD) and asthma are 2 of the leading causes of deaths in the Philippines and the world. According to World Health Organization, 600 million people worldwide suffer from COPD while 12% of Philippine population of 90 million have asthma. Objectives (Nurse Centered) After 2 days of nurse-patient interaction and data gathering, student nurses will be able to: Cognitive Identify the underlying cause(s) or risk factors that contributed to the condition of the patient; Enumerate the signs and symptoms of the disease and the pathologic changes occurring during the course of the disease; Develop critical thinking abilities so as to determine appropriate interventions and medical management of the disease condition and care indicate. Affective Recognize the importance of developing a practice of performing Display the proper knowledge and skills in providing effective accurate and complete assessment findings nursing care to the patient Psychomotor Perform a cephalocaudal assessment on the patient 3|COPD CASE STUDY.

Monitor and evaluate patients recovery during hospitalization Provide health teachings to the patient especially factors that will

contribute to the continuity of care. II. NURSING ASSESSMENT A. Personal Data This is the case of Mr. COPD, 75 years of age, male, married and a natural born Filipino who lives in #4 Paseo De Espanam Villa Angela, Angeles Ciy. He was admitted in hospital last August 23, 2011 at 8:00PM with a chief complaint of difficulty of breathing (DOB), several months prior to admission with a complaint of DOB and chest pain, with admitting diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure(CHF), T/C Acute Coronary Syndrome (ACS), Diabetes Mellitus (DM) B. Personal History (The data obtained were based from the patients chart and the interview conducted by the student nurses with the relatives of Mr. COPD) Mr. COPD was born on January 12, 1936 via home delivery at Lubao. He is the third among the four children of Mr. And Mrs. XY (not their real names). This nuclear type of family who lives in Lubao Pampanga uses Kapampangan as their medium of communication. Mr. COPD and hes family are all Catholic. It was stated during interview that Mr.COPD didnt finish college due to some personal matters. He had three children, all born via normal spontaneous delivery.

4|COPD CASE STUDY.

During the interview, the wife of Mr. COPD stressed that they practice proper garbage disposal outside the house by putting their garbage in sack and collected regularly every 3 days.

Mr.COPD smokes 1 pack per day since he was 20 years old and with regards to cultural beliefs and practices of Mr. COPD and their family, they stated that they do not seek the opinion or help of the herbolarios for treatment of certain disease conditions. They also do not use herbal medicines as a form of immediate of their ailments. They however emphasized that they do self medication with over the counter drugs like Paracetamol and Neozep to treat common and minor disease conditions such as fever and colds.

C. Family Health-Illness History This information is based from the interview conducted with the wife and children of Mr. COPD. Some data were not able to obtain for the reason that the children and wife of Mr. COPD could not anymore recall some specific facts such as the dates of certain events. As to what stated in the personal history of Mr. COPD, he is the third among the four children of Mr. And XY (not their real names).The grandparents of Mr. COPD on his mother side and his father side was already dead. He was not able to remember the cause of death because he was still young at that time. His father has four siblings, two boys and two girls. His mother has 2 siblings, one boy and one girl. His father, uncle and aunt has a history of hypertension. For the siblings of Mr. COPD, the first two eldest were already dead. Mr. COPD could not provide the age and date of death. According to him, his eldest brother died because of ulcer and eldest sister died because of head injury. The 5|COPD CASE STUDY.

youngest sister was born on April 5, 1960, currently living in states with her children, with a history of hypertension.

As for the wife of Mr. COPD who was born on August 12, 1935 presently living at Villa Angela Angeles City together with Mr. COPD and their youngest child. The oldest child Uno 35 years of age, Dos 32 years of age, and Tres 30 years of age. Their children didnt acquire any illness coming from Mr. COPD. D. History of Past Illness According to Mr. COPD, when he had a fever, cough or colds he usually self-medicate, he takes Paracetamol until fever subsides. Likewise if he catches cough and colds he takes Neozep and other over the counter drugs to treat these conditions. Hes been hospitalized last June 3, 2011 due to S/P Bypass. E. History of Present Illness The patient had a difficulty of breathing when his wife and child hurried him to the Hospital at 8:00 in the evening, The patients diagnosis was pleural effusion, having fluids in the left lung. Mr. COPD also has an asthma and hypertension, he treat this conditions by going to a Doctor for a regular check-up. The Doctors are also taking in consideration of Mr. COPD having an Acute Coronary Syndrome (ACS) and Diabetes Mellitus (DM).

6|COPD CASE STUDY.

7|COPD CASE STUDY.

F. Physical Examination STUDENT NURSE-PATIENT INTERACTION Vital Signs Temperature: Pulse Rate: Respiratory Rate: Blood Pressure: General appearance: Head and Face: Eyes: General: eyes are symmetrical, no abnormal protrusion noted, no discharges noted on both eyes,, with parallel eye movement upon inspection Pupils: black in color, with equal size approximately 3-4mm Eyebrows: equal distribution of hair on both side upon inspection Eyelids and Eyelashes: no evidence of infection, no nodules and tenderness noted upon palpation Sclerae: whitish sclerae with evident capillaries, no jaundice noted Conjuctiva: pale conjunctiva Vision: unable to see clearly near and far objects 8|COPD CASE STUDY. no tenderness of the scalp upon palpation Skull: normal skull configuration, no abnormal elevation or depression. Face: symmetrical in shape, with appropriateness of facial expression, no tenderness upon palpation Hair: hair is black and with white strands and straight. 36.7C 88 bpm 23 cpm 110/70 mmHg

Ears: Nose: General: symmetrical nares, no discharge, no bleeding or swelling noted Mouth and Throat: Neck: Blood vessels: no distension on jugular vein is noted Trachea: placed on the midline of the neck, no masses noted and thyroid gland palpated during swallowing Integumentary: Chest: Barrel chest Increased RR 25bpm 9|COPD CASE STUDY. Skin: fair complexion, with warm and dry skin, no swelling and lesion noted. Nails: short, no clubbing of fingers. Mouth: complete teeth, negative halitosis Lips; pale in color, no swelling on both lips and gums Tongue: pinkish to reddish in color, no lesions and able to take tongue in and out when instructed Soft palate and uvula: no swelling on palate and uvula in midline External: symmetrical appearance of pinna, no lesions or abnormal discharges or swelling Internal: yellowish discharges noted upon inspection

Shortness of breath Use of accessory muscles Dyspnea Asymmetrical chest expansion ( with difficulty expanding on the right side of the thorax)

Lungs:
Tight breathe sounds

Gastrointestinal Abdomen: no scar, no protruding mass or discharge on the umbilicus.

