Biographical

(Chronic Obstructive Pulmonary Disease) Presented by the Group 1

Abool, Gretchen Absin, Ariane Aguirre, Ferdinand Mark Alayon, Marion Kaz Alba, Aileen Alborte, Ma. Shaynie Allado, Molena Amoroso, Nicolai Avelino, Alyanna Samantha Baria, Charles Noel Batuigas, Kim Leo Baydo, Janella Beluso, Roxanne Benemile, Diane Claire Biclar, Archie Bonilla, Darrylle Calar, Andrea Fay Castro, Ma. Jessal Junn Clores Liane Vi Contreras, Lew Marvin BSN 2-Fenwick April 23, 2008

NURSING PROCESS I.

Biographical Data Name: L.M. Date of Interview: April 17, 2008 In Patient No. : NOF Time of Interview: 4:30 pm Age: 78 years old Date of Admission: April 16, 2008 Sex: Male Time of Admission: 2:00 a.m. Religion: Roman Catholic Ward: MW Address: Brgy. 10, Roxas City Birth Date: August 5, 1929 Birth Place: Mambusao, Capiz Race: Brown Nationality: Filipino Physician: Dr. B. Person to notify in case of Emergency: Y. M. Relationship to Patient: daughter Name of Wife: E. A. Informants: Primary: Patient Secondary: Chart and Folks Vital Signs Upon Assessment: TPR- BP – 37.3˚C , 103, 23, 130/70 mmHg

II.

Client’s Health History A. Chief Complaint Subjective: Difficulty of breathing B. History of Present Illness: One day prior to admission, patient experienced difficulty of breathing, at 5:30 pm, his complications intensified. Nebulization started, and was given Asmasolon 1 tab to relieve difficulty of breathing. Complications persisted. Patient requested to be brought to the hospital to be admitted at 2:00 am. He had undergone monthly checkup for his condition, his latest checkup was last March 25, 2008. Patient takes Myrin PForte as his PTB maintenance. C. Past Health History Patient hasn’t received immunization for health maintenance. Started smoking during the onset of WWII, consumes 2-3 packs of cigarette per day. Quit smoking in 1972, when he was 43 years old. Parents of patient died of old age, as well as siblings, one daughter of patient died of breast cancer. He usually stays 6 -7 days in the hospital his recent admission was at CEH, December 31 – January 2, 2008 with the same chief complaints and complications.

D. Family History Heredofamilial Disease

Paternal

Maternal

Cancer Asthma Diabetes Mellitus Hypertension Others No known heredofamilial diseases except that his daughter was diagnosed and died of breast cancer at the age of 45. She underwent chemotherapy for three (3) months prior to her death. E. Psychosocial History Patient is 78 years old. He does household chores like chopping of wood, plants vegetables in his backyard like radish, pechay, “kamoteng kahoy”, and corn. They are seven in one household, has four rooms with two bedrooms. His educational attainment is Grade 6, stopped during the WWII. His livelihood once was delivering bangus fry to Iloilo City and back again. Patient’s wife is still smoking. His family lives in a house made of mixed materials. He sleeps for about seven (7) hours at night, from 9 pm - 4 am. Listens to radio and idles in the balcony for about half an hour when he wakes up in the morning. Watches television for news updates only. Patient resides in a congested neighborhood near the street. His daughter used to splash water on their gate façade toward off dust during dry summer months. Water source is NAWASA and water purifier. III.

Patterns of Functioning A. Fluids and Nutrition HOME

HOSPITAL

Breakfast usually is rice, fish, or shrimp, coffee Small frequent meals (Soft) according to and sometimes bread. Usually taken at 8:00 physicians order. Eats Lugaw and drinks am. Lunch is usually vegetables with soup. Sustagen for breakfast. Takes rice and Eats 2 -3 cups of rice. Taken at 11: 00 am. vegetables with soup for lunch. At night, he Dinner is usually vegetables with soup, taken eats rice, fish, and soup. He consumes half of at 6:30 pm. Drinks 5-6 glasses of water a day. the servings from breakfast to dinner. Drinks 4[ 5 glasses of water.

