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A Case Study
Presented to the Faculty ofThe Ateneo de Davao University
College of Nursing
A Case Study onChronic Obstructive Pulmonary Disease secondary to
Pulmonary Tuberculosis
Submitted toMr. Dude Arnel Lopez, RN
Clinical Instructor – Panelist of the Case Study
Submitted by:
[Group 1-A]
Ampilanon, Rae MaikkoBatuhan, Katherene
Beltran,MaribelCampaner, Marie Allexis
BSN-3H
2
23 April 2010
3
TABLE OF CONTENTS
I. Acknowledgement.....................................................................................................4
II. Introduction..............................................................................................................5
III. Objectives (General & Specific)..............................................................................7
IV. Patient’s Data...........................................................................................................9
V. Family Background and Health History...................................................................12
VI. Developmental Data.................................................................................................17
VII. Definition of Complete Diagnosis............................................................................22
VIII. Physical Assessment.................................................................................................24
IX. Anatomy and Physiology.........................................................................................30
X. Etiology and Symptomatology.................................................................................34
XI. Pathophysiology.......................................................................................................44
4
XII. Doctor’s Order..........................................................................................................57
XIII. Diagnostic Exams.....................................................................................................67
XIV. Drug Study...............................................................................................................93
XV. Nursing Theories......................................................................................................106
XVI. Nursing Care Plan....................................................................................................111
XVII. Discharge Plan (M. E. T. H. O. D.) .........................................................................136
XVIII. Prognosis………………………………………..............…………………………140
XIX. Recommendation......................................................................................................144
XX. References................................................................................................................147
5
ACKNOWLEDGMENT
In our journey toward the accomplishment of this endeavor, there were people who made
this a successful one. In this case analysis, we would like to express our heartfelt gratitude to the
following that made a striking contribution and helped us along the way.
First and foremost is to our Almighty Father, for without the life and the wisdom that he
has given us, we will not be able to accomplish this task.
To our family, who has always been there for us and supporting us emotionally and
financially.
To our clinical instructors, Ma’am Neriza Gudoy R.N., for allowing us to improve
ourselves better as student nurses by imparting knowledge and skills; and to Sir Dudes Lopez,
R.N., for the guidance, support, encouragement and for sharing to us valuable lessons not just in
nursing but in life as well. Our first 2 weeks of summer duties were full of learnings, fun and
laughter and we couldn’t ask for more.
To the staff of Ricardo Limso Medical Center and Davao Medical Center, for allowing us
to practice and hone our knowledge and skills; and to DMC Medical-Communicable Pavilion for
the assistance and for allowing us to get a case for our case presentation.
To the subject of this case study and to his family, for allowing us to make them as the
subject of this study and for being cooperative in the whole process of assessment, interviews
and interventions.
To the whole group, for constantly helping and understanding each other. Through thick
and thin, together we will soar higher.
And lastly, to whomever inspires us at this time, for motivating us to do better and for
loving us unconditionally.
6
INTRODUCTION
Life, amidst its complexities and predicaments, is the greatest treasure a certain
individual can have at his very time of subsistence. Through life, one is able to feel simple things
that can give him the satisfaction and completeness that no any worldly splendor can give. Even
so, illnesses are part of everyone's life, it only varies on severity. People can either let them
control their lives, or they themselves can take control. Unfortunately, the human body’s
homeostasis may be altered at any point of time.
Chronic Obstructive Pulmonary Disease, as defined by the Global Initiative for Chronic
Obstructive Lung Disease (GOLD) is a disease state characterized by airflow limitation that is
not fully reversible. COPD may include diseases that cause airflow obstruction such as
emphysema and chronic bronchitis or any combination of these disorders. People with COPD
commonly become symptomatic during the middle adult years and the incidence of the disease
increase with age. Although certain aspects of lung function normally decreases with age, COPD
accentuate and accelerates these physiologic changes.
According to the 2007 World Health Organization estimates, there are currently 210
million people suffering from COPD worldwide. It is the 6th leading cause of death worldwide.
However, the World Health Organization projected that by the year 2030, it will become the 3rd
leading cause of death due to an increase in smoking rates and demographic changes in many
countries.
. In the Philippines, The World Health Organization (WHO) estimates that COPD, as a
single cause of death, shares 4th and 5th places with HIV/AIDS (after coronary heart disease,
7
cerebrovascular disease and acute respiratory infection) having 33, 709 or 46.10 percent per 100,
000 population as of 2003. Furthermore, Dr. Luisito Isidor, chair of Philippine College of Chest
Physicians’ COPD Council mentioned that the Philippine Burden of Lung Disease study
indicated that 12 percent or one in eight individuals 40 years and above suffer from COPD.
In the 2007 Press Release of the Region 11 Center for Health Development, 36% of every
100,00 has COPD. And from this number, 2 out of 8 patients die daily.
Last April 19-22, 2010, we had our hospital duty at the Med Communicable Pavilion of
Davao Medical Center where we found many worthy cases. In this paper, the subject of our
study will be addressed as “Lito”, a 41 year old who had an unlucky fate. Pulmonary
Tuberculosis struck him when he was 28 years old. It was treated that year too. However, the
disease came back at the year 2006. From then on, he has been living a life destined only to him.
Making things worse is the current diagnosis of Chronic Obstructive Pulmonary Disease. With
these facts, we found his case substantially credible and interesting enough to be studied and
presented.
8
OBJECTIVES
General Objective:
The main aim of the group is to be able to present the case presentation of our
selected client that would present a comprehensive discussion of the pathological mechanism
of the illness to yield significant information for the case study.
Specific Objectives:
In order to meet the general objective, the group aims to:
Cognitive:
Interpret the pertinent data gathered from the patient and his significant others,
Evaluate the present developmental stage of the patient according to the theories of
Erikson, Kohlberg and Piaget,
Define the complete diagnosis of the patient,
Rationalize the doctor’s order obtained from the patient’s chart,
Interpret the laboratory test results of the patient,
Relate the patient’s disease with the different nursing theories specifically those of
Nightingale, Orem and Henderson,
Psychomotor:
State the past and present health history of the client,
Trace the family genogram,
Present the cephalocaudal assessment obtained from the patient,
Discuss the anatomy and physiology of the organ involved in the patient’s disease,
9
Present the etiology and symptomatology of the patient’s disease,
Trace the pathophysiology of the patient’s disease,
Present the medications given to the client, including their respective modes of action,
indications, contraindications, side effects, adverse reactions, nursing responsibilities, and
importance to the client’s condition;
Discuss the surgical procedure performed to the patient and its important interventions in
the pre, intra, and post operative phase.
Present a specific, measurable, attainable, realistic and time-bounded nursing care plans
for the client,
Justify the client’s prognosis according to the different criteria,
Affective:
Establish rapport to the patient and the patient’s significant others,
Provide the patient and family with proper discharge planning (M.E.T.H.O.D),
Inform suitable recommendations to the client, his significant others and community, and
the medical world, etc.
10
PATIENT’S DATA
Personal Data:
Patients Name: “Lito”
Age: 40 years old
Gender: Male
Birth date:
Birth Place
Civil Status
Occupation
April 28, 1969
Davao City
Single
Unemployed
City Address:
Family Income:
Socioeconomic class:
Matina, Davao City.
4000-6000/month
Middle class
Nationality: Filipino
Religion [Denomination]: Christianity [Roman Catholic]
Educational Attainment: Highschool undergrad (2nd year)
Number of Siblings: 8
11
Ordinal Rank: 2nd
Clinical/ Admitting Data:
Date of admission: April 16, 2010
Time of admission: 9:27 pm
Hospital & Hospital Number: Davao Medical Center, Davao City [2064421]
Ward [Room & Bed Numbers]: Med CP [Room 4 Bed 5]
Attending Physician: Dr. Emerson Taghoy
Admitting Diagnosis: COPD secondary to PTB
12
Vital signs on admission:
Temperature:
Pulse Rate:
Respiratory Rate:
Blood pressure: :
Source of Information:
Final diagnosis:
37.7 Degrees Celsius
97 Beats per Minute
45 Cycles per Minute
130/80 mmHg
Patient, patient’s mother and Patient’s Chart
Chronic Obstructive Pulmonary Disease secondary to Pulmonary
Tuberculosis
13
FAMILY BACKGROUND AND HEALTH HISTORY
HEALTH BACKGROUND
A. Family Background
“Lito” is a 40 year old male and second in a brood of 8. He is single and is
currently living with his parents and siblings. In the maternal side, no known cases of
COPD and PTB were reported that can be genetically influential and thereafter, be
inherited. However, several cases of PTB were present in the paternal side which
includes some of the patient’s grandfathers.
The patient is currently unemployed since 2009 because of his illness. The
family’s source of income is from the patient's mother and father who own an eatery
however they had to stop their business and now they are both running a small “sari sari”
store. And according to the mother, the patient’s siblings also contribute money to the
household at times. From this, the family can afford eating three times a day. Their usual
diet is composed of fish and vegetables. They only cook meat once or twice a week.
According to the patient’s mother, PTB has been present in the paternal side of
the family although she stated these relatives were not living close to them and they have
not been in contact with them for a long time. She stated that one uncle died because of
PTB but this happened a long time ago and that they haven’t met this certain uncle. In the
maternal side, hypertension is the only diseases identified to be genetic in etiology.
14
B. Past Health History
The patient was born via normal spontaneous vaginal delivery. There were no
complications or abnormalities when he was delivered. His mother reported that the
patient received complete immunization when he was an infant.
According to the patient’s mother, “Lito” was admitted at DMC when he was
about 5 months old due to vomiting and diarrhea but was cured after 1 week. He was also
diagnosed with Typhoid fever last 1997 and was admitted at the same institution.
He has no asthma, hypertension, diabetes mellitus and any known allergies to
food and drug. He has been smoking since he was 12 years old with an average of 1 pack
per day. He regularly drinks alcoholic beverages such as Emperador since he was 17
years old.
C. History of Present Illness
Last 1997, the patient has been diagnosed with PTB while working in Cavite as a
construction worker. He returned to Davao, and was referred to Matina Health Center and
was given DOTS treatment which he had complied with. Alongside, they also sought the
help of a “quack doctor”. He felt better after the treatment and was asymptomatic. He
returned to Manila to work.
Then last 2006, while working as security guard at a school in Manila, the patient
experienced dyspnea which prompted him to stop smoking. He also reported that he was
exposed to dust and dirt frequently since he was always staying beside the road making
him exposed to heat and air pollution. He consulted a private consultant and was advised
15
to take Myril P for his tuberculosis. He took the medicine for 3 months 3 tabs a day but
stopped taking the drug because of financial reasons. According to him the dyspnea
stopped but he has experienced occasional coughing since then.
Then last September 2008, he experienced extreme dizziness, severe cough and
weight loss which prompted his admission at San Lazaro hospital in Manila. He was
diagnosed with PTB and was given DOTS treatment plus 60 injections of streptomycin.