Musculoskeletal: Upper extremities: equal in size, symmetrical in shape, and equally strong pulses Lower extremities: equal in size, symmetrical in shape and equally strong pulses, (-) edema F. Diagnostics and Laboratory Procedures Procedure Hematology (CBC) Hemoglobin To measure the 12.8 total blood. amount of hemoglobin in the 11.6-15.6 g/dl Hemoglobin is normal range. within Date Ordered 08/23/11 Indication/ Purpose Results Normal Values
Analysis and Interpretation

Hematocrit

To aid diagnosis 40.4

36.0-47.0 %

HCT is within

10 | C O P D C A S E S T U D Y .

of states

abnormal of

normal range.

hydration, polycythemia and anemia and aids in calculation of erythrocyte indices.

RBC

To provide data 4.70 for calculating MCV and MCH, which reveal RBC size and HGB to other content support for and

4.20-5.40 x 10 RBC is within 12/L normal range.

hematologic tests diagnosing and anemia polycythemia

WBC Differential Count

To

determine 19.37 or

4.6-10.6 9/L

10 WBC increased which indicates presence to

is

infection inflammation

of

infection due retained

11 | C O P D C A S E S T U D Y .

secretions.

Neutrophillis

To of

provide the

a 74.2

40-74 %

Neutrophils are increased due which indicates bacterial infection. Lymphocyte to inflammation

numeric estimate clients immune status

Lymphocyte s

To

determine 19.1

19-48 %

is normal range.

within

immune function, provides a gross measure nutritional status in

Results Eosinophils Monocytes Basophils To of provide the a 4.4 0-7 % 3-9 % 0.2 % numeric estimate clients 2.1 0.2 immune status. range.

are

within normal

Platelet count Platelet Count To platelet production and to diagnose and 12 | C O P D C A S E S T U D Y . evaluate 217 150-400x 10 9/K is normal range. within

monitor

severe MCV is within 82-98 FL normal range.

thrombocytosis or thrombocytopenia Mean Corpuscular Volume (MCV) The ration of HCT 86.0 to the RBC count, expresses average the and whether undersized (microcytic) oversized (macrocytic) normal. MCH Mean Corpuscular Hemoglobin (MCH) MCHC Mean Corpuscular Hemoglobin Concentrati on (MCHC) It helps to 33.7 32-38 % distinguish normally colored (normochromic) RBCs from paler (hypochromic) RBCs. NURSING RESPONSIBILITIES: Before the Procedure 13 | C O P D C A S E S T U D Y . range. is To gives the 28.2 28-33 PG weight of HGB in an average cell. range. is within normal or or size the if

erythrocytes indicates

within normal

Explain the procedure to the pt. and why it is indicated. Inform the patient that fluid and food restriction is not required. Inform the patient that a blood sample will be taken. Tell the patient that he may experience transient discomfort from the needle puncture. Fill up laboratory request form properly and send it to the laboratory technician during the collection of sample/specimen.

During the Procedure Inform the patient that pain may be felt through prick in the needle. Instruct the patient to calm down to avoid uneasiness.

After the Procedure Apply brief pressure to prevent bleeding Apply warm compress if Hematoma will develop at the venipuncture site.

14 | C O P D C A S E S T U D Y .

Procedure Blood Chemistry Glucose RBS

Date Ordered 08/23/11

Indication/ Purpose

Results

Normal Values

Analysis and Interpretation

This measures amount blood reveal individual patterns blood changes. and

test 250.91 the mg/dl of to

75-111 mg/dl

Increase indicate type 2.

in DM

blood glucose

glucose in the

of glucose

Blood Urea Nitrogen (BUN)

This test is to measure amount blood form and measurement of renal function. in of the of the urea, a

44.38

7-21 mg/dl

Increased BUN reflect physiological

in may a

nitrogen in the

response to a relative decrease the kidney. of blood flow to

15 | C O P D C A S E S T U D Y .

Creatinine

This measures amount

test 1.89 the of

.5-1.69 mg/dl

Increased creatinine shows kidney deficient. that is filtering of the

creatinine in the blood. It is used to diagnose renal and impaired function assess glomerular filtration. Sodium To check for 134 137-145

Hyponatremia indicates Shift of water from intracellular compartment to extracellular compartment with resultant of dilution sodium.

water balance.

Potassium

To acid

measure 3.9 base and muscle

3.6-5.0

Potassium within indicate acceptable acid

is

normal

balance normal activity.

range. Results

base

16 | C O P D C A S E S T U D Y .

balance standard

and

muscle activity. Chloride This test is to measure body's fluid level or acid-base balance. CK-MB CKMB levels, 2 Less than 16 Result is within U/L normal range. 98 101-111 Decreased in chloride indicate hypochloremia level

along with total CK, are tested in persons who have chest pain to have diagnose they had whether

a heart attack

17 | C O P D C A S E S T U D Y .

NURSING RESPONSIBILITIES: Before the Procedure

Double check doctors order. Check vital signs. Explain the procedure.

During the Procedure Stay with the patient. Assist with the collection of the specimen if allowed. Label the specimen.