B. Rest and Sleep HOME

HOSPITAL

Sleeps from 9:00 pm and wakes up at 4:00 am. Sleeps seven (7) hours. Took naps for about 2 – 3 hours every afternoon. Uses two (2) pillows on head and a blanket. Usually sleeps on mattress and on side lying position. Prays before going to sleep.

Sleeps from 8:00 pm and wakes up at 1:00 am. Sleep is usually disturbed due to vital signs taking by student nurses. Rests in bed semifowlers position.

C. Elimination HOME

HOSPITAL

Defecates once a day. Urinates freely.

Defecates watery stools 3x a day. Urinates frequently. Assisted by folks in going to the Comfort Room.

D. Activity and Exercise HOME

HOSPITAL

Wakes up at 4:00 am. Idles in his backyard. Listens to radio. Does nothing all day.

Patient sits in bed assisted by folks for personal needs and hygiene.

E. Personal Hygiene HOME

HOSPITAL

Takes a bath once a day. Changes clothes twice Sponge bath done by folks. Assisted by folks in a day. Brushes teeth once a week or if desired. oral care, perineal hygiene, and overall personal hygiene.

IV.

DIAGNOSTIC EXAMS

DIAGNOSTIC RESULTS

Na+

Result (↓ or ↑) 129mmol/L ↓

Normal Range 135-148

K+ Creatinine

3.7mmol/L 137.02µmol/L

3.50-5.30 71.0-133.0

Reason for Patient Values Resulted from inadequate sodium intake caused by profuse loss bowel movement and inadequate fluid intake. WNL Resulted from fluid volume deficit caused by loss bowel movement

CHEST X Ray Results Impression: > > > > > >

Minimal PTB both upper lobes w/ fibrosis stable Bilateral Pneumonia Calcified Pleural Plaque ® and Granuloma’s Bilateral Stable Pulmonary Emphysema Bilateral Pleurodiaphragmatic Adhesion Atheromatous Aorta.

V.

PHYSICAL EXAMINATION A. General Appearance Awake, sitting on bed with IVF of D5NM 1L x 18hrs. Infusing well at right hand vein and with the presence of 02 inhalation infusing well on patient’s nares. Able to speak words with limitations due to difficulty of breathing. The patient pauses and rest for a while before answering the next question. Conscious, conversant and oriented to time, person and place.

B. Vital Signs Upon Interview a. Pulse – 103 b. Respiration – 23 breaths per minute c. Temperature – 37.1˚C d. Blood Pressure – 130/70 mmHg e. Date taken - April 17, 2008 f. Time taken – 4:30 pm C. Physical Assessment a. Integument      

Skin color is deep brown, evenly distributed; light colors of the skin are found in palms and nails. Skin is relatively dry through the body with minimal amount of perspiration on axilla and scalp. Skin texture is rough. Poor skin turgor, skin slowly returns to its original shape after squeezed. Skin temperature is relatively warm through out the body. Skin lesions noted on face and on feet. 6 moles noted on face, dark brown in color, size vary from small to large, distribution is discrete, individual moles are separate and distinct. Callus noted on right and left ankle of the feet. Edema noted on left arm.

b. Head and Neck 1. Hair   

Hair in the body is evenly distributed, texture is fine and short and black in color. Hair in axilla is curly, about 1 inch in length, and thick. Hair in head is short about 2 inch long, thin, unevenly distributed, patchy hair loss noted, black with grey in color, shiny and smooth. Small like perspiration noted.

2. Scalp   

No dandruff noted No lesions noted Moist and oily

3. Head  Head is normocephalic and symmetrical  Head is positioned to midline and has an oral contour

 

No masses noted Temporal pulse rate is 103 b/m, amplitude of pulse is normal, pulse rhythm is regular

4. Neck      

Carotid vein is visible Wrinkles noted Difficulty to flex No enlargement of thyroid glands Trachea in midline No masses and nodules noted

5. Face  Color is brown  Presence of wrinkles especially on forehead  Capable of facial movements like elevation of eyebrows, lowering of eyebrows, closing of eyes, able to smile grin and frown, facial movements symmetrical.  Mustache noted; length is about 1 cm, color is black with grey and is thick.  Lesions noted on face and on feet. 6 moles noted on face, dark brown in color, size vary from small to large, distribution is discrete, individual moles are separate and distinct. 6. Eyes  Hair in eyebrow are thick evenly distributed; eyebrow are symmetrical and of equal movements  Eyelashes are equally distributed and are straight  Eyelids closes symmetrically, drooping upper eyelid  Sclera is yellowish in color  Iris is round, cloudy and slightly bluish in color  No redness noted, no edema noted, no inflammation, no lesion noted  Good visual acuity 7. Nose  Nasal septum positioned in midline  Nose is symmetrical  Color of nose is brown  No deformity noted  No tenderness noted upon palpation  Evenly distributed ciliary hairs  Discharges noted; thick, whitish  Flaring noted  Air movement in and out is obstructed 8. Ears        

Dark brown in color Tenderness and masses not noted Symmetrical Hair follicles noted Pinna recoils back Cerumen noted Good hearing acuity Ears firm and no tender



Hears normal voice tones

9. Mouth and Pharynx             

Lips is dark pink in color Dry lips Ability to purse lips Mouth is symmetrical aligned to pharynx Lips is symmetric Tongue moves freely Tongue in midline Teeth color is dirty white Soft and hard palate is pink Poor gag reflex Plague and tartar is present Incomplete dentilation Smooth and soft, no nodules, no lesions

c. Chest and Thorax       

Poor skin turgor No masses noted Decreased respiratory excursion Barrel chest Adventitious breath sounds noted Chest is symmetrical Dullness on the ribs

d. Breast    

No discharges noted Areola dark in color Lymph nodes not palpable Nipple everted

e. Abdomen     

Hyperactive bowel sounds No pain upon percussion No tenderness noted Absence of scars Umbilicus in midline position

f. Upper and lower extremities         

Skin is brown in color Symmetrical Skin is dry Nails untrimmed, dirty and clubbing Good capillary refill, 2 seconds Complete digits Muscle grade 2/5 Edema noted Lesions noted, callus noted

g. Genitalia

    

Scant amount of hair present Penile skin intact Penis smooth and is semi-formed Present loose scrotal skin and is darker in color than the rest of the body Scrotum is assymmetric

VIII. Textbook Discussion Overview of the system Respiratory System The major function of the respiratory system is to supply the body with oxygen and to dispose of carbon dioxide. There are four distinct events collectively called respiration must occur: 1. Pulmonary ventilation. Air must move into and out of the lungs so that the gases in the air sacs (alveoli) of the lungs are continuously changed and refreshed. This process of pulmonary ventilation is commonly called breathing. 2. External respiration. Gas change between the pulmonary blood and alveoli must take place. It is a gas exchange between the blood and body exterior. 3. Respiratory Gas transport. Oxygen and carbon dioxide must be transported to and from the lungs and tissue cells of the body via the bloodstream. 4. Internal respiration. At systemic capillaries, gas exchanges must be made between the blood and tissue cells. In internal respiration, gas exchanges are occurring between the blood and cells inside the body. The respiratory system consists of the organs that exchange these gases. These organs are the nose, pharynx, larynx, trachea, and lungs. Nose– is formed by a framework of cartilage and bone covered with skin and lined internally with mucous membrane. On the undersurface of the nose is formed by the nasal bones that help support the external nose and hold it in a fixed position. Pharynx- also called the throat. It is a tube approximately 5 inches long. Its walls are made of skeletal muscle lined with mucous membrane. The pharynx is a passageway for both air and food and forms a resonating chamber fro speech sounds. Larynx or Voice Box- it is very short passageway that connects the pharynx with trachea. Its walls are supported by nine pieces of cartilage. Trachea- also referred to as the windpipe. It is a tubular passageway for air approximately 4.5 inches in length and about 1 inch in diameter. The tracheal epithelium is pseudostratified, ciliated columnar cells with goblet cells and basal cells. Lungs- are paired, cone-shaped organs located in and filling the pleural divisions of the thoracic cavity. The apex of the lungs is about 4 cm above the first rib, and the base of the lungs rests on the diaphragm. CHRONIC OBSTRUVTIVE PULMONARY DISEASE Chronic Obstructive Pulmonary Disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible. COPD may include diseases that cause airflow obstruction (e.g., emphysema, chronic bronchitis) or a combination of these disorders. Theses diseases have certain features in common: 1. Patients almost always have a history of smoking;

2. dyspnea, labored breathing, 3. coughing and frequent pulmonary infections are common; 4. most COPD victims are hypoxic, retain carbon dioxide and have respiratory acidosis. Chronic Bronchitis, the mucosa of the lower respiratory passages becomes severely inflamed and produces excessive amounts of mucous. The pooled mucus impairs ventilation and gas exchange and dramatically increases the risk of lung infections. In Emphysema, the alveoli enlarge as the walls of adjacent chambers break through, and chronic inflammation promotes fibrosis of the lungs. As the lungs become less elastic, the airways collapse during expiration and obstruct outflow of air. As a result, these patients use an incredible amount of energy to exhale, and they are always exhausted. Because air is retained in the lungs, oxygen exchange is surprisingly efficient, and cyanosis does not usually appear until late in the disease. PATHOPHYSIOLOGY 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. Over time, this injuryand-repair process causes scar tissue formation and narrowing of the airway lumen. 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 occur as a result of exposure to cigarette smoke or use of tobacco products or as a result of the release of inflammatory mediators. CLINICAL MANIFESTATIONS COPD is characterized by three primary symptoms: cough, sputum production, and dyspnea on exertion. These symptoms worsen over time. Chronic cough and sputum production often precede the development of airflow limitation by many years. Weight loss is common because dyspnea interferes with eating, and the work of breathing is energy-depleting. Often patient cannot participate in even mild exercise because of dyspnea. The patient with COPD is at risk for respiratory insufficiency and respiratory infections, which in turn increase the risk for acute and chronic respiratory failure. MEDICAL MANAGEMENT RISK REDUCTION Smoking cessation is the most effective intervention to prevent COPD its progression. Nurses play a key role in promoting smoking cessation and educating patients about ways to do so. Patients diagnosed with COPD who continue to smoke must be encourage ad assisted to quit. Factors associated with continued smoking vary among patients and may include the strength of nicotine addiction, continued exposure to smoking-associated stimuli, stress, depression and habit. Because there are multiple factors associated with continued smoking, successful cessation often requires multiple strategies. The health care provider should promote cessation by explaining the risk of smoking and personalizing the “at risk” message to the patient. Smoking cessation can begin in a variety of health care settings like the outpatient clinic, pulmonary rehabilitation, community, hospital, and the patient’s home. Regardless of the setting, the nurse has the opportunity to teach the patient about the risks of smoking and the benefits of smoking cessation. NURSING MANAGEMENT The nurse plays a key role in identifying potential candidates for pulmonary rehabilitation and in facilitating and reinforcing the material learned in the rehabilitation program. However, the nurse

can be instrumental in teaching the patient and family as well as facilitating specific services for the patient. PATIENT EDUCATION Patient education is a major component of pulmonary rehabilitation and includes a wide variety of topics. Depending on the length and program, topics may include normal anatomy and physiology of the lung, pathophysiology and changes with COPD, medications and home oxygen therapy, nutrition, respiratory therapy treatments, symptom alleviation and smoking cessation. BREATHING EXERCISES. The breathing pattern of most people with COPD is shallow, rapid, and inefficient; the more severe the disease, the more inefficient the breathing pattern. With practice, this type of upper chest breathing can be changed to diaphragmatic breathing, which reduces the respiratory rate, increases alveolar ventilation, and sometimes helps expel air as much air as possible during expiration. Pursed lip breathing helps slow expiration, prevents collapse of small airways, and helps the patient to control the rate and depth of respiration. INSPIRATORY MUSCLE TRAINING. Once the patient masters diaphragmatic breathing, a program of inspiratory muscle training may be prescribed to help strengthen the muscle used in breathing. This program requires that the patient breathe against resistance for 10-15 minutes everyday. ACTIVITY PACING A patient with COPD has decreased exercise tolerance during specific periods of the day. This is especially true on arising in the morning, because bronchial secretions collect in the lungs during the night while the person is lying down. The patient has difficulty bathing or dressing. Activities requiring the arms to be supported above the level of the thorax may produced fatigue or respiratory distress but may be tolerated better after the patient has been up and moving around for an hour or more. SELF CARE ACTIVITIES As gas exchange, airway clearance, and the breathing pattern improve, the patient is encouraged to assume increase participation in the self-care activities. The patient is taught to coordinate diaphragmatic breathing with activities such as walking, bathing, bending, or climbing stairs. The patient should bathe, dress, and take short walks, resting as needed to avoid fatigue and excessive dyspnea. Fluids should always be readily available, and the patient should begin to drink fluids without having to be reminded. If postural drainage is to be done at home, the nurse instructs and supervises the patient before discharge or in the outpatient setting. PHYSICAL CONDITIONING Physical conditioning techniques include breathing exercises and general exercises intended to conserve energy and increase pulmonary ventilation. There is a close relationship between physical fitness and respiratory fitness. Graded exercises and physical conditioning programs using treadmills, stationary bicycles, and measured level-walks can improve symptoms and increase work capacity and exercise tolerance. Any physical activity that can be done regularly is helpful. Light weight portable oxygen systems are available for ambulatory patients who require oxygen therapy during physical activity. OXYGEN THERAPY

Oxygen supplied to the home comes in compressed gas, liquid, or concentrator systems. Portable oxygen systems allow the patient to exercise, work and travel. To help the patient adhere to the oxygen prescription, the nurse explains the proper flow rate and required number of hours for oxygen use as well as the dangers of our arbitrary changes in flow rates or duration of therapy. The nurse cautions the patient that smoking with or near oxygen is extremely dangerous. The nurse also reassures the patient that oxygen is not addictive and explains the need for regular evaluations of blood oxygenation by pulse oximetry or arterial blood gas analysis.

NUTRITIONAL THERAPY Nutritional assessment and counseling are important aspects in the rehabilitation process for the patient with COPD. Approximately 25% of patients with COPD are undernourished. A thorough assessment of caloric needs and counseling about meal planning and supplementation are part of the rehabilitation process. COPING MEASURE. Any factors that interferes with normal breathing quite naturally induces anxiety, depression and changes in behavior. Many patients find the slightest exertion exhausting. Constant shortness of breath and fatigue may make the patient irritable and apprehensive to the point of panic. Restricted activity (and reversal of family roles due to loss of employment), the frustration of having to work to breathe, and the realization that the disease is prolonged and unrelenting because the patient to react with anger, depression and demanding behavior. Sexual function may be compromised, which also diminishes self-esteem. In addition, the nurse needs to provide education as support to the spouse/significant other and family because the care giver role in end-stage COPD can be difficult.

References: Medical-Surgical Nursing 10 edition; Suzanne C. Smeltzer, Brenda Bare Human Anatomy & Physiology in Health and Diseases 3rd edition by Shirley Burke Fundamentals of Anatomy and Physiology 2nd edition by Donald C. Rizzo Essentials of Human Anatomy and Physiology by Elaine M. Marieb th