He complied with the medications for 6 months with the help of his mother. After that
they returned to Davao where he was asymptomatic but had experienced occasional
cough.
However last April 12-14, 2010, the patient experienced fever during dawn for 3
days accompanied by dizziness and dyspnea. And last april 15, 2010, the patient and his
mother proceeded to “Brigada” where he had a check up and was given herbal
medications. However the following day April 16, 2010, the patient collapsed and was
rushed to Davao Medical Center which prompted his present admission.
D. Effects/ Expectations of Illness to Self/ Family
According to the patient, he has been battling PTB for almost 13 years already
and this has given disappointment to the way he sees himself as a son and as a brother.
And now that he has developed another complication, he stated he wants to be cured so
that they will stop spending money on his hospitalization and medication. He states he
feels bad because he doesn’t have money to buy his own medicines and he hopes he will
get better as soon as possible.
According to his mother, she believes that his son will be cured if they will see a
quack doctor for his son’s condition. She stated her desire for her son to see the quack
16
doctor who “cured” him last 1997. And according to her, they are running out of money
and she hopes his son will recover as soon as possible because their debt is getting bigger
as the days come by. She also stated that she thinks her son will get better if he will
practice healthy habits such eating nutritious foods and adequate rest. She also stated that
the patient’s siblings, who reside outside Davao city, are hoping that the patient will get
better soon and that they are encouraging the patient to get well.
17
GENOGRAM:
PAPAUNCLE 1
◊
UNCLE 1 MAMA
LOLA 1
Ѳ
LOLA 2
Ѳ
LOLO 2
Ѳ
LOLO 1
Ѳ◊
UNCLE 2 AUNTIE AUNTIE
Piolo
Ѳ
LITO
Ω
Anne ErichToniSamEnchongBea
LEGEND:
Ѳ- Deceased
◊- Hypertension
Ω- Tuberculosis
---- - PATIENT
DEVELOPMENTAL DATA
Erikson's Stages of Psychosocial Development
Erikson's stages of psychosocial development as articulated by Erik
Erikson explain eight stages through which a healthily developing human should pass
from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new
challenges. Each stage builds on the successful completion of earlier stages. The challenges of
stages not successfully completed may be expected to reappear as problems in the future.
Stage Description Result Justification
Middle
Adulthood
(25 to 65
years old)
GENERATI
VITY vs.
STAGNATI
ON
According to Erik Erikson,
the developmental task in middle
adulthood is to form a sense of
generativity, a sense of concern for
guiding the next generation.
During middle age the
primary developmental task is one
of contributing to society and
helping to guide future generations.
When a person makes a
contribution during this period,
NOT
ACHIEVED
Our client has not achieved
generativity even though he is able to exhibit
behaviors that are well acceptable for his age
and has understood the responsibilities of
middle –aged person but still, the client is
unproductive due to his illness. Because of
his illness, he quit his job and has not earned
a living for his family.
The client was working towards the
betterment of the society. He is a good
citizen. But, all people have imperfections,
19
perhaps by raising a family or
working toward the betterment of
society, a sense of generativity- a
sense of productivity and
accomplishment- results. In
contrast, a person who is self-
centered and unable or unwilling to
help society move forward
develops a feeling of stagnation- a
dissatisfaction with the relative
lack of productivity.
Those who are successful
during this phase will feel that they
are contributing to the world by
being active in their home and
community. Those who fail to
attain this skill will feel
unproductive and uninvolved in the
world.
our client has vices. He is a chain smoker and
an alcoholic and that makes him a bad
example for the next generations. In this way,
he’s not making the society move forward.
He’s not helping towards the guidance of the
future generation especially to his niece and
nephews.
20
Kohlberg's Stages of Moral Development
This theory specifically addresses moral development in children and adults. The
morality of an individual’s decision was not Kohlberg’s concern; rather, he focused on the
reasons an individual makes a decision.
Stage Description Result Justification
Conventional
Stage (Law
and Order
Orientation)
The conventional level of moral
reasoning is typical of
adolescents and adults. In this
stage, it is important to obey
laws, dictums and social
conventions because of their
importance in maintaining a
functioning society; Right is
being good, with the values and
norms of family and society at
large. The self enters society by
filling social roles; therefore
society must learn to transcend
individual needs. A central
ideal or ideals often prescribe
what is right and wrong, such
as in the case of
fundamentalism. If one person
ACHIEVED In this stage of Kohlberg's
Moral Development theory, the
client must follow the laws in order
to maintain a good functioning in
the society as a good citizen. The
client expressed that it is important
to follow rules and regulations
inculcated to us by the society. He
has not violated any laws and for
him, that makes him a good citizen.
He added that in order for you to
become a good citizen you must not
commit any crime.
He is in the stage four, the
Conventional level, it is said that
following the laws and dictums of
the society is significant to maintain
a good functioning in the society, so
21
violates a law, perhaps
everyone would—thus there is
an obligation and a duty to
uphold laws and rules. When
someone does violate a law, it
is morally wrong;
responsibility is thus a
significant factor in this stage
as it separates the bad domains
from the good ones. Most
active members of society
remain at stage four, where
morality is still predominantly
dictated by an outside force.
we have concluded our client has
done his role to the society.
Theory of Cognitive Development
The Theory of Cognitive Development is a comprehensive theory about the nature and
development of human intelligence first developed.
Stage Description Result Justification
22
Formal
operational
stage
(12–
Adulthood)
In this stage, individuals
move beyond concrete
experiences and begin to think
abstractly, reason logically and
draw conclusions from the
information available, as well
as apply all these processes to
hypothetical situations
CHARACTERISTICS:
Solves abstract and
hypothetical problems
Thinks in combinations
with other objects
Ability to acquire and
utilize knowledge
Good activity is talk time
Achieved The client was able to reason
out when there are questions asked
to him. He is capable of answering
it all.
He was high school undergraduate
but for him, he had acquired
knowledge from his teachers,
classmates, friends and the everyday
lessons he has learned through
experience and that knowledge was
being used everyday especially in
understanding the things that’s
happening. He usually talks to his
friends whenever he has problems
and whenever he needs someone to
talk to. We had also established
rapport with the client despite he
had difficulty speaking because he’s
having shortness of breath.
23
DEFINITION OF COMPLETE DIAGNOSIS
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Chronic obstructive pulmonary disease (COPD) refers to chronic bronchitis and
emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways
become narrowed. This leads to a limitation of the flow of air to and from the lungs causing
shortness of breath.
Charlene J. Reeves, Gayle M. Roux, Robin Lockhart. Medical-surgical nursing. Copyright ©
1995. Chapter 15, page 556.
COPD stands for chronic obstructive pulmonary disease. This is a term used for a number
of conditions; including chronic bronchitis and emphysema. COPD leads to damaged airways in
the lungs, causing them to become narrower and making it harder for air to get in and out of the
lungs.
Wilma J. Phipps, Judith K. Sands, Jane F. Marek. Medical-Surgical Nursing: Concepts &
Clinical Practice, 6th Edition. USA. Copyright © 2000.
Chronic obstructive pulmonary disease is any disorder that persistently obstructs
bronchial airflow. COPD mainly involves two related diseases -- chronic bronchitis and
emphysema. Both cause chronic obstruction of air flowing through the airways and in and out of
the lungs. The obstruction is generally permanent and progresses over time.
Barbara Janson-Cohen. Medical Terminology: An Illustrated Guide 5th edition. Copyright ©
2007. page 623.
24
PULMONARY TUBERCULOSIS
Tuberculosis (TB) is a potentially fatal contagious disease that can affect almost any part
of the body but is mainly an infection of the lungs. It is caused by a bacterial microorganism, the
tubercle bacillus or Mycobacterium tuberculosis.
Jane Hokanson Hawks. Medical-surgical Nursing: Clinical Management for Positive Outcomes.
Copyright © 2008. Chapter 39, page 975.
An infectious disease of humans and animals caused by the tubercle bacillus and
characterized by the formation of tubercles on the lungs and other tissues of the body, often
developing long after the initial infection.
Betty Davis Jones. Comprehensive Medical Terminology. Copyright © 2008. Chapter 12 page
475.
An infectious disease caused by the bacterium Mycobacterium tuberculosis that is
transmitted through inhalation and is characterized by cough, fever, shortness of breath, weight
loss, and the appearance of inflammatory substances and tubercles in the lungs. Tuberculosis is
highly contagious and can spread to other parts of the body, especially in people with weakened
immune systems.
Ann Ehrlich, Carol L. Schroeder. Medical Terminology for Health Professions. Copyright ©
2004. page 368.
25
PATIENT ASSESSMENT
DATE AND TIME OF ASSESSMENT: April 19, 2010 @ 2:00 P.M.
I. GENERAL SURVEY
The client is 40 years old and male. Upon assessment, he is lying supine on bed, awake,
conscious and coherent and oriented to time, person and place. He talks coherently and has a
sense of reality. He has an IVF Bottle # 3 of D5LR 1L at 300 cc level at 30 drops per minute
infusing well at right metacarpal vein. He is connected to supplementary oxygen of 2 liters per
minute via face mask. He is not in respiratory distress but effortful breathing is noted. His hair is
not well combed and is dressed in street clothes. Slight body odor is noted. He has an
ectomorphic type of body built and looks according to his age. He is cooperative during the
whole course of assessment.
II. VITAL SIGNS AND CLINICAL MEASURMENT
The client had a body temperature of 37.2°C, afebrile. His cardiac rate was 73 beats per
minute with no skip beats noted. His pulse rate was 96 beats per minute; full pulses noted
and equal to both extremities. His blood pressure was 80/60 mmHg; slightly below normal
range. His respiratory rate was 28 cycles per minute; tachypneic. His height measures 5
feet and 5 inches.
III. THE INTEGUMENT
26
a. SKIN
Skin color is light brown and generally uniform on all areas except on armpit and soles of
the feet where it is lighter. No edema noted on any part. Moisture is noted on armpits.
Temperature on all areas is uniform and within normal range. Skin turgor is good as skin springs
back to previous state after being pinched. Lesions and nodules are distributed at several areas of
his body. A papule is seen on his back.
b. HAIR
Hair is evenly distributed over the scalp. It is black in color. It is thick and oily. Dandruff
is noted on the scalp hair.
Hair is evenly distributed over the extremities. Facial hair is present. He has an unshaved
mustache. Axillary hair is present.
c. NAILS
The patient has a convex curvature on his nails. Fingernails and toenails have smooth
texture. The patient has pale fingernail and toenail beds. Intact epidermis is surrounding the
nails. Fingernails and toenails are unclean and untrimmed. Capillary refill time of 3 seconds is
noted.