After the Procedure Observe venipuncture site for bleeding or hematoma formation. Apply pressure bandage. In case of hematoma formation, instruct the patient to apply warm compress. Procedure Hemoglobin A1C (HBA1C) HBA1C Date Ordered 8/24/11 A Indication/ Purpose test that the of to 6.0 4.5-6.3% Results Normal Values
Analysis and Interpretation

HBA1C within the reference range indicates that a diabetic person control. with good glucose

measures amount hemoglobin bound

glucose. It is a measure of how much glucose has been in the blood during the past two to four

18 | C O P D C A S E S T U D Y .

months. NURSING RESPONSIBILITIES: Before and During the Procedure No special preparation is required. Blood is collected by venipuncture in a tube containing EDTA anticoagulant after disinfecting the puncture site. After the Procedure Discomfort or bruising may occur at the puncture site. Pressure to the puncture site until the bleeding stops reduces bruising; warm packs relieve discomfort. Some people feel dizzy or faint after blood has been drawn and should be treated accordingly.

19 | C O P D C A S E S T U D Y .

NURSING RESPONSIBILITIES: Procedure Date A Indication/ Purpose blood test Result Normal Values Analysis and Interpretation Respiratory Acidosis

Ordered Arterial Blood 8/23/11 Gas(ABG)

used to provide information that helps and patients respiratory metabolic acid/base electrolyte homeostasis, and adequacy oxygenation. assess of and and assess manage

pH pCO2 PO2 HCO3 B.E. O2 Sat.

7.36 48.8 57.7 23 7.1 90.2

7.35-7-45 35-45mmHg 8-100mmg 22-26mEq/L +/-2mEq/L 97%

20 | C O P D C A S E S T U D Y .

Before the Procedure Ensure that the patient/parent of child has signed appropriate documents for the procedure Explain to patient/parent that arterial blood analysis evaluates how well the lungs and blood are delivering oxygen systematically as well as the extent that carbon dioxide is being eliminated from the body Tell the patient/parent that this test requires a blood sample. Explain who will perform the arterial puncture, when it will occur, and where the puncture site will be: radial, brachial, or femoral artery. Inform the patient/parent that he will not need to restrict food or fluids for this test. Instruct the patient to breathe normally during the test and warn him that he may experience a brief cramping or throbbing pain at the puncture site.

During the Procedure Wait for at least twenty minutes before drawing arterial blood when starting, changing, or discontinuing oxygen therapy, changing/ starting mechanical ventilation settings, or after extubation. Use a heparinized syringe in drawing the blood sample. Perform an arterial puncture or draw from an existing arterial blood line. Before sending the sample to the laboratory, note whether the patient was breathing room air or was receiving oxygen therapy when the sample was collected.

21 | C O P D C A S E S T U D Y .

Note the flow rate of oxygen therapy and the method of delivery if the patient was on the therapy during the time of extraction.

Note the patients temperature.

After the Procedure Apply pressure for three to five minutes on Arterial puncture site. If the patient is receiving anticoagulant, hold the pressure on site for 5 minutes or longer if necessary. If the puncture site is on the arm, dont tape the entire circumference as this may restrict circulation Monitor the patients vital signs and observe for signs of circulatory impairment such as swelling, discoloration, pain, numbness, and tingling in the arms or legs.

Assess bleeding from the puncture site.

Date Procedure Blood Chemistry ABG Ratio Ordered 8/25/11

Indication/Purpose

Results

Normal Values

Analysis

and

Interpretation

Is a blood test that 1.57 is performed using blood from an artery.

1.1-2.5g/l

ABG is within normal range

22 | C O P D C A S E S T U D Y .

Sodium

To check for water 135 balance.

137-145mmo/l

Hyponatremia indicates Shift of water from intracellular compartment to extracellular compartment with resultant dilution sodium. of

Potassium

To measure acid 4.0 base balance and normal activity. muscle

3.6-5.0mmo/l

Potassium

is

within normal range. Results indicate acceptable acid balance standard muscle activity base and

Procedure Blood Chemistry Glucose FBS

Date Ordered 8/25/11

Indication/ Purpose

Result

Normal Values

Analysis and Interpretation

This measures amount glucose in

test 278.58 the of the

76-111mg/dl

Increase indicate type 2.

in DM

blood glucose

23 | C O P D C A S E S T U D Y .

blood reveal

and

to

individual patterns of blood glucose changes. BUN This test is to measure amount nitrogen in the of the 53.99 7-21mg/dl Increased BUN reflect physiological response to a relative decrease the kidney of blood flow to in may a

blood in the form of urea, and a measurement of renal function

Creatinine

This measures amount

test 1.81 the of

0.5-1.69mg/dl Increased creatinine shows kidney deficient that is filtering of the

creatinine in the blood. It is used to impaired function assess glomerular filtration. The uric acid 10.32 M-3.5diagnose renal and

Increased

in

24 | C O P D C A S E S T U D Y .

Uric Acid (Male)

blood test is used to detect of high this levels blood.

4.5mg/dl

uric indicates

acid

hyperuricemia.

compound in the

Cholesterol

This test is used 142.41 to estimate risk of developing disease disease. specifically heart a

200-239mg/dl Result below 200 mg/dL is considered desirable and reflects a low risk of heart disease.

Triglycerides (Male)

This test is used to monitor those who have risk factors for heart disease.

76.11

up 200mg/dl

to Result range/ risk.

is low

within normal

Serum glutamic oxaloacetic transaminase /aspartate aminotransferase SGOT/AST

aspartate aminotransferase (AST) test is often part of an initial screening for liver disease.

22

5-35u/l

Result is within normal range.

25 | C O P D C A S E S T U D Y .

Total Protein

The total protein 59 test measures the total two amount classes of of

58-80g/l

Result range.

is

within normal

proteins found in the fluid portion of your albumin globulin. blood: and

Albumin

albumin testing is 36 used in a variety of settings to help diagnose disease

35-60g/l

Result range.

is

within normal

Globulin

This test is used 23 to measure the of amount

18-32g/l

Result range.

is

within normal

globulin, a kindof serum protein in the blood. NURSING RESPONSIBILITIES: PRIOR: Double check doctors order Check vital signs Explain the procedure. 26 | C O P D C A S E S T U D Y .

