A CASE STUDY OF A PATIENT W/CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Presented by:

Name :Princess J. Macabare

BSN 3- Nightingale

 

Presented to:

Professor :Miss. Mabini

INTRODUCTION             Domingo is a 60 year old retired

policeman who was constantly having cough during the last 2 weeks before he was brought to the hospital by his youngest daughter. Lately, he has been experiencing troubles in breathing. He described it as a difficulty in expiration during breathing. For this reason, he asked his youngest daughter who is living just two blocks away from him to take him to the hospital.

          

Domingo admits to be a chronic smoker, consuming two packs per day and drinks alcoholic beverages regularly with his friends. After undergoing a thorough examination, his physician ordered a series of sputum tests and other lung tests. Chronic infection was detected in the lungs most probably due to smoking which irritates the bronchi and bronchioles. There was also obstruction of the airways which is responsible for Domingo difficulty in expiration. He was diagnosed to have chronic obstructive pulmonary disease (COPD).

The chronic infection as is seen in Domingo case is caused by his excessive smoking or other substances which irritate the bronchi and the bronchioles. The principal reason for the chronic infection is that the irritant seriously deranges the normal protective mechanisms of the airways, including partial paralysis of the cilia of the respiratory epithelium by the effects of nicotine; as a result, mucus cannot be moved easily out of the passageways

Nursing diagnosis reveals ineffective airway clearance which is related to excessive and tenacious secretions. The assessment criteria include Domingo ability to maintain an upright position, cough and sputum. Diagnosis further reveals activity intolerance related to fatigue and inadequate oxygenation for activities

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 ( 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.

ANATOMY AND PHYSIOLOGY: 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.

NURSING HEATH HISTORY 1. Personal Data Mr. X 60 yrs. old, male, Iglesias ni

Cristo, Filipino residing at 9181 Mahogan St. Acasia Pinagbuhatan PC 1600 was admitted first time at Pasig City General Hospital.

2. Chief Complaint 3 day PTC , patient complaint of productive

cough with greewish phlegm, no fever , DOB, difficulty of breathing chest pain .related noted weakness, drowsiness and patient had difficulty fetching himself and walking.

3. History of Present Illness Patient had DOB, back pain and

fever @ cough

Past Medical Illness He is always admitted in the hospital in

Medical City every year but after 6 month he admitted at Pasig City General Hospitals. At the same reason the patient complaint of productive cough with greewish phlegm and weakness, drowsiness and patient had difficulty fetching himself and walking.

5. Family Heath Histories Patient was the second among the five

siblings. A history of heart failure was noted on the maternal side while history of heart disease and HPN on the paternal side.

6. Social Histories The patient a policeman he also retard .

His wife is full housewife . She had six siblings the eldest is 26 and the youngest is 15 yrs old.

FUNCTIONAL HEALTH PATTERNS

Health Perception and heath management pattern

Patient wife claimed that his husband was healthy figure and strong immunity to disease. She also claimed that her husband also have a fever, colds, and other discomfort which was relieved on taking some of the over-the-counter medication. She also claimed that her husband is non-diabetic and but asthmatic. He is also a smoker; and alcoholic drinker

Nutrition and Metabolic Pattern On her daily menu, patient eat a lot of

fatty and salty foods such as barbecue and sinigang . The patient favorite foods were those native products.

Patient has non difficulty in defecating; normally she had her bowel movement 3 a day. She described her urine as clear and yellowish. She mentioned that she drinks at least’s 8 glasses of water a day

c. Rest and Activity Patient wife verbalized that her

husband usually had difficulty of getting back to sleep when she had been awaken .She usually slept at a maximum of 5 hours per a day.

D. Self-perception and Self-concern pattern

She said that she contented with her family. With regards to her body appearance, she also felt that she becoming fat because of her increasing weight. The patient feels so much depressed she had got hospitals. According to patient, these situations make her angry, and depress. The patient also fears death and accidents with her family and relatives, the patients always used to pray.

E. Role- relationship pattern The patient said she is not busy

person like other. She said that even she not busy, she makes sure that she had a quality for her family. Sometimes, she the one who takes in charge in making general decision with her family.