IV. THE HEAD
a. SKULL AND FACE
The patient has normocephalic head with a circumference of 48 cm. There is a smooth
and uniform consistency of skull and no masses and nodules noted. There is a symmetric facial
features with symmetric facial movements. The patient is able to raise his eyebrows, close his
27
eyes, frown, and smile. Facial hairs are noted. No tenderness of frontal and maxillary sinuses
upon palpation
b. EYES AND VISION
Hairs in the eyebrow are black. Eyebrows are symmetrically aligned and has equal.
movement. Eyelids close symmetrically. No edema is noted over lacrimal gland. The eyelashes
are curled outward. Skin is intact and no discoloration is noted. Eyelids close symmetrically.
Sclera appears white. Conjunctiva is red. No edema or tenderness is noted over the lacrimal
gland. Pupils are equally round and reactive to light accommodation with pupil size of 3 mm.
Both eyes are coordinated and move in unison with parallel alignment. The patient can see
objects in periphery when looking straight ahead.
c. EARS AND HEARING
Ears are bilaterally symmetrical with no swelling or thickening. The color of the auricles
is the same as facial skin. It is symmetrical and aligned with the outer canthus of the eye. It is
mobile, firm and not tender and recoils after being folded. Cerumen accumulation not noted.
There are no foul smelling, serous, or purulent discharges noted. Normal voice tones are heard.
He is able to hear the ticking of the wrist watch
d. NOSE AND SINUSES
The nose is symmetric and straight. No discharges or flaring is noted. Skin is the same as
facial skin. It is non tender are presence of lesions is not noted. Nasal mucosa was pinkish. Both
left and right nares were patent, with no discharges; air could freely move in and out when the
patient breathes Air moves freely as the client breathes through the nares. The maxillary and
frontal sinuses are non tender.
e. MOUTH AND OROPHARYNX
28
The outer lips have a uniform pink color. It has a soft and dry texture. He is able to
pursed lips. The inner lips have a uniform pink color and have soft and moist texture. Only 28
adult teeth are present with dental carries noted.
The tongue is in central position and can move freely without difficulty. It has thin
whitish coating. There is a smooth tongue base with prominent veins.
The uvula is pinkish in color and is positioned in the midline.
Tonsils are not inflamed.
V. THE NECK
Muscles are equal in size with head positioned in the center. There is a coordinated and
smooth movement with no discomfort as the patient flexes, hyperextend, and laterally flexes the
head. Sternocleidomastoid muscle strength is equal as the patient was able to move his head
against the resistance of the hand. There is also an equal strength of trapezius muscles as the
patient was able to shrug his shoulders against the resistance of the hand. Lymph nodes are not
palpable.
VI. THE THORAX AND LUNGS
a. ANTERIOR CHEST
Patient has a respiratory rate of 28 cycles per minute, slightly above normal range.
Dyspnea is noted when patient is not connected to supplemental oxygen. His chest circumference
is 85 cm. The client breathes with thoracic movement as observed.. The patient’s shoulders raise
upon breathing indicating an effortful breathing. Wheezing and crackles are heard upon
auscultation
29
b. POSTERIOR CHEST
Spine is vertically aligned and straight. Skin is intact and uniform in temperature. There
were no masses and tenderness noted. Wheezing and crackles are noted upon auscultation.
VI. HEART
a. Heart and Central Blood Vessels
Point of maximum impulse and beat is auscultated at the 5th intercoastal space left
midclavicular line. The patient has a cardiac rate of 100 beats per minute, within normal range
and no skip beats noted. Abnormal heart sounds not noted upon auscultation.
b. Carotid Arteries and Jugular Veins
Symmetric pulse volumes with full pulsations and thrusting quality were noted upon
inspection and palpation of the carotid artery. Presences of bruits were not noted. Presence of
jugular vein distention is also not noted.
c. Peripheral Vascular System
There is symmetric pulse volume with full pulsations on all peripheral pulses. Limbs are
not tender and are symmetric in size. Cyanosis and jaundice are not noted in any areas of the
periphery. Capillary refill time is 3 seconds.
VII. Breast and Axillae
Skin color is uniform that of the abdomen. The color of his areola is dark brown.
Both nipples were everted. The axilla appears moist. No lesions and bruises is seen upon
inspection nor masses, discharges and tenderness during palpation. Axillary, subclavicular and
supraclavicular lymphs nodes are not tender.
30
IX. Abdomen
The abdomen has uniform skin color and same as the chest. Skin is dry. Abdominal
contour is flat; flat in shape. Abdominal movements are symmetric that are caused by respiration.
Umbilicus is located at the center with no signs of infection and protrusions. Bowel sounds are
audible. No tenderness noted and it is relaxed and has a consistent tension.
X. Genito- Urinary
The patient has a diaper where he urinates freely without experiencing any difficulty. The
patient has reported that there were no lesions, tenderness, and masses on his penis and anus.
XII. Musculoskeletal
a. Upper Extremities
Upon inspection, no lesions, scars and redness is noted on arms and shoulders. No
tenderness, inflammations, or masses is evident on elbows. There is no missing and deformed
fingers, contractures, bone enlargements, nodules or redness. Tenderness and nodules were not
noted on the left wrist, hands and fingers upon palpation. It is free from inflammation and with
normal angle curvature. Client is able to extend both arms. Palm is able to stay in both prone and
supine in a good manner without difficulty. Joints are able to move smoothly. He is able to
exhibit strong hand grip on both arms. Reflex on the upper extremity was good. No hand tremors
noted.
b. Lower Extremities
Upon inspection, muscles are equal on both sides of the lower extremities. No contracture
and tremors noted. No deformities noted. When asked to raise his legs one at a time, the patient
31
has difficulty doing it. The patient is able to flex and dorsiflex his feet. The patient has difficulty
ambulating as he experiences pain, gets easily tired and nauseated when walking.
32
ANATOMY AND PHYSIOLOGY
Respiratory System
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.
33
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 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
Air travels to the lungs through a series of air tubes and passages. It enters the body
through the nostrils or the mouth, passing down the throat to the larynx, or voice box, and then to
the trachea, or windpipe. In the chest cavity the trachea divides into two branches, called the
right and left bronchi or bronchial tubes, that enter the lungs.
In the adult human, each lung is 25 to 30 cm (10 to 12 in) long and roughly conical. The
left lung is divided into two sections, or lobes: the superior and the inferior. The right lung is
somewhat larger than the left lung and is divided into three lobes: the superior, middle, and
inferior. The two lungs are separated by a structure called the mediastinum, which contains the
heart, trachea, esophagus, and blood vessels. Both right and left lungs are covered by an external
membrane called the pleura. The outer layer of the pleura forms the lining of the chest cavity.
The branches of the bronchi eventually narrow down to tubes of less than 1.02 mm (less
than 0.04 in) in diameter. These tubes, called bronchioles, divide into even narrower tubes, called
alveolar ducts. Each alveolar duct ends in a grapelike cluster of thin-walled sacs, called alveoli (a
single sac is called an alveolus). From 300 million to 400 million alveoli are contained in each
34
lung. The air sacs of both lungs have a total surface area of about 93 sq m (about 1000 sq ft),
nearly 50 times the total surface area of the skin.
In addition to the network of air tubes, the lungs also contain a vast network of blood
vessels. Each alveolus is surrounded by many tiny capillaries, which receive blood from arteries
and empty into veins. The arteries join to form the pulmonary arteries, and the veins join to form
the pulmonary veins. These large blood vessels connect the lungs with the heart.
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.
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
35
into the left side of your heart. From there, it is pumped all around your body to supply oxygen
to cells and organs.
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.
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.
36
ETIOLOGY AND SYMPTOMATOLOGY
A. ETIOLOGY
Predisposing
Factors
Present/ Absent Rationale Justification
Genetics Absent 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
Although there was a
relative diagnosed
with PTB there is no
medical diagnosis
would also indicate
any genetic factor
present in the patient
that would predispose
him to such disease
condition.
37
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.
Childhood
respiratory Disorders
Absent Disorders in the respiratory
system during childhood
can predispose an
individual to be susceptible
to COPD. Childhood
respiratory disorders
weakens the respiratory
system of an individual and
making it sensitive to any
irritants.
No childhood
respiratory disorders
were reported by the
patient.
38
Precipitating
Factors
Present/ Absent Rationale Justification
Environment Present Environmental conditions
such as those with high
incidences of inhalational
exposure to noxious
substances can trigger
COPD.
Inhalational exposures
can trigger an
inflammatory response in
airways and alveoli that
leads to disease in
genetically susceptible
people. The process is
thought to be mediated by
an increase in protease
activity and a decrease in
antiprotease activity
The patient worked as
a school security guard
last 2006, wherein he
stayed at the side of
the road daily and
according to him he
was exposed to dirt
and dust all the time.
He also worked as a
carpenter in a
construction site and
he was frequently
exposed to dust and
dirt.
Smoking PresentThe most important risk
The patient has been
39
factor for COPD is
cigarette smoking..
Smoking depresses the
activity of scavenger cells
and affects the respiratory
tract’s 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,
smoking since he was
12 years old.
40
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.
Infection PresentEntry of microorganisms
such as H. influenza and
pseudomonas aurginosa
can cause damage to the
respiratory system which
can eventually turn to
COPD.
Sputum Culture
reveals presence of
tuberculosis pathogen.
B. SYMPTOMATOLOGY
Symptoms Present/Absent Rationale Justification
41
Wheezing Present Wheezing is the high-
pitched sound of air
passing through
narrowed airways. A
person with COPD
may wheeze during an
acute exacerbation or
chronically.
Sometimes the
wheezing is heard
only at night or with
exertion.
Bronchodilators can
relieve wheezing
quickly Wheezing
indicates presence of
accumulated
secretions in the
lungs.
Wheezing is heard upon
auscultation.
Dyspnea Present Obstruction of the
airway and
accumulation of
secretions contribute
The patient is having difficulty
in breathing at certain
occasions.
42
to difficulty in
breathing.
Hypoxia Absent Inadequacy of oxygen
to body tissues occur
in patients with
COPD as impairment
of airflow occur.
ABG results show no signs of
hypoxia. The patient is also
provided with supplemental
oxygen via face mask
Accessory muscle
use upon breathing
Present Due to impaired
airflow and airway
obstruction, COPD
patients exert effort in
breathing. In
advanced cases,
patients tend to use
accessory muscles
upon breathing in
order to aid in
respiration.
During physical assessment, the
patient’s shoulders raise upon
breathing indicating an effortful
breathing, using the muscles in
the neck and shoulders.
Hoover’s sign Present It refers to inward
movement of the
lower rib cage during
inspiration, implying
The patient is observed to
display Hoover’s sign.
43
a flat, but functioning,
diaphragm, often
associated with
COPD. COPD, and
more specifically
emphysema, often
lead to
hyperexpansion of the
lungs due to air
trapping. The
resulting flattened
diaphragm contracts
inwards instead of
downwards, thereby
paradoxically pulling
the inferior ribs
inwards with its
movement.
Weight loss Present Patients with severe
COPD work hard and
burn a lot of calories
The patient, as reported by
the SO has become thinner
and apparently lost some
44
just breathing. These
patients also become
short of breath in the
very act of eating, and
so may not eat enough
to replace the calories
they use.
weight.
Barrel Chest Present When the lungs
become enlarged, the
diaphragm is
displaced downward
and is unable to
contract efficiently.
Consequently, chest
diameter tends to
widen in order to
accommodate the
structural changes of
the lungs
The patient’s chest diameter
is widened.
Pursed Lip
breathing
Absent Because airflow out
of the lungs becomes
limited, exhalation
The patient did not manifest
this symptom.
45
takes longer. Because
the alveoli lose their
elasticity, one tries to
shorten the time
needed for exhalation
by forcefully
exhaling.
Unfortunately, forced
exhalation increases
pressure on the lungs
and causes
structurally weakened
airways to collapse.
To prevent airways
from closing during
forced exhalation,
pursed-lip breathing is
used: The lips are
narrowed together,
which slows
exhalation at the
mouth. This keeps
positive pressure in
46
the airways, thus
preventing their
collapse and allowing
some forced
exhalation.
Productive cough Present A productive cough is
caused by
inflammation and
excessive amounts of
mucus in the airways.
Coughing becomes
less effective because
of obstructed airflow.
The patient has productive
cough.
Cyanosis Absent People who have a
poor supply of oxygen
usually have a bluish
tinge to their skin,
lips, and nailbeds,
called cyanosis
The patient is not cyanotic.
Appearance of nail beds and
other parts of the body
appear normal, no bluish
discoloration is observed.
Hemoptysis Absent COPD is one of the
more common causes
The patient did not manifest
this symptom.
47
of hemoptysis. It
usually occurs during
an acute exacerbation,
when there is a lot of
coughing with
purulent sputum
(sputum containing
pus). Usually, there
are only very small
amounts of blood
streaking the sputum.
Granulomas/
lesions
Present These nodular-type
lesions form from an
accumulation of
activated T
lymphocytes and
macrophages, which
creates a micro-
environment that
limits replication and
the spread of the
mycobacteria.This
environment destroys
Lesions were noted on the
patient’s back.
48
macrophages and
produces early solid
necrosis at the center
of the lesion;
however, the bacilli
are able to adapt to
survive.
PATHOPHYSIOLOGY
49
Predisposing Factors:
GeneticsChildhood respiratory
Disorders
Precipitating Factors:
EnvironmentSmoking
Inhalation of pathogen
Droplets settle throughout the airways
Majority becomes trapped to the upper respiratory tract where mucus secreting goblet cells
exist
Production of mucus
Cilia sweeps mucus upward
Mucus containing trapped microorganisms becomes expelled out of the body
Productive cough
Bacteria bypasses mucociliary system reaches the alveoli
Cell mediated immune response
Ingestion by macrophages
Mycobacteria continues to multiply slowly at the rate of 25-32 hours
50
Production of proteolytic enzymes and cytokines to degrade bacteria
Cytokines attract T-lymphocytes
Cell mediated immune response occur
Macrophages present mycobacterial antigens on their surface to T-cells
immune process continues for 2 to 12 weeks; the microorganisms continue to grow
Skin test detection
Formation of granulomas around M. tuberculosis microorganisms
Skin lesions and nodules appear
fibrosis and calcification of lesions
( in persons with adequate immune system)
Bacteria is contained in the dormant healed lesions
granuloma formation is initiated yet ultimately is unsuccessful in containing the bacilli (in less immunocompetent persons)
Liquefication of necrotized tissues, the fibrous wall loses structural integrity.
semiliquid necrotic material drain into a bronchus or nearby blood vessel, leaving an air-filled cavity at the original site
Destruction of alveolar/ lung structures,
Accumulation of microorganisms and secretions
51
Hyperactivity of cells lining the bronchial tree
Smooth muscle of airways constrict and narrow
Mucus plugging, mucosal edema, bronchospasm
Cilia functions poorly Destroyed alveolar attachments
Decreased ability to eliminatesecretions
Accumulation of secretions
Breeding of microorganisms
Increased susceptibility to other infections
Airway obstruction
decreased airway support and closure during expiration
Loss of elastic recoil and lung hyperinflation
Airflow limitation
HypoxiaCyanosisDyspneaAccessory Muscle UseHoover’s Sign Weight LossBarrel ChestPursed Lip Breathing
Wheezing
hemoptysis
52
NARRATIVE PATHOPHYSIOLOGY
Once inhaled, the infectious droplets settle throughout the airways. The majority of the
bacilli are trapped in the upper parts of the airways where the mucus-secreting goblet cells exist.
The mucus produced catches foreign substances, and the cilia on the surface of the cells
constantly beat the mucus and its entrapped particles upward for removal. This system provides
the body with an initial physical defense that prevents infection in most persons exposed to
tuberculosis.
Bacteria in droplets that bypass the mucociliary system and reach the alveoli are quickly
surrounded and engulfed by alveolar macrophages, the most abundant immune effector cells
present in alveolar spaces. These macrophages, the next line of host defense, are part of the innate
immune system and provide an opportunity for the body to destroy the invading mycobacteria
and prevent infection. Macrophages are readily available phagocytic cells that combat many
pathogens without requiring previous exposure to the pathogens. Several mechanisms and
macrophage receptors are involved in uptake of the mycobacteria. The mycobacterial
lipoarabinomannan is a key ligand for a macrophage receptor. The complement system also plays
a role in the phagocytosis of the bacteria. The complement protein C3 binds to the cell wall and
enhances recognition of the mycobacteria by macrophages. Opsonization by C3 is rapid, even in
the air spaces of a host with no previous exposure to M tuberculosis. The subsequent
phagocytosis by macrophages initiates a cascade of events that results in either successful control
of the infection, followed by latent tuberculosis, or progression to active disease, called primary
progressive tuberculosis. The outcome is essentially determined by the quality of the host
defenses and the balance that occurs between host defenses and the invading mycobacteria.
53
After being ingested by macrophages, the mycobacteria continue to multiply slowly, with
bacterial cell division occurring every 25 to 32 hours. Regardless of whether the infection
becomes controlled or progresses, initial development involves production of proteolytic
enzymes and cytokines by macrophages in an attempt to degrade the bacteria. Released cytokines
attract T lymphocytes to the site, the cells that constitute cell-mediated immunity. Macrophages
then present mycobacterial antigens on their surface to the T cells. This initial immune process
continues for 2 to 12 weeks; the microorganisms continue to grow until they reach sufficient
numbers to fully elicit the cell-mediated immune response, which can be detected by a skin test.
For persons with intact cell-mediated immunity, the next defensive step is formation of
granulomas around the M tuberculosis organisms. These nodular-type lesions form from an
accumulation of activated T lymphocytes and macrophages, which creates a micro-environment
that limits replication and the spread of the mycobacteria. This environment destroys
macrophages and produces early solid necrosis at the center of the lesion; however, the bacilli are
able to adapt to survive. In fact, M tuberculosis organisms can change their phenotypic
expression, such as protein regulation, to enhance survival. By 2 or 3 weeks, the necrotic
environment resembles soft cheese, often referred to caseous necrosis, and is characterized by
low oxygen levels, low pH, and limited nutrients. This condition restricts further growth and
establishes latency. Lesions in persons with an adequate immune system generally undergo
fibrosis and calcification, successfully controlling the infection so that the bacilli are contained in
the dormant, healed lesions. Lesions in persons with less effective immune systems progress to
primary progressive tuberculosis.
54
For less immunocompetent persons, granuloma formation is initiated yet ultimately is
unsuccessful in containing the bacilli. The necrotic tissue undergoes liquefaction, and the fibrous
wall loses structural integrity. The semiliquid necrotic material can then drain into a bronchus or
nearby blood vessel, leaving an air-filled cavity at the original site. In patients infected with M
tuberculosis, droplets can be coughed up from the bronchus and infect other persons. If discharge
into a vessel occurs, occurrence of extrapulmonary tuberculosis is likely. Bacilli can also drain
into the lymphatic system and collect in the tracheobronchial lymph nodes of the affected lung,
where the organisms can form new caseous granulomas.
When these bacilli are not effectively contained by the body’s cell mediated immune
response, many different complications commence. Primary reaction is inflammation.
Inhalational exposures can trigger an inflammatory response in airways and alveoli that leads to
disease in genetically susceptible people. The process is thought to be mediated by an increase in
protease activity and a decrease in antiprotease activity. Lung proteases, such as neutrophil
elastase, matrix metalloproteinases, and cathepsins, break down elastin and connective tissue in
the normal process of tissue repair. Their activity is normally balanced by antiproteases, such as
α1-antitrypsin, airway epithelium–derived secretory leukoproteinase inhibitor, elafin, and matrix
metalloproteinase tissue inhibitor. In patients with COPD, activated neutrophils and other
inflammatory cells release proteases as part of the inflammatory process; protease activity
exceeds antiprotease activity, and tissue destruction and mucus hypersecretion result. Neutrophil
and macrophage activation also leads to accumulation of free radicals, superoxide anions, and
hydrogen peroxide, which inhibit antiproteases and cause bronchoconstriction, mucosal edema,
55
and mucous hypersecretion. Neutrophil-induced oxidative damage, release of profibrotic
neuropeptides (eg, bombesin), and reduced levels of vascular endothelial growth factor may
contribute to apoptotic destruction of lung parenchyma.
The inflammation in COPD increases with increasing disease severity, and, in severe
(advanced) disease, inflammation does not resolve completely with smoking cessation. Neither
does this inflammation appear responsive to corticosteroids.
Bacteria, especially Haemophilus influenzae, colonize the normally sterile lower airways
of about 30% of patients with COPD. In more severely affected patients (eg, those with previous
hospitalizations), Pseudomonas aeruginosa colonization is common. Smoking and airflow
obstruction may lead to impaired mucus clearance in lower airways, which predisposes to
infection. Repeated bouts of infection increase the inflammatory burden that hastens disease
progression. There is no evidence, however, that long-term use of antibiotics slows the
progression of COPD.Another consequence is airflow limitation. The cardinal pathophysiologic
feature of COPD is airflow limitation caused by airway obstruction, loss of elastic recoil, or both.
Airway obstruction is caused by inflammation-mediated mucus hypersecretion, mucus plugging,
mucosal edema, bronchospasm, peribronchial fibrosis, or a combination of these mechanisms.
Alveolar attachments and alveolar septa are destroyed, contributing to loss of airway support and
airway closure during expiration. Enlarged alveolar spaces sometimes consolidate into bullae,
defined as airspaces ≥ 1 cm in diameter. Bullae may be entirely empty or have strands of lung
tissue traversing them in areas of locally severe emphysema; they occasionally occupy the entire
hemithorax. These changes lead to loss of elastic recoil and lung hyperinflation triggering signs
and symptoms such as increased work of breathing, as does lung hyperinflation. Increased work
56
of breathing may lead to alveolar hypoventilation with hypoxia and hypercapnia, although
hypoxia is also caused by ventilation/perfusion. In this case, several signs commence such as
dyspnea, Hoover’s sign, weight loss, pursed lip breathing and use of accessory muscles upon
breathing.
DOCTOR’S ORDER
57
DATE ORDER RATIONALE REMARKS
04/16/10 Please admit patient under
yellow service med cp level3.
For close monitoring of the
patient and proper management
of his condition.
Admitted
Secure consent to care Consent to care is the permission
obtained from a patient/guardian
to perform medical management
needed for the patient. To secure
the consent of the patient is
important for legal purposes.
Obtained.
Diet as Tolerated DAT, Diet as Tolerated is a
particular diet that is given when
client can tolerate any food he
desires that is nutritious, if this
will not lead to any
complications.
Patient
informed.
Monitor vital signs q4 then
record
Vital signs are important for
baseline assessment and to
monitor patients condition which
evaluates the whole treatment
course, especially the medications
he received that could be a
Taken and
recorded.
58
contributing factor in the
variation results of the vital signs
Laboratory Tests:
Complete Blood Count with
platelet
CBC with PC determines the
quantity of each quantity of blood
cell in a given specimen of blood,
often including the amount of
hemoglobin, hematocrit, and the
proportion of various white blood
cells. This is done to know any
condition of the client that may
affect his medical management.
Done, with
result attached
to chart.
Urinalysis Urinalysis is performed to screen
for urinary tract disorders, kidney
disorders, urinary neoplasm and
other medical conditions that
produce changes in the urine.
This test also is used to monitor
the effects of treatment of known
renal or urinary condition. This
test is also used to monitor the
effects of certain procedures done
Done, without
result.
59
to patient and to check if genito-
urinary is in normal state or not.
Chest Xray Posterior anterior
view
An x-ray (radiograph) is a
noninvasive medical test that
helps physicians diagnose and
treat medical conditions. This is
done to help diagnose or monitor
treatment for conditions such as
pneumonia, emphysema and
other lung conditions. They are
ordered for symptoms of
shortness of breath, cough, or
chest pain.
Done, with
result attached
to chart.
Serum Creatinine The test is done to evaluate
kidney function. Creatinine is
removed from the body entirely
by the kidneys. If kidney function
is abnormal, creatinine levels will
increase in the blood because less
creatinine is released through
your urine.
Done, with
result attached
to chart
Serum electrolytes (Na, K) This is done to measure the Done, with
60
concentration of electrolytes
which are needed for both the
diagnosis and management of
renal, endocrine, acid-base, water
balance, and many other
conditions. Their importance lies
in part with the serious
consequences that follow from
the relatively small changes that
diseases or abnormal conditions
may cause. This is done for
diagnosing dietary deficiencies,
excess loss of nutrients due to
urination, vomiting, and diarrhea,
or abnormal shifts in the location
of an electrolyte within the body.
result attached
to chart
Venoclysis: PNSS 1L to run at
100 cc/hour
Intravenous lines provide easy
access for drug administration
intravenously (IVTT). Plain
normal saline solution is isotonic
to body fluid and is commonly
used for rehydration.
Hooked and
regulated.
O2 inhalation 2-4 L/min Hypoxia can be a strong driving Given via face
61
force in patients with COPD;
administering oxygen will reduce
this drive in these patients.
Additionally, there will be a loss
of physiological hypoxic
vasoconstriction which is partly
protecting the patient from the
effects of areas of gross alveolar
hypoventilation.
mask.
Meds:
1) Ceftriaxone 1g IV BID Ceftriaxone is often used (in
combination, but not direct, with
macrolide and/or aminoglycoside
antibiotics) for the treatment of
community-acquired or mild to
moderate health care-associated
pneumonia.
Given
2) Azithromycin 500mg 1
tab OD
Azithromycin is an azalide, a
subclass of macrolide antibiotics.
It is effective against susceptible
bacteria causing pneumonia and
Given
62
other bacterial infections.
3) Acetylcysteine 600mg+
1glass of water
An antioxidant drug used to
reduce the thickness of mucus
and ease its removal.
Acetylcysteine with hydration
significantly reduces the risk of
contrast nephropathy in patients
with chronic renal insufficiency.
Given
Watch out for dyspnea and
other unusualities
This is done to monitor patient
closely and to avoid hypoxia.
Done
Refer accordingly This may create a collaborative
treatment among the client and
the health care providers; thus it
also makes a good coordination
on the treatment of the client.
Done.
4/19/10 Referred for BP 80/50
ABG now ABG testing is mainly used in
pulmonology, to determine gas
exchange levels in the blood
related to lung function. This is
ordered since the patient has
Done, with
result attached
to chart
63
impaired lung function.
Paracetamol 500mg po qid
(hold)
Paracetamol is ordered to reduce
fever.
Given
IVF PNSS @ 100cc/hr-
maintenance
Plain normal saline solution is
isotonic to body fluid and is
commonly used for rehydration.
Regulated.
IVF PNSS 500cc over 80mins
now
This is done to increase the
patient’s blood pressure.
Given.
Refer for any unusualities. This may create a collaborative
treatment among the client and
the health care providers; thus it
also makes a good coordination
on the treatment of the client.
Done.
Sputum AFBx3 GSCS, Sputum AFB is done to determine
if the patient is positive for
tuberculosis or other kinds of
infection. It is done three times to
check for accuracy. Gram Stain
culture and sensitivity is done to
detect and identify bacteria or
fungi that infect the lungs or
Done, with
result attached
to chart
64
breathing passages.
Continue meds This is done until desired effects
are met.
Given.
Continue IVF PNSS @
100cc/hr
Plain normal saline solution is
isotonic to body fluid and is
commonly used for rehydration.
Regulated.
12:50
1) Salbutamol nebulization q6 It is used for the relief of
bronchospasm in conditions such
as asthma and chronic obstructive
pulmonary disease.
Given.
2) Continue all meds This is done until desired effects
are met.
Given.
3) Refer accordingly This may create a collaborative
treatment among the client and
the health care providers; thus it
also makes a good coordination
on the treatment of the client.
Done
4/20/20104) please give paracetamol 500mg
q6
Paracetamol is ordered to reduce
fever. This is ordered since the
patient is febrile.
given
65
Increase caloric and protein
intake
This is because people with
COPD require 10 times as many
calories to breathe than a healthy
person. And because of the added
effort that it takes to breathe,
people with COPD typically have
a higher energy requirement than
most. Protein has a high caloric
value and also in tuberculosis,
there is a considerable wasting of
body tissues. Therefore, it is
essential to increase protein
intake.
Patient
informed.
Diagnostics: 2D Echo An echocardiogram is a test in
which ultrasound is used to
examine the heart. This is done to
check any abnormalities of the
heart, assess the heart’s function
and determine the presence of
disease of the heart muscle.
Order given; not
done.
4/21/10 Still for 2D echo
66
Continue medications This is done until desired effects
are met.
Done
Refer accordingly This may create a collaborative
treatment among the client and
the health care providers; thus it
also makes a good coordination
on the treatment of the client.
Done
67
DIAGNOSTIC EXAMS
COMPLETE BLOOD COUNT AND PLATELET COUNT
The CBC is a series of different tests used to evaluate the blood and the cellular components of RBC’s, WBC’s and
platelets. The CBC is used to assess the patient for anemia, infection, inflammation, polycythemia, hemolytic disease, and the effects
of ABO incompatibility, leukemia and dehydration status
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
April
16,
2010
Hemoglobin 135 – 175
g/L
The test that
measures the
amount of
hemoglobin per
liter of blood.
122 Low Hemoglobin is
decreased in:
hemorrhage,
bleeding,
anemia,
hemolytic
anemia, fluid
overload, fluid
1. Discuss and explain the
procedure and purpose of
the test.
2. Inform the patient that no
fasting is needed.
68
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
retention,
pregnancy,
cirrhosis of the
liver and
hyperthyroidism.
A low
hemoglobin is
referred to as
anemia.
3. Assess the patient for any
factor that will probably
affect the results of the
test.
4. Make sure patient is well
hydrated. Dehydration
elevates the test results.
5. If patient is connected to
IVF, make sure that the
blood is not taken from
the arm connected to the
IVF. Hemodilution
Hematocrit 0.36 – 0.48 Hematocrit is a
blood test that
measures the
percentage of the
volume of whole
0.27 Low A low
hematocrit is
referred to as
anemia.
69
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
blood that is
made up of red
blood cells. This
measurement
depends on the
number of red
blood cells and
the size of red
blood cells.
causes false decrease of
the test results.
6. After the puncture, assess
the site for bleeding or
bruising.
7. If patient is under
treatment from an
infection, inform the
patient that the test will
be repeated to monitor
progress.
8. Any abnormality noted
RBC count 4.20 – 6.10 The test measures
the circulating
RBCs in 1 cubic
millimeter of
04.55 Normal Low RBC may
indicate blood
loss, anemia,
hemorrhage,
70
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
blood.
bone marrow
failure,
leukemia, and
malnutrition
will be reported to the
physician.
WBC count 5.0 – 10.0 This is to
determine the
inflammation and
for further test of
any problems. It
will identify
certain persons
with increase
susceptibility to
infection through
6.36 Normal Increased
Elevated in
acute infectious
disease, and in
lymphocytic and
monocytic
fractions in viral
disease, acute
leukemia, and
following
71
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
measuring the
total amount of
WBC in the body.
surgery or
trauma.
Neutrophil 55 – 75 Neutrophils serve
as the body's
primary defense
against infection
through the
process of
phagocytosis.
Neutrophils seek
out bacteria or
88 High Increased
Indicates
presence of
bacterial or
parasitic
infections.
72
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
necrotic tissue at
the site of the
injury and destroy
them through the
engulfment
process known as
phagocytosis.
Lymphocyte 20 – 35 Identifies
invading
substances,
including viruses,
bacteria,
incompatible
6 Low Decreased
Decrease is
associated with
SLE, burns,
trauma, and
73
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
erythrocyte, and
tissue grafts or
transplants.
administration of
corticosteroids.
Monocyte 2 – 10 Monocytes have
phagocytic
action. It removes
dead or injured
cells, cell
fragments, and
microorganism.
This test is done
to diagnose an
6 Normal Normal
74
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
illness such as
inflammatory
diseases.
Eosinophils 1 – 8
Eosinophils
initiate allergic
responses and act
against parasitic
infestation. The
test is use to
diagnose worm
infestation.
0 LowNo eosinophil
response.
Basophil 0 – 1 Basophils initiate
type 1 allergic
responses.
1 Normal Normal
75
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
Basophils are not
well understood
as other white
cells. They
appear to play a
role in allergic
and anaphylactic
reactions.
Platelet count 150 – 400 The test measures
all platelets
present in 1 cubic
millimeter of
blood. The
89 Low Low platelet
count indicates a
decrease in
circulating
clotting factors
76
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
platelet count is
used to assess the
ability of the bone
marrow to
produce and to
identify the
destruction of
loss of platelets in
the circulation.
in the body of
the patient,
making the
patient likely to
have bleeding.
MCH
25.7-32.20
The mean
corpuscular
hemoglobin, or
"mean cell
hemoglobin"
26.8 Normal Normal
77
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
(MCH), is the
average mass of
hemoglobin per
red blood cell in a
sample of blood.
It is reported as
part of a standard
complete blood
count. MCH
value is
diminished in
hypochromic
anemias.[1]
78
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
MCHC 32.30-36.50 The mean
corpuscular
hemoglobin
concentration, or
MCHC, is a
measure of the
concentration of
hemoglobin in a
given volume of
packed red blood
cells. It is
reported as part of
a standard
complete blood
32.20 low Decrease: iron
deficiency
anemia,
hypochromic-
low hemoglobin
concentration
Normal:
normochromic-
acute blood loss,
aplastic anemias,
acquired
hemolytic
anemia
79
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
count.
MCV 79-92.20 The mean
corpuscular
volume, or "mean
cell volume"
(MCV), is a
measure of the
average red blood
cell volume (i.e.
size) that is
reported as part of
a standard
complete blood
83.3 normal Low:
microcytosis-
small RBC
High:
macrocytosis—
large RBC
80
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
count
Chemistry
Potassium 3.5 – 5.5
The test measures
potassium levels
of the blood.
4.6 Normal Normal
Sodium 136 – 155
The test measures
the sodium levels
in the blood.
130.80 Low
Low sodium
levels in the
body indicate
hyponatremia,
Creatinine 53 – 115
The test usually
indicates renal
function.
52.20 Low
This measures
renal sufficiency.
The lower the
level of
81
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
creatinine in the
body, the
healthier the
kidneys are.
Glucose RBS 4.10-6.60
High glucose
levels indicate
insufficient or no
production of
insulin by the
body. This
indicates Diabetes
Mellitus.
6.8 High
The patient is
diabetic.
Dili man
diabetic ang
patient dba???
82
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
ABG Analysis - Often used to identify the specific acid-base disturbance and the degree of
compensation that has occurred. This is done to determine the concentrations of carbon
dioxide, oxygen and bicarbonate, as well as the pH of the blood. Its main use is in
pulmonology, to determine gas exchange levels in the blood related to lung function It is
also used in nephrology, and used to evaluate metabolic disorders such as acidosis and
alkalosis.
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
April 19,
2010
pH
7.35 – 7.45 pH indicates the
acid-base level of
the blood, or the
hydrogen ion (H+)
7.49 high Alkalosis Pretest:
1. Explain the importance
of the procedure to the
patient or watcher.
Inform the patient or
83
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
concentration watcher that the test
requires blood sample.
2. Instruct the patient to
breath normally during
the test.
3. Warn that a brief
cramping or throbbing
pain may occur at the
puncture site.
4. Take note of the patient’s
temperature and
respiratory rate.
5. If patient is receiving O2
therapy, discontinue O2
84
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
from 15 to 20 minutes
before drawing the
sample to measure ABG
on room air.
Post Test:
1. Apply pressure on the
puncture site.
2. After applying pressure,
tape a gauze pad firmly
over it.
3. Monitor VS. Observe for
signs of circulatory
impairment such as
85
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
swelling, discoloration,
pain, numbness or
tingling in the bandaged
arm.
4. Watch for bleeding from
the punctured site.
86
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
PaCO2 35 – 45
mmHg
PaCO2 indicates
how much
oxygen the lungs
are delivering to
the blood. It
indicates how
efficiently the
lungs eliminate
carbon dioxide.
36.3 normal normal
87
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
PaO2
75 – 100
mmHg
Indicates how
much oxygen the
lungs are
delivering to the
blood.
134.6 high
HCO3 22 – 26
meq/L
Indicates whether
a metabolic
problem is
present (such as
ketoacidosis). A
low HCO3-
indicates
27.1 high
88
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
metabolic
acidosis and a
high HCO3-
indicates
metabolic
alkalosis.
BE (ecf)
Base excess
+/- 2
mmol/L
The base excess
indicates whether
the patient is
acidotic or
alkalotic. A
negative base
3.8 high alkalotic
89
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
excess indicates
that the patient is
acidotic. A high
positive base
excess indicates
that the patient is
alkalotic.
O2Sat 80 – 100% This indicates
impaired
respiratory
function such as
respiratory
98.9% normal normal
90
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
weakness or
paralysis, airway
obstruction,
bronchiole
obstruction,
asthma,
emphysema, and
from damaged or
filled with fluid
because of
disease.
91
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
CO2 23-30 This indicates
impaired
respiratory
function such as
respiratory
weakness or
paralysis, airway
obstruction,
bronchiole
obstruction,
asthma,
emphysema, and
from damaged or
filled with fluid
28.3 normal normal
92
Date ExamNormal
ValueRationale
Result of
PatientRemarks
Clinical
SignificanceNursing Responsibilities
because of
disease.
Sputum Exam
The purpose of a sputum analysis is to help identify microorganisms that are causing respiratory disease or infection. The most
common reason for obtaining a sputum specimen is to test for infectious tuberculosis. A sputum analysis, however, is also used to
identify disease-producing organisms that may be causing pneumonia, bronchitis, lung abscess, or other respiratory disease. A sputum
analysis may be used to identify conditions such as: aspiration pneumonia, histoplasmosis, cryptococcosis, blastomycosis,
mycoplasma pneumonia, plague, mycobacterial infection, and pneumocystic pneumonia.
93
Specimen 1st 2nd 3rd
Visual Apperance Mucopurulent Mucopurulent Salivary
Reading 2+ 2+ 0
Laboratory Diagnosis positive
Gram Stain Culture and Sensitivity
Predominant Organism Presence of 7cm gram positive cocci appearing in pairs
Polymorphonuclear >25
Epithelial Cells <10
94
DRUG STUDY
Generic Name: Paracetamol
Brand Name: Biogesic
Classification: Non-narcotic analgesic, Antipyretic
Dosage: 500 mg tab qid
Mode of Action: Decreases fever by hypothalamic effect leading to sweating and
vasodilation. Also inhibits the effect of pyrogens on the hypothalamic
heat-regulating centers. May cause analgesia by inhibiting CNS
prostaglandin synthesis; however, due to minimal effects on peripheral
prostaglandin synthesis, it has no anti-inflammatory or uricosuric
effects. Antipyretic and analgesic effects are comparable to those of
aspirin
Indication: Control of pain due to headache, earache, dysmenorrheal, arthralgia,
myalgia, musculoskeletal pain, arthritis, immunizations, teething,
tonsillectomy; to reduce fever in bacterial or viral infections; as a
substitute for aspirin in upper GI disease, aspirin allergy, bleeding
disorders, clients on anticoagulant therapy, and gouty arthritis.
Contraindication Contraindicated in patients hypersensitive to drug; renal insufficiency,
95
anemia; clients with cardiac or pulmonary disease
Drug
Interactions:
Activated charcoal, cholestyramine and colestipol: Decreased
absorption
Barbiturates, carbamezepine, diflunisal, hydantoins, isoniazid,
rifabutim, rifampin, sulfinpyrazone: Increased risk of hepatotoxicity
Hormonal contraceptives: Decreased efficacy
Oral anticoagulants: Increased anticoagulant effect
Phenothiazines: Severe hypothermia
Zidovudine: Increased risk of granulocytopenia
Side/ Adverse
Effects:
Hematologic: hemolytic anemia, neutropenia, leukopenia,
pancytopenia
Hepatic: jaundice
Metabolic: hypoglycemia
Skin: rash urticaria
Nursing
Responsibilities:
1. Assess vital signs
2. Document presence of fever. Rate pain, noting type, onset,
location, duration and intensity.
3. Instruct the client to take the drug only for complaints
indicated.
96
4. Tell the client not to exceed the recommended dose; do not take
longer for 10 days.
5. Give the drug with food to avoid GI upset.
6. Encourage the client to avoid using other over-the-counter drug
preparations; if the client needs an OTC preparation, instruct
the client to consult the health care provider.
7. Discuss with the client the possible side effects of the drug.
8. Reassess the vital signs to evaluate the efficacy of the drug.
9. If any of the side effects occur, report it immediately to the
physician.
Generic Name: Ceftriaxone sodium
Brand Name: Rocephin
Classification: Antibiotic
Dosage: 1 g IV bid
Mode of Action: Bactericidal: Inhibits bacterial cell wall synthesis, causing
cell death.
Indication: Lower Respiratory tract infections caused by
Streptococcus pneumoniae, Staphylococcus aureus,
Haemophilus influenza, Escherichia coli, and Proteus
97
mirabilis.
UTI caused by E.coli, Klebsiella, Proteus vulgaris, P.
mirabilis.
Meningitis caused Streptococcus pneumoniae,
Haemophilus influenza.
Dermatologic infections caused by Klebsiella, S. aureus,
P. mirabilis.
Bone and joint infection caused by by Streptococcus
pneumoniae, Staphylococcus aureus, Escherichia coli,
Klebsiella pneumonia, Proteus mirabilis and
Enterobacter.
Contraindication Contraindicated with allergy to cephalosphorins or
penicillins.
Drug interactions: Increased nephrotoxicity with aminoglycosides.
Increased bleeding effects with oral anticoagulants.
Disulfiram-like reaction may occur if taken within 72 hr
after ceftriaxone administration.
Side/ Adverse Effects: CNS: headache, dizziness, lethargy
GI: nausea, vomiting, diarrhea, abdominal pain, flatulence,
hepatotoxicity
GU: nephrotoxicity
98
Hematologic: decreased WBC, platelets and Hct
Hypersensitivity: ranging from rash to fever to anaphylaxis
Nursing Responsibilities: 1. Ask the client if he/she has any history of allergy with
the drug.
2. Tell the client to take the full course of therapy as
prescribed.
3. Have vitamin K available in case of
hypoprothrombinemia occurs.
4. Do not mix it with other antimicrobial drugs.
5. Discontinue if hypersensitivity reaction occurs.
6. Discuss the possible side effects to the client like
stomach upset or diarrhea.
7. Report any unusualities to the physician immediately.
Generic Name: Azithromycin
Brand Name: Zithromax
Classification: Macrolide
Dosage: 500 mg, 1 tab OD
99
Mode of Action: Bacteriostatic or bactericidal in susceptible bacteria
Indication: Treatment of lower respiratory tract infections: Acute
bacterial exacerbations of COPD due to H. influenza, S.
pneumoniae.
Treatment of uncomplicated skin infections due S.
aureus, S. pyogenes
Treatment of acute sinusitis
Treatment of mild to moderate COPD caused by S.
pneumoniae, H. influenzae, Mycoplasma pneumoniae
Contraindication Contraindicated with hypersensitivity to azithromycin,
erythromycin or any macrolide antibiotic.
Drug interactions: Decreased serum levels and effectiveness of
azithromycin with aluminium and magnesium
containing antacids.
Possible increased effects with theophylline
Possible increased anticoagulant effects of warfarin
Side/ Adverse Effects: CNS: dizziness, headache, vertigo, somnolence, fatigue
GI: diarrhea, abdominal pain, nausea, dyspepsia, flatulence,
melena, vomiting
Other: superinfections, photosensitivity
Nursing Responsibilities: 1. Ask the client if he/she has any history of allergy with
100
the drug.
2. Tell the client to take the full course of therapy as
prescribed.
3. Instruct the client not to take antacids.
4. Tell the client that the drug may be taken with or
without food.
5. Explain to the client the possible side effects of the drug
such as abdominal cramping, diarrhea, fatigue, and
headache.
6. If any unusualities occur, report to the physician
immediately.
Generic Name: Acetylcysteine
Brand Name: Mucomyst
Classification: Mucolytic
Dosage: 600 mg + 1 glass of water
Mode of Action: Mucolytic activity: Splits links in the muco-proteins
contained in respiratory mucus secretions, vdecreasing
viscosity of the mucus.
101
Indication: Mucolytic adjuvant therapy for abnormal, viscid, or
inspissated mucus secretions in acute and chronic
bronchopulmonary disease (emphysema with bronchitis,
tuberculosis, pneumonia), in pulmonary complications of
cystic fibrosis, and in tracheostomy care
Contraindication Contraindicated with hypersensitivity to acetylcysteine; use
caution and discontinue immediately if bronchospasm
occurs.
Drug interactions: Drug stability and safety of Acetylcysteine when mixed
with other drugs in a nebulizer have not been established.
Side/ Adverse Effects: GI: nausea, stomatitis
Hypersensitivity: Urticaria
Respiratory: Bronchospasm
Others: rhinorrhea
Nursing Responsibilities: 1. Ask the client if he/she has any history of allergy with
the drug.
2. Tell the client to take the full course of therapy as
prescribed.
3. Use water to remove residual drug solution on the
patient’s face after administration through face mask.
4. Inform patient that nebulisation may produce an initial
102
disagreeable odor, but the odor will soon disappear.
5. Explain the possible side effects to the client including
an increased productive cough, nausea and GI upset.
6. Report difficulty in breathing or nausea.
Generic Name: Albuterol sulfate
Brand Name: Salbutamol
Classification: Bronchodilator
Dosage: 1 nebule q6
Mode of Action: Acts relatively selectively at beta2- adrenergic receptors to
cause bronchodilation and vasodilation
Indication: Inhalation: Treatment of acute attacks of bronchospasm
Contraindication
Hypersensitivity to albuterol; tachycardia, tachyarrythmisa
caused by digitalis intoxication; hypertension, coronary
insufficiency, CAD, COPD patients with degenerative heart
103
disease.
Drug interactions: Decreased bronchodilating effects with beta-adrenergic
blockers
Decreased effectiveness of insulin, oral hypoglycaemic
drugs
Decreased serum levels and therapeutic effects of
digoxin
Increased risk of toxicity when used with theopylline
and aminophylline
Increased symphatomimetic effects with other
symphatomimetic drugs
Side/ Adverse Effects: CNS: restlessness, anxiety, fear, tremor, drowsiness,
weakness, vertigo, headache
CV: cardiac arrhythmias, tachycardia, palpitations,
angina pain
GI: nausea, vomiting, heartburn
Respiratory: coughing, bronchospasm
Nursing Responsibilities: 1. Ask the client if he/she has any history of allergy with
the drug.
2. Instruct the client not to exceed recommended dosage of
the drug because it may loss its effectiveness or may
104
cause adverse effects.
3. Explain the possible side effects of the drug like
dizziness, drowsiness, fatigue, rapid heart rate, nausea
and vomiting
4. Encourage the client to eat small frequent meals to
avoid vomiting.
5. Assist the client in performing his daily activities
because it may cause drowsiness and dizziness.
6. Instruct the client to perform oral care to avoid changes
in taste.
7. Perform gentle back tapping after the administration of
the drug through inhalation.
105
NURSING THEORIES
Florence Nightingales’s Environmental Theory
Florence Nightingale, the “lady with the lamp” defined Nursing as: “The act of
utilizing the environment of the patient to assist him in his recovery.” And that it involves the
nurse's initiative to make up environmental settings suitable for the gradual restoration of the
patient's health, and that external factors associated with the patient's surroundings affect life or
biologic and physiologic processes, and his development.
Nightingale formulated the environmental theory which focuses on changing and
manipulating the environment in order to put the patient in the best possible conditions for nature
to act. She identified 5 environmental factors: fresh air, pure water & efficient food supplies,
efficient drainage, cleanliness/sanitation and light/direct sunlight. Any deficiencies in these 5
factors produce illness or lack of health, but with a nurturing environment, the body could repair
itself.
In the case of the client, he needs an environment that is conducive for his recovery; he
needs a quiet and clean environment. Our client in DMC MED- CP does not have a clean
surrounding, and the room is crowded, so sanitation and cleanliness is not well maintained. The
room is quite noisy and sometimes the doors were being slammed by the watchers, and that
could give the client an environment not conducive for resting. The hospital also has efficient
drainage system specifically in the comfort room. The client should also eat more nutritious
foods and drink adequate water to boost his immune system and restore his energy. The client
has not eaten a well balanced diet as he had poor appetite and he has a difficulty in eating and
106
finishing the food because he’s running out of breath. The client has not gotten fresh air and
direct sunlight since he has not gone out of the hospital.
Dorothea Orem’s Self-Care Theory
Orem defined Nursing as, “The act of assisting others in the provision and management of
self-care to maintain/improve human functioning at home level of effectiveness.” Orem’s theory
centers on activities that adult individuals perform on their own behalf to maintain life, health
and well-being. She determined three related concepts: (1) Self-care – activities an individual
performs independently throughout life to promote and maintain personal well-being, (2) Self-
care deficit – results when self-care agency (Individual’s ability) is not adequate to meet the
known self-care needs and (3) Nursing System – nursing interventions needed when individual is
unable to perform the necessary self-care activities:
1. Wholly compensatory – nurse provides entire self-care for the client.
2. Partial compensatory – nurse and client perform care; client can perform
selected self-care activities, but also accepts care done by the nurse for needs the client
cannot meet independently.
3. Supportive-educative – nurse’s actions are to help the client develop/learn
their own self-care abilities through knowledge, support and encouragement.
Our client has a self-care deficit since the client needs assistance in doing his activities of
daily living. In doing his ADL’s, he’s dependent on his mother who’s with him.
107
As nurses it is our duty to provide care for our client but we also need to promote to the client
self- sufficiency and independence. Since the client is partially compensatory, we can offer
ourselves to the client in order for him to meet his needs, we can assist him in doing his ADL’s.
We, as nurses should dedicate ourselves to the client and be there for him whenever he needs our
help. We, as responsible care givers must do our duty and that is to render quality care for our
client. It is also our job to promote independence to the client, through giving the client health
teachings and encouragement as these will aid client develop his own self- care capability. We
must encourage the client to be independent in doing his daily activities, just like feeding himself
as the client can perform it independently but since the client is dependent in some of his
activities like ambulating, we should instruct the watcher to offer themselves to the client and
assist the client in doing his daily activities.
Virginia Henderson’s Definition 14 Basic Needs
Henderson defined nursing as: “Assisting the individual, sick or well, in the performance
of those activities contributing to health or its recovery (or to peaceful death) that an individual
would perform unaided if he had the necessary strength, will or knowledge”. She formulated a
nursing theory which focuses on person’s basic needs and she enumerated 14 basic needs that a
person must possess.
The following are the14 basic needs:
1. Breathing normally
2. Eating and drinking adequately
3. Eliminating body wastes
108
4. Moving and maintaining desirable position
5. Sleeping and resting
6. Selecting suitable clothes
7. Maintaining body temperature within normal range
8. Keeping the body clean and well-groomed
9. Avoiding dangers in the environment
10. Communicating with others
11. Worshipping according to one’s faith
12. Working in such a way that one feels a sense of accomplishment
13. Playing/participating in various forms of recreation
14. Learning, discovering or satisfying the curiosity that leads to normal development
and health and using available health facilities.
In our client’s case, he was not able to meet some of these needs, the client is not breathing
normally, he needs supplemental oxygen via face mask in order for him to breathe. The patient
does not eat adequately and often does not finish his meals because he had shortness of breath.
He was not able to wear suitable clothing; in fact, he doesn’t wear any shirt to cover his upper
body parts for few days. The client was not able to keep himself clean; he’s not well-groomed
and has unkempt hair. He was not able to avoid the dangers in the environment that’s why he had
acquired his illness. He has not participated in various forms of recreation. He was not also able
to maintain normal range of temperature since he had an elevated temperature last April 21,
2010.
109
However, the client has met some of the needs enumerated by Henderson. He was able to
eliminate his body wastes and was able to maintain or move on his desired position but with
assistance. The patient tried his best to communicate with us and had established rapport with
him. He believes in God and never loses hope; he worshipped according to one’s faith. When he
was not ill yet, he really felt that he was really an accomplished person since he was able to
provide his family’s needs through working hard. He was also able to have adequate rest and
sleep since most of the time the client was sleeping and resting on his bed. The client was also
utilizing the services given by the health care facilities.
110
NURSING CARE PLAN
Date
&
Time
Cues Need Nursing DiagnosisObjective of
CareNursing Interventions Evaluation
A
P
R
I
L
Subjective:
“Maglisod ko ug
ginhawa sukad
nitukar ni akong
sakit.”as verbalized
by the patient.
Objective:
A
C
T
I
V
I
Ineffective airway
clearance related to
thick, viscous
secretions
secondary to COPD
® COPD is a
condition of chronic
After 6 hours
span of care,
the patient
will be able to
improve
airway
patency as
manifested
by:
1) Monitor respirations for rate, depth
and ease, presence of tachypnea; note
deep or shallow breathing, nasal flaring,
panting, and grunting.
® Reveals rate and type of respirations
(baseline for deviations) that are related
to age and condition of the patient,
changes that indicate obstruction of
airways and lungs resulting in extreme
April 16, 2010
@
2pm
GOAL
PARTIALLY
MET
111
16,
2010
@
8:00
AM
Suppresion
of productive
cough
crackles
noted upon
auscultation
nasal flaring
noted
use of
accessory
muscles
when
breathing
gasping,
panting and
grunting
noted during
T
Y
-
E
X
E
R
C
I
S
dyspnea with
expiratory airflow
limitation that does
not significantly
fluctuate. It is caused
by noxious particles
or gases, most
commonly from
smoking which
perpetuates an
ongoing
inflammatory
response that results
in airway narrowing
and hyperactivity.
Airways become
edematous, excessive
a. Maintain
patent
airway
with
breath
sounds
clearing
b) demonst
rate
behavior
s to
improve
and
maintain
patent
changes in depth of respirations which
are abnormal.
2). Elevate head of the bed in a Semi-
Fowlers position.
® Positioning facilitates chest expansion
and respiratory efficiency by reducing
pressure of abdominal organs
3) Assist in performing deep breathing
exercises.
® Promotes ease and deeper breathing by
enlarging tracheo-bronchial tree and
would help remove secretions.
After my 6
hours span of
care my patient
was able to
improve airway
patency as
evidenced by:
a.
maintena
nce of a
patent
airway.
b.
112
respiration
labored
breathing
tachypnea
Vital Signs:
RR: 28 cpm
(Normal: 16
– 20 cpm)
PR: 96 bpm
BP: 80/60
mmHg
Smoker for
28 years (1-2
cigarette
pack per day)
with O2 at
E
P
A
T
T
E
R
n
mucus production
occurs and cilia
function weakly.
Patients face
increasing difficulty
clearing secretions
with disease
progression.
Accordingly, they
develop a chronic
productive cough and
dyspnea. Increase in
mucus secretion as
well as the inability to
expel such can cause
respiratory tract
obstruction thus,
airway
such as
deep
breathin
g
exercises
,
increase
oral
fluid
intake
and head
elevated
in a
semi-
fowler’s
4) . Assist with measures to improve
effectiveness of cough effort.
® Cough can be persistent but
ineffective, especially if patient is
elderly, acutely ill, or debilitated.
Coughing is most effective in an upright
or in a head-down position after chest
percussion.
5) Encourage patient to increase oral
fluid intake within level of cardiac
tolerance. Provide warm/tepid liquids.
Recommend intake of fluids between,
instead of during meals.
® Hydration helps decrease the viscosity
of secretions, facilitating expectoration.
demonstr
ation of
behaviors
to
improve
and
maintain
patent
airways
such as
performa
nce of
deep
breathing
exercises,
increased
fluid
113
2lpm via face
mask
resulting to
ineffective airway.
Luxner, Karla L.
Delmar’s Nursing
Care Plans. 3rd
edition. USA:
Thomson Delmar
Learning. 2005. pp.
66-67.
position.
c. expecto
rate
sputum
effectiv
ely by
breathin
g
deeply
before
coughin
g.
d. verbaliz
e
Using warm liquids may decrease
bronchospasm. Fluids during meals can
increase gastric distension and pressure
on the diaphragm.
6) Administer medications as indicated:
> Ceftriaxone, Azithromycin
Various antimicrobials may be indicated
for control of respiratory infection/
pneumonia.
> Acetylcysteine
Antioxidant drugs are used to reduce the
thickness of mucus and ease its removal.
>Salbutamol
intake
and head
elevation
with
semi-
fowler’s
position.
c.
expectora
tion of
mucus
secretions
effectivel
y by
breathing
114
underst
anding
of
therape
utic
manage
ment
regimen
These medications relax smooth muscles
and reduce local congestion, reducing
airway spasm, wheezing, and mucus
production.
7). Instruct to splint the chest while
coughing. Splint with a towel or pillow.
® Splinting reduces chest discomfort and
avoids exerting too much force.
8). Instruct not to suppress a productive
cough. Encourage to expectorate sputum
whenever he feels the urge to cough it
out. Instruct to take deep breaths before
coughing and expectorating the sputum.
deeply
before
coughing.
d.
verbalizat
ion of
understan
ding vis-
a-vis
therapeuti
c
managem
ent
regimen
as patient
115
® Suppressing a cough would prevent
expectoration of secretions which could
obstruct the airways leading to
interference with gas exchange thus,
resulting to difficulty of breathing.
Taking deep breaths before coughing
would facilitate easy expectoration of
sputum.
9) Provide information about the things
he has to do, and why he has to do it such
as optimal positioning (sitting position)
and frequent position changes to
facilitate easy removal of secretions.
® Having knowledge about things will
give the patient an idea on how to do
verbalize
d, “ana
diay na,
kelangan
pud dili
lang naka
higda,
mas
gwapo
man jud
ning
nakalingk
od diay ta
noh pag
mag ubo
para
maayog
116
such procedures and would improve
compliance with the treatment regimen.
10. For patients with reduced energy,
pace activities. Maintain planned rest
periods.
® Fatigue is a contributing factor to
ineffective coughing.
11. Explain effects of smoking, which
includes second-hand smoke.
® Smoking contributes to bronchospasm
and increased mucus production in the
airways.
gawas
ang
plema.
Mag
inom na
sad kog
tubig
pirminte
bisag
ginagmay
lang
sugod
karon..
However
patient’s breath
sounds were not
clear and
117
crackles were
noted upon
auscultation.
Date Cues Need Nursing
Diagnosis
Plan of Care Nursing Interventions Evaluation
118
April
21,
2010 @
12:00
noon
SUBJECTIVE
CUES:
“Medyo init
lagi akong
paminaw”
OBJECTIVE
CUES:
T= 38.0
ºC
Flushed
skin
Skin
warm
to
touch
N
U
T
R
I
T
I
O
N
A
L
-
M
E
T
A
Hyperthermia
related to
increased
metabolic activity
secondary to
COPD secondary
to PTB
® An increased
metabolic activity
triggers the
hypothalamus, the
body’s
thermoregulator,
to increase the
thermoregulation
in the body,
At the end of 1 hour
of nursing care, the
patient will be able
to:
Demonstrate
a temperature
within
normal range
of 36.5°C-
37.5 °C;
1. Provide tepid sponge bath as
needed.
® Through TSB, heat is lost by
evaporation and conduction.
2. Increase oral fluid intake.
® To support circulating volume
and tissue perfusion.
3. Promote bed rest and limit
movements.
® To reduce metabolic
demands/oxygen consumption.
4. Promote surface cooling, by
undressing or loosening the
GOAL MET
April 21, 2010 1:00 P.M.
At the end of 1 hours of
nursing care, the patient:
Demonstrated a
normal temperature:
36.8 ºC
119
B
O
L
I
C
P
A
T
T
E
R
N
causing the
temperature and
other vital signs
to increase
beyond normal
levels.
Nursing Pocket
Guide to
Diagnoses,
Prioritized
Interventions and
Rationale
Doenges et. al.
clothing of the patient
®Through this, heat is lost by
radiation and conduction.
5. Administer Paracetamol 500
mg PO as ordered.
® To assist with measures that
would bring body temperature
into normal level.
6. Monitor temperature every 30
minutes
® To assesse any change in
temperature after
pharmacologic management
was given
7. Administer replacement fluids.
® To support circulating
120
volume and tissue perfusion.
8. Provide supplemental oxygen
®To offset increased oxygen
demands and consumption.
9. Provide adequate ventilation.
®The heat in the environment
may affect the increasing
temperature of the client.
Date Cues Needs Nursing
Diagnosis
Objective of
Care
Nursing Interventions Evaluation
A
SUBJECTIVE:
“Wala kaayo
N
U
Imbalanced
Nutrition: Less
At the end of 6
hours of nursing
1. Discuss eating habits, including
food preferences and intolerances
April 20, 2010 @
12:30 p.m
121
P
R
I
L
2
0,
2
0
1
0
@
8:00 AM
ko’y gana
mukaon,
hangakon
man gud
dayon ko,”as
verbalized by
the client.
OBJECTIVE:
Poor appetite
Hemoglobin
= 122 g/L
Was not able
to finish food
given to her.
T
R
I
T
I
O
N
A
L
-
M
E
T
A
B
O
than Body
Requirements
related to
decreased in
appetite
secondary to
COPD
secondary to
PTB.
® The taste
affects the
degree of
appetite of a
person. The
decrease in the
taste
perception also
care, the patient
will be able to:
Demonstrate
an increase in
appetite;
Verbalize
understanding
about the
significance of
proper
nutrition and
its benefits to
the body.
on food.
® To assess evaluate client’s
likes and dislikes.
2. Monitor or explore attitudes
toward eating and food
®Many psychological,
psychosocial, and cultural factors
determine the type, amount, and
appropriateness of food
consumed.
3. Encourage nutritious foods and
increase in oral fluid intake.
®To facilitate in providing proper
nutrition that the body needs.
4. Recommend ways to aid patient
with meals as needed. Ensure a
pleasant environment, facilitate
GOAL MET
At the end of 6
hours span of
nursing care, the
patient was able to
demonstrate an
increase in appetite
as evidenced by
finishing food given
to him. He was able
to acknowledge the
significance of
proper nutrition and
was able to
understand its
benefits to the body
and verbalized,
122
7-3 shift BMI=15.05
Height=
5’5’’
Weight= 41
kgs.
L
L
I
C
P
A
T
T
E
R
N
causes
decrease in
appetite
resulting to
imbalance
nutrition less
than body
requirements,
Nurses’ Pocket
Guide by
Doenges et. al.
proper position, and provide good
oral hygiene.
®To aid in increasing the appetite
of the patient and helps in
enhancing the intake.
5. For patients with changes in sense
of taste, encourage use of
seasoning or flavoring agents.
®To aid in the sense of taste thus
increasing the appetite of the
patient and it also enhances the
client’s food satisfaction.
6. Discourage beverages that are
caffeinated or carbonated.
®It can cause a decrease in
appetite.
7. Minimize unpleasant odors or
“mukaon na kog
daghan para
muhimsog nako”.
123
sights.
® Unpleasant odors or sights may
have a negative effect on client’s
appetite or eating.
8. Emphasize the importance of well
–balanced and nutritious intake
and discuss the benefits of
nutritious foods to the body.
® To alleviate client knowledge
regarding the importance of well-
balanced intake of healthy foods.
9. Encourage patient to rest.
® To promote adequate rest and
sleep.
10. Consult dietitian for further
assessment and recommendations
regarding food preferences and
124
nutritional support.
® Dietitians have a greater
understanding of the nutritional
value of foods and may be helpful
in assessing specific ethnic or
cultural foods.
Date /
Time
Cues Need Objectives of Care Nursing Diagnosis Nursing Interventions Evaluation
A
P
Subjective:
Patient
verbalized:
A
C
Activity intolerance
related to shortness of
breath secondary to
Within 6 hours span
of care, our patient
will be able to
improve activity
1) Instruct rationale for breathing
exercises, coughing effectively, and
general conditioning exercises
® Pursed-lip and
April 20, 2010
@
125
R
I
L
20,
2
0
1
0
“Maglisod
man ko ug
lihok, dali
lang ko
hangakon.”
As verbalized
by the patient.
Objective:
- generalized
body malaise
noted
- limited
range of
T
I
V
I
T
Y
E
X
E
R
COPD
® COPD is a
condition of chronic
dyspnea with
expiratory airflow
limitation that does