DURING: Direct the patient to breathe normally and to avoid unnecessary movement while doing the procedure. Observe standard precautions, and follow the general guidelines. Promptly transport the specimen to the laboratory for processing and analysis. Promptly transport the specimen to the laboratory for processing and analysis. AFTER: The patient may return to normal activities after collecting the sample and may start taking medications that were discontinued before the test.

CBG MONITORING NORMAL VALUES 70-110mg/dl Date and Time 8/24/11 2PM 10PM 8/25/11 6AM 3PM 6PM 332mg/dl 363mg/dl 210mg/dl 27 | C O P D C A S E S T U D Y . CBG Result 83mg/dl 412mg/d

8/26/11 12MN 6AM 11AM 71mg/dl 193mg/dl 190mg/dl

PURPOSE: Blood glucose monitoring reveals individual patterns of blood glucose changes, and helps in the planning of meals, activities, and at what time of day to take medications. Also, testing allows for quick response to high blood sugar

(hyperglycemia) or low blood sugar (hypoglycemia). This might include diet adjustments, exercise, and insulin (as instructed).

II. ANATOMY AND PHYSIOLOGY (Book-Based)

28 | C O P D C A S E S T U D Y .

The respiratory system consists of all the organs involved in breathing. These include the nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important things: it brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes wrong with part of the respiratory system, such as an infection like pneumonia, chronic obstructive pulmonary diseases, it makes it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide. Common respiratory symptoms include breathlessness, cough, and chest pain. The

Upper Airway and Trachea When you breathe in, air enters your body through your nose or mouth. From there, it travels down your throat through the larynx (or voicebox) and into 29 | C O P D C A S E S T U D Y .

the trachea (or windpipe) before entering your lungs. All these structures act to funnel fresh air down from the outside world into your body. The upper airway is important because it must always stay open for you to be able to breathe. It also helps to moisten and warm the air before it reaches your lungs.

The Lungs Structure The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen into the body, which we need for our cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We each have two lungs, a left lung and a right lung. These are divided up into lobes, or big sections of tissue separated by fissures or dividers. The right lung has three lobes but the left lung has only two, because the heart takes up some of the space in the left side of our chest. The lungs can also be divided up into even smaller portions, called bronchopulmonary segments. These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment receives its own blood supply and air supply.

COPD VERSUS HEALTHY LUNG 30 | C O P D C A S E S T U D Y .

How they work Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream. Traveling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide.

31 | C O P D C A S E S T U D Y .

Blood Supply The lungs are very vascular organs, meaning they receive a very large blood supply. This is because the pulmonary arteries, which supply the lungs, come directly from the right side of your heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs so that the carbon dioxide can be blown off, and more oxygen can be absorbed into the bloodstream. The newly oxygen-rich blood then travels back through the paired pulmonary veins into the left side of your heart. From there, it is pumped all around your body to supply oxygen to cells and organs.

The Work of Breathing

The Pleurae The lungs are covered by smooth membranes that we call pleurae. The pleurae have two layers, a visceral layer which sticks closely to the outside surface of your lungs, and a parietal layer which lines the inside of your chest wall (ribcage). The pleurae are important because they help you breathe in and out smoothly, without any friction. They also make sure that when your ribcage expands on breathing in, your lungs expand as well to fill the extra space. 32 | C O P D C A S E S T U D Y .

The Diaphragm and Intercostal Muscles When you breathe in (inspiration), your muscles need to work to fill your lungs with air. The diaphragm, a large, sheet-like muscle which stretches across your chest under the ribcage, does much of this work. At rest, it is shaped like a dome curving up into your chest. When you breathe in, the diaphragm contracts and flattens out, expanding the space in your chest and drawing air into your lungs. Other muscles, including the muscles between your ribs (the intercostal muscles) also help by moving your ribcage in and out. Breathing out (expiration) does not normally require your muscles to work. This is because your lungs are very elastic, and when your muscles relax at the end of inspiration your lungs simply recoil back into their resting position, pushing the air out as they go. The Respiratory System and Ageing The normal process of ageing is associated with a number of changes in both the structure and function of the respiratory system. These include: Enlargement of the alveoli. The air spaces get bigger and lose their

elasticity, meaning that there is less area for gases to be exchanged across. This change is sometimes referred to as senile emphysema.

The compliance (or springiness) of the chest wall decreases, so that it The strength of the respiratory muscles (the diaphragm and intercostal

takes more effort to breathe in and out.

muscles) decreases. This change is closely connected to the general health of the person. All of these changes mean that an older person might have more difficulty coping with increased stress on their respiratory system, such as with an infection like pneumonia, than a younger person would.

33 | C O P D C A S E S T U D Y .

PREDISPOSING FACTORS

Risk factors for COPD include environmental exposures and host factors. The most important risk factor for COPD is cigarette smoking. Other risk factors are pipe, cigar, and other types of tobacco smoking. In addition, passive smoking contributes to respiratory symptoms and COPD. Smoking depresses the activity of scavenger cells and affects the respiratory tracts ciliary cleansing mechanism, which keeps breathing passages free of inhaled irritants, bacteria, and other foreign matter. When smoking damages this cleansing mechanism, airflow is obstructed and air becomes trapped behind the obstruction. The alveoli greatly distend, diminished lung capacity. Smoking also irritates the goblet cells and mucus glands, causing an increased accumulation of mucus, which in turn produces more irritation, infection, and damage to the lung. In addition, carbon monoxide (a by product of smoking) combines with hemoglobin to form carboxyhemoglobin. Hemoglobin that is bound by carboxyhemoglobin cannot carry oxygen efficiently.

34 | C O P D C A S E S T U D Y .

A host risk factor for COPD is a deficiency of alpha antitrypsin, an enzyme inhibitor that protects the lung parenchyma from injury. This deficiency predisposes young people to rapid development of lobular emphysema, even if they do not smoke. Genetically susceptible people are sensitive to environmental factors (eg. Smoking, air pollution, infectious agents, allergens) and eventually developed chronic obstructive symptoms. Carriers of this genetic defect must be identified so that they can modify environmental risk factors to delay or prevent overt symptoms of disease. PATHOPHYSIOLOGY (Book-Based) In COPD, the airflow limitation is both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. The inflammatory response occurs throughout the airways, parenchyma, and pulmonary vasculature. Because of the chronic inflammation and the bodys attempts to repair it, narrowing occurs in the small peripheral airways. Over time, this injury-and-repair process causes scar tissue formation and narrowing of the airway lumen. Airflow obstruction may also be caused by parenchymal destruction, as is seen with emphysema, a disease of the alveoli or gas exchange units. In addition to inflammation, processes related to imbalances of proteinases and antiproteinases in the lung may be responsible for airflow limitation. When activated by chronic inflammation, proteiness and other substances may be released, damaging the parenchyma of the lung. The parenchymal changes may occur as a consequence of inflammation or environmental or genetic factors (eg. Alpha1-antitrypsin deficiency). Early in the course of COPD, the inflammatory response causes pulmonary vasculature changes that are characterized by thickening of the vessel wall. These changes may result from exposure to cigarette smoke, use of tobacco products, and the release of inflammatory medicators.

35 | C O P D C A S E S T U D Y .

CHRONIC BRONCHITIS Lung damage and inflammation in the large airways results in chronic bronchitis. Chronic bronchitis is defined in clinical terms as a cough with sputum production on most days for 3 months of a year, for 2 consecutive years. In the airways of the lung, the hallmark of chronic bronchitris is an increased number (hyperplasia) and increased size (hypertrophy) of the goblet cells and mucous glands of the airway. As a result, there is more mucus than usual in the airways, contributing to narrowing of the airways and causing a cough with sputum. Microscopically there is infiltration of the airway walls with inflammatory cells. Inflammation is followed by scarring and remodeling that thickens the walls and also results in narrowing of the airways. As chronic bronchitis progresses, there is squamous metaplasia (an abnormal change in the tissue lining the inside of the airway) and fibrosis (further thickening and scarring of the airway wall). The consequence of these changes is a limitation of airflow. Patients with advanced COPD that have primarily chronic bronchitis rather than emphysema were commonly referred to as blue bloaters because of the bluish color of the skin and lips (cyanosis) seen in them. The hypoxia and fluid retention leads to them being called Blue Bloaters. ACUTE BRONCHITIS PHYSICAL MANIFESTATIONS One of the most common symptoms of COPD is shortness of breath (dyspnea). People withCOPD commonly describe this as: My breathing requires effort, I feel out of breath, or I can not get enough air in. People with COPD typically first notice dyspnea during vigorous exercise when the demands on the lungs are greatest. Over the years, dyspnea tends to get 36 | C O P D C A S E S T U D Y .

gradually worse so that it can occur during milder, everyday activities such as housework. In the advanced stages ofCOPD, dyspnea can become so bad that it occurs during rest and is constantly present. Other symptoms of COPD are a persistent cough, sputum or mucus production, wheezing, chest tightness, and tiredness. People with advanced (very severe) COPD sometimes develop respiratory failure. When this happens, cyanosis, a bluish discoloration of the lips caused by a lack of oxygen in the blood, can occur. An excess of carbon dioxide in the blood can cause headaches, drowsiness or twitching (asterixis). A complication of advanced COPD is cor pulmonale, a strain on the heart due to the extra work required by the heart to pump blood through the affected lungs. Symptoms of cor pulmonale are peripheral edema, seen as swelling of the ankles, and dyspnea. There are a few signs of COPD that a healthcare worker may detect although they can be seen in other diseases. Some people have COPD and have none of these signs. Common signs are:

tachypnea, a rapid breathing rate wheezing sounds or crackles in the lungs heard through a stethoscope breathing out taking a longer time than breathing in enlargement of the chest, particularly the front-to-back distance

(hyperinflation)

active use of muscles in the neck to help with breathing breathing through pursed lips increased anteroposterior to lateral ratio of

the chest (i.e. barrel chest). EMPHYSEMA Emphysema is a chronic obstructive pulmonary disease (COPD, as it is otherwise known, formerly termed a chronic obstructive lung disease). It is often caused by exposure to toxic chemicals, including longterm exposure to tobacco smoke. Emphysema is 37 | C O P D C A S E S T U D Y .

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 isnt always immediately deadly, and treatment is available.

38 | C O P D C A S E S T U D Y .

39 | C O P D C A S E S T U D Y .

IV. PATHOPHYSIOLOGY (client based)

40 | C O P D C A S E S T U D Y .

41 | C O P D C A S E S T U D Y .

V.PATIENT AND HIS CARE I. Medical Management Treatment Date ordered Date given Date changed D5W 1LxKVO or discontinued 8/23/11 8/24/11 D5W is a preparation of IV solution that has 5% dextrose in pure water (so no salt, unlike normal saline which contains salt). It is mainly used to maintain a patient's blood sugar if they are not able to eat for some reason. This medication is a solution given by vein (through an and calories to the body. It is also used as a mixing solution (diluent) for other IV medications. Dextrose is a natural sugar found in the body and serves as a major energy source. When used as an energy source, dextrose allows the body to preserve its muscle mass. Redness, swelling, pain, or irritation at injection site may oc cur. General Description Indication/Purpose Patients Response

IV). It is used to supply water the

42 | C O P D C A S E S T U D Y .

PNSS 1LxKVO

8/25/11

Sodium Chloride Injection, *Sodium Chloride Injection, There is no febrile USP fluid dose is and a sterile, USP is indicated as a source response, infection, venous thrombosis or *0.9% Injection, indicated priming Sodium USP for use Chloride is also as a in site of phlebitis injection, extending from the extravasations and hypervolemia electrolyte in single for nonpyrogenic solution for of water and electrolytes. replenishment intravenous administration. It contains no antimicrobial agents. The nominal pH is 5.5 (4.5 to 7.0). Composition, and ionic osmolarity, below: 0.45% Sodium Chloride Injection, USP USP contains with of (calc). an 154 It 4.5 g/L Sodium Chloride, (NaCl) osmolarity mOsmol/L

containers

solution

hemodialysis procedures.

concentration are shown

contains 77 mEq/L sodium

43 | C O P D C A S E S T U D Y .

and 77 mEq/L chloride. 0.9% Sodium Chloride Injection, USP contains 9 g/L Sodium Chloride, USP (NaCl) with an osmolarity of 308 mOsmol/L (calc). It contains chloride. 154 mEq/L sodium and 154 mEq/L

Nursing Responsibilities Before the Procedure Check the doctors order regarding to what type of IVF to be used and also its volume and rate. Explain the procedure to the patient. Gather all materials needed for the insertion of IVF to save time and not to waste time for looking for other materials.

44 | C O P D C A S E S T U D Y .

Wash hands before and after the procedure to prevent contamination from insertion site.

During the Procedure Place patient in a comfortable position to facilitate easy insertion of IV line and to decrease patients fear about the procedure. Make sure that we give the proper IV fluid and drop rate accurately because patient may experience fluid overload or dehydration. Check for its patency by observing the backflow of blood upon insertion.

After the Procedure Press the site where the needle was inserted and secure it with micropore. Check the site of hand where the needle is inserted if bulging is not visible. If so, reinsertion is to be undertaken. Advice patient to avoid scratching the site less movement of the hand where the needle was inserted to keep it in place. Instruct patient and significant others to inform the nurse on duty if bulging of the site is visible, if there is back flow of blood of if IVF is not infusing well. Observe the IV site at least every hour for signs of infiltration or other complications fluid or electrolyte overload and air embolism. IVF regulation should be checked and monitored upon receiving patient. Always check the doctors order for new orders regarding the IVF supplement of the patient.

45 | C O P D C A S E S T U D Y .

Always check if the IVF is infusing well and intact. Monitor the patients skin integrity. Provide comfort for the patient. Remove and dispose used items. Report and record as appropriate.

46 | C O P D C A S E S T U D Y .

Treatment

Date ordered Date given Date changed or discontinued 8/24/11

General Description

Indication/Purpose

Patients Response

Nebulization Duavent

method

of Treatment of acute severe Responded well to & in of routine the treatment and chronic had an effective during entire rate and quality of to respirations the nebulization therapy.

administering a drug asthma

by spraying it into the management respiratory passages bronchospasm of the patient. unresponsive

conventional therapy

Nursing Responsibilities

47 | C O P D C A S E S T U D Y .

Before the Procedure Determine current vital signs, level of consciousness. Remove cup portion of the nebulizer Draw up prescribed amount of the mediation in the eye dropper Place medication in the medicine cup with 3cc normal saline Return cup to the nebulizer Place oxygen tubing on the nipple on the nebulizer and attach other end to the compressor or oxygen tank. Turn on the compressor or tank until mist is seen coming out of the mouthpiece. Place the mouthpiece in patients mouth and instruct to take slow, deep breaths. During the treatment, monitor the pulse. If the pulse increases to more than 20 beats a minute, discontinue the treatment. Otherwise, continue until the medication is used up. After the Procedure Record the procedure and patients immediate response. Assess the patients is condition, ABG and the functioning equipment at a regular intervals. Determine patient comfort with oxygen use. Following the treatment, use postural drainage, percussion, assisted coughing and/or suctioning, as appropriate.

During the Procedure

48 | C O P D C A S E S T U D Y .

Treatment

General Description

Indication/Purpose

Patients Response

49 | C O P D C A S E S T U D Y .

Oxygen Theraphy 2- 3 lpm

Oxygen therapy is the administration intervention, purposes chronic patient care. in and of which both acute oxygen as a medical can be for a variety of

It is used to treat and Responded well to prevent provides oxygen adequate to symptoms and the treatment quality entire and of during oxygen manifestations of hypoxia. It had an effective rate supplemental and patients spontaneous the with respirations

respirations but inadequate therapy oxygenation and to aid the respirations patients. of asthmatic

Nursing Responsibilities

50 | C O P D C A S E S T U D Y .

Before the Procedure Determine current vital signs, level of consciousness and most recent ABG. Assess risk of carbon dioxide retention with oxygen administration.

During the Procedure Show the nasal cannula to patient and explain the procedure. Make sure the humidifier is filled to the appropriate mark. Attach the connecting tube from the nasal cannula to the humidifier outlet. Set the flow rate at prescribed LPM. Feel to determine if oxygen is flowing through the tips of the cannula. Place the tips of the cannula in the patients nose and adjust straps around ears for snug, comfortable fit.

After the Procedure Record the flow rate used and immediate patient response. Assess the patients is condition, ABG and the functioning equipment at a regular intervals. Determine patient comfort with oxygen use.

II. MEDICATIONS

51 | C O P D C A S E S T U D Y .

Name of drugs Generic name Brand name

Date Ordered, Date Performed Date changed

Route or Admn Dosage and Frequency of Admn

Indication or Purpose

Clients response to the medication

Generic Name: Hydrocortisone Brand Name: Solu-cortef NURSING RESPONSIBILITIES:

8/23/11 8/24/11 8/25/11 8/26/11

250 mg IV, Suppression of Further inflammation Initially given 100 immune system and was suppressed. mg IV Q 6 hrs. modification of normal immune 200mg then, 100 system. mg Q 6 hrs.

Instruct patient to take medication directly as ordered. Instruct patient to notify health care professional if symptom of underlying disease worsens. Caution patient to take medication only when directed. Caution women that medications should not be used extensively. Advise patient to consult doctor before taking other medications.

Name of drugs

Date

Route or Admn Dosage

Indication

Clients 52 | C O P D C A S E S T U D Y .

Generic name Brand name

ordered, Date performed, Date changed 08/23/11 08/24/11

and Frequency of Admn

or Purpose

response to the medication

Generic Name Fentanyl Brand Name Duragesic

5mg OD

This promotes healing to an injured area of the body

The client complied on the actions of the drug.

NURSING RESPONSIBILITIES: Instruct patient to notify health care professional if symptom of underlying disease worsens. Monitor the blood glucose level of diabetic patient who are receiving transdermal fentanyl because each unit contains about 2 g of sugar. Instruct patient to choose a site with intact (not irritated or irritated) skin on a flat surface, such as chest, back and upper arm. Urge patient not to cut or use damaged patches because the drug may be released too rapidly, which could cause a life-threatening overdose.

53 | C O P D C A S E S T U D Y .

Name of drugs Generic name Brand name

Date ordered, Date performed, Date changed 8/23/11 8/24/11

Route or Admn Dosage and Frequency of Admn

Indication or purpose

Clients response to the medication

Generic Name: Omeprazole (Antiulcer agents) Brand Name: Losec

20mg BID

GERD/maintenance Patient did not of healing in erosive feel any gastric esphagitis. irritation.

NURSING RESPONSIBILITIES: Instruct patient to take medication directly as ordered. Instruct patient to notify health care professional if symptom of underlying disease worsens. Assess patient routinely for epigastric and abdominal pain. Caution patient to take medication only when directed Administer doses before meals preferably in the morning; should be swallowed whole, do not crush or chew Advise patient to consult doctor before taking other medications. May cause occasional drowsiness and dizziness.

54 | C O P D C A S E S T U D Y .

Name of drugs Generic name Brand name

Date ordered, Date performed, Date changed 08/24/11 08/25/11

Route or Admn Dosage and Frequency of Admn

Indication or Purpose

Clients response to the medication

Generic Name: Doxofylline Brand Name: Ansimar

400mg tab BID

Bronchial asthma. It Patient did not relaxes bronchial feel any gastric smooth muscle by irritation. action on beta2 receptors with a little effect on the heart rate.

NURSING RESPONSIBILITIES: Monitor heart rate, CNS stimulation, notify physician if palpitations, chest pain, tachycardia occurs. Assess lung sounds, pulse and blood pressure before administration and during peak of medication. Not amount, color, and character of sputum produced Monitor pulmonary function tests before initiating therapy and periodically during therapy to determine effectiveness of medication. Observe for wheezes. If conditions occur, withhold medication and notify physician of other health care professional immediately.

55 | C O P D C A S E S T U D Y .

Name of drugs Generic name Brand name

Date ordered, Date performed, Date changed 08/24/11 08/25/11

Route or Admn Dosage and Frequency of Admn

Indication or Purpose

Clients response to the medication

Generic Name: Fluimucil Brand Name: Acetylcysteine

600 mg tab in 50cc TID

To treat respiratory affections characterized by thick and viscous hypersecretions; acute and chronic bronchitits and its exacerbations; pulmonary emphysema and bronchiectasis.

The clients phlegm decreases viscosity.

NURSING RESPONSIBILITIES Be aware that acetylcysteine may have a disagreeable odor, which disappears as treatment progresses. Monitor effectiveness of therapy and advent of adverse/allergic effects Instruct patient in appropriate use and adverse effects to report.

56 | C O P D C A S E S T U D Y .

Name of drugs Generic name Brand name

Date ordered, Date performed, Date changed 08/24/11 08/25/11

Route or Admn Dosage and Frequency of Admn

Indication or Purpose

Clients response to the medication

Generic Name: Isosorbide Mononitrate Brand Name: Elantan

20mg tab BID

To treat or prevent The clients BP angina. decrease.

NURSING RESPONSIBILITIES Use isosorbide cautiously in patients with hypovolemia or mild hypotension. Monitor for increased hypotension and reduced cardiac output. Give drug 1 hour before or 2 hours after meals. Give with meals if patient experiences severe headaches or adverse GI reactions. Monitor blood pressure frequently during isososrbide therapy. Advise patient to to avoid potentially hazardous activities.

57 | C O P D C A S E S T U D Y .

Name of drugs Generic name Brand name

Date ordered, Date performed, Date changed 08/23/11 08/24/11 08/25/11 08/26/11

Route or Admin Dosage and Frequency of Admin

Indication Or purpose

Clients response to the medication

Generic Name: Furosemide Brand Name: Lasix

60 mg IV stat 40 mg IV stat 400 mg 1 tab OD

To reduce edema clients blood caused by cirrhosis, pressure was heart failure, and maintained renal disease, including nephritic syndrome.

NURSING RESPONSIBILITIES Use furosemide cautiously in patient with advanced hepatic cirrhosis. For once day dosing, give drug in the morning so patients sleep wont be interrupted by increased need to urinate. Expect to discontinue furosemide at maximum dosage if oliguria persist for more than 24 hours.

58 | C O P D C A S E S T U D Y .

Inform diabetic patient that furosemide may increase blood glucose level, and advise him to check his blood glucose level frequently.

Name of drugs Generic name Brand name

Date ordered, Date performed, Date changed 08/24/11

Route or Admin Dosage and Frequency of Admn

Indication or Purpose

Clients response to the medication

Generic Name: Digoxin Brand Name: Lanoxin

0.5 mg IV stat

To treat heart failure, atrial flutter, atrial fibrillation, and paroxysmal atrial tachycardia with rapid digitalization.

Clients heart rate was able to maintain in normal rate

NURSING RESPONSIBILITIES Before giving each dose, take patients apical pulse and notify prescriber if pulse is below 60 beats/minute.

59 | C O P D C A S E S T U D Y .

Instruct patient to take drug at the same time each day to help increase compliance. Instruct patient to take a missed dose as soon as he remembers if within 24 hours of scheduled dose. Urge patient to notify prescriber if he experiences adverse reactions, such GI distress or pulse changes.

Name of drugs Generic name Brand name

Date ordered, Date performed, Date changed 08/24/11

Route or Admn Dosage and Frequency of Admn

Indication or Purpose

Clients response to the medication

Generic Name: Albuterol Brand Name: Combivent

Neb Q6

To treat The client did bronchospasm in not experience patients with COPD difficulty of who require more breathing. than one bronchodilator

60 | C O P D C A S E S T U D Y .

NURSING RESPONSIBILITIES : Monitor serum potassium because drug may cause transient hypokalemia. Frequently monitor heart and rhythm and blood pressure in patients with a history of arrhythmias, coronary artery insufficiency, or hypertension because the drug may cause adverse cardiovascular effects in this patients. Advise patient to contact prescriber before using other inhaled drug.

Name of drugs Generic name Brand name

Date ordered, Date performed, Date changed

Route or Admn Dosage and Frequency of Admn

Indication or Purpose

Clients response to the medication

61 | C O P D C A S E S T U D Y .

Generic Name: Amiodarone Hydrochloride Brand Name: Cordarone

08/25/11

200 ml 1 tab OD

To treat life- The client threatening, recurrent complied on the ventricular fibrillation medications. and hemodynamically unstable ventricular tachycardia when this arrhythmias dont respond to other drugs or when patients cant tolerate other drugs.

NURSING RESPONSIBILITIES : Monitor continuous ECG; check increased PR and QRS intervals, arrhythmias, and heart rate 60 beats/ min. Instruct patient to report abnormal bleeding or bruising, Explain that frequent monitoring and laboratory tests will be needed during treatment.

62 | C O P D C A S E S T U D Y .

Name of drugs Generic name Brand name

Date ordered, Date performed, Date changed 08/25/11 08/26/11

Route or Admin Dosage and Frequency of Admn

Indication or Purpose

Clients response to the medication

Generic Name: Pregabalin Brand Name: Lyrica

75mg cap BID

To relieve The client neuropathic pain complied on the associated with medications. diabetic peripheral neuropathy

NURSING RESPONSIBILITIES Monitor patient closely for adverse reactions. Notify prescriber if significant adverse reactions persist. Alert patient that drug may cause edema and weight gain. Instruct diabetic patients to inspect their skin while taking pregabalin.

63 | C O P D C A S E S T U D Y .

Name of drugs Generic name Brand name

Date ordered, Date performed, Date changed 08/25/11

Route or Admn Dosage and Frequency of Admn

Indication or Purpose

Clients response to the medication

Generic Name: Tramadol Brand Name: Dolcet

1 tablet stat

Moderate to acute or chronic pain and in painful diagnostic therapeutic measures.

The client complied on the medications. And did not feel any pain anymore.

NURSING RESPONSIBILITIES : Assess for level of pain relief Assess BP & PR Assess bladder bowel function Monitor for respiratory depression & seizures

64 | C O P D C A S E S T U D Y .

To be taken with meals to avoid GI upset. Encourage coughing & deep breathing every 2 hrs. to prevent atelectasis & pneumonia.

65 | C O P D C A S E S T U D Y .

III. Diet Type of Diet Date Ordered/Date Given/date Changed NPO except on meds or discontinued Upon admission NPO is a medical Typical reasons for NPO Patients comply with (8/23/11) instruction and fluids for meaning instructions from are the the given diet. to withhold oral food prevention of aspiration a pneumonia, e.g. in those patient reasons. meds to various who will undergo general Doctors anesthetic, or those with swallowing gastrointestinal or acute Alcohol warrant the musculature, or in case eat bleeding, gastrointestinal General Description Indication/Purpose Patients Response

order is NPO except weak meaning or patient is not allowed of drink anything but can take blockage, medicines oral. through pancreatitis. vomiting

overdoses that result in also NPO instructions for a period of time.

DM Diet

8/24- 25/11

The diet most often In

cases

of Patients comply with

66 | C O P D C A S E S T U D Y .

1500Kcal/day

recommended is high hypoglycemia, they are the given diet. in dietary fiber, advised to have food or soluble drink that can raise blood a long-acting especially

fiber, but low in fat glucose quickly, followed (especially saturated by fat). carbohydrate (such as rye bread) to prevent risk of further hypoglycemia. Nursing Responsibilities : Before the Procedure Check the doctors order. Check the right client. Be sure that the diet is properly instructed. Monitor if the client complies with the given diet. Be sure patient is taking or eating food he can tolerate

During the Procedure

After the Procedure Assess for patients condition; how he responds to the diet

67 | C O P D C A S E S T U D Y .

IV. Activity and Exercise Type of Exercise Date ordered Date started Date changed General Description Indication/Purpos e Patients Response

Nursing Responsibilities Before the Procedure Check the doctors order. Check the right client. Be sure that the diet is properly instructed. Monitor if the client complies with the given diet. Be sure patient is taking or eating food he can tolerate Assess for patients condition; how he responds to the diet

During the Procedure

After the Procedure

68 | C O P D C A S E S T U D Y .

VII. PATIENTS DAILY PROGRESS Admission Nursing Problems Vital Signs Diagnostics and Laboratory Procedures Day 1 Day 2

Medical Management

Pharmacotherapy Diet NPO

69 | C O P D C A S E S T U D Y .

REFERENCES

Expert Committee on the Diagnosis and Classification of COPD Fagot-Campagna A, Pettitt DJ, Engelgau MM, et al. An epidemiologic review and a public health perspective. J Pediatr 2000; 136:664-72. American Diabetes Association. Standards of medical care in diabetes2009. Diabetes Care 2009; 32(suppl 1):s15. The 2005 Philippine Health Statistics: Department of Health NATIONAL EPIDEMIOLOGY CENTER. http://www.doh.gov.ph/files/phs2005.pdf Karch,A.M.(2010). Nursing Drug Guide. Williams and Wilkins: Philippines Seeley,et al.(2007). Essentials of Anatomy and Physiology Sixth Edition. McGraw-Hill International Edition: Philippines Weber,J.R.(2008). Nursing Health Assessment Sixth Edition. Williams and Wilkins: Philippines Huether, S. and Mccance, K. (2003). Understanding Pathophysiology. Smeltzer, S. and Bare, B. (2005). Medical Surgical Nursing. Black, J. (2008). Medical-Surgical Nursing 8th edition. Elsevier: Singapore

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