F. Sexuality Reproductive Pattern The patient had no sexual

experience since she was single.

G. Coping and stress tolerance pattern -Psychosocial development The patient is 60 years old and with

this stage, it has shown a positive resolution. -Psychosexual development On this age, energy is directed is full

sexual maturity as well as the functioning and the development of skill which is needed in order to cope with the environment.

Cognitive development With this stage, the patient

was rational in thinking in everything she does. Reasoning is deductive and futuristic as obviously observable when she communicates with other people.

-Moral development The patient believes in a

higher moral principle which applies equality, justice, and due process.

Spirituals development The patient is a Iglesias ni Cristo …

F. Value –Belief pattern Patient was satisfied with her life. She said that the most important to her was her family …..

PHYSICAL ASSESSMENT

General Appearance Normal findings under appearance are

appropriately dressed, no bad odors, has a normal color, has a smooth texture, has a good turgor and a warm and dry skin, looks according to age and has a normal range of vital signs such as 12-20 cpm in respiratory rate, 60-100 bpm in pulse rate and 36.5-37.5°c in temperature.

The patient non as normal findings. Her gait is stumbling she is unable to walk

The client is hypertensive

Mental StatusNormal finding under mental status are conscious, coherent and aware of time, place and cooperative.

The patient’s level of consciousness is drowsy; she is incoherent and disoriented in time and place and is restless.

Because the patient had stroke her brain was affected.

Assessment

Diagnosis

Objective

Intervention

Rationale

Evaluation

Subjective

“Sumasaki ang tiyankosaharap at likod”

 

Objective:

 

Pain scale:

6 out of 10

>face grimace connotes pain

 

Acute pain related to mass in the abdomen

After 8 hours of nursing intervention the patient’s pain level will decrease from 6 will turn down to 2 out of 10.

 

Independent:

Assess patient for level of pain

 

 

 

Encourage deep breathing for relaxation

 

Performed repositioning

Independent

Help establish plan of care and show concern for patient

Enables patient for non-drug treatment for pain.

May relieve pain and enhance good circulation.

After 8 hours of nursing intervention the patient’s level of pain will decrease from 6 will turn down to 2 out of 10.

 

 KARDEX  

Standing Order 

 08/22/12

Diet: DAT Position : HBR   

IV Fluids   08/22/12  IVF:ML: PLRT Lx KVO

Laboratory  08/22/12 # : Sputum GSICS Diagnosis exam -FU CXR    

Special Endorsement    08/22/12  >old chart & n.s >D/c levophed, Monitoring BP accordingly Diagnodis COPD

Theoretical concept

Cure (Physician) Prescribed appropriate medicine for the

patient Visit the patient frequently for further

observations Informing consent Explaining possibilities Performing appropriate procedures to the

client.

Core (Patient) Completion of laboratory Taking proper medication at right time

and right dose Informing the nurse/ doctor with

unusual sensations/feelings Cooperate with any procedures and

doctor’s order  

Care (Nurse) VS q4, Counselling Regulate IVF

Laboratory

Urea 4.7 mmol/L 2.5-6.1 Decrease urea Low urea levels are not common and are not

usually a cause for concern. They can be seen in severe liver disease or malnutrition but are not used to diagnose or monitor these conditions. Low urea levels are also seen in normal pregnancy

Assess nutritional support-Evaluate hemodialysis therapy-Evaluate hydration-Evaluate liver function-Evaluate patients with lymphoma

after chemotherapy (tumorlysis)-Evaluate renal function-Monitor the effects of drugs

known to be nephrotoxic or hepatotoxic

Creatinine4746-92Increase creatinineIncreased creatinine levels in the blood suggest diseases or conditions that affect kidney function

Correlate the elevated createnine levels to clinical problems. Low levels indicates small muscle mass which is mostly found in amputees and in clients with muscle disease.

  -As ordered by the physician, hold all

medications for 24 hours before the test as some medications may affect the result.

  -Check the urine output in 24 hours. Renal

insufficiency may happen when urine output is less than 600ml for 24 hours.

Sodium 134 137-145 Decrease sodium Normal Normal Potassium 4.0 3.6-5.0 Adequate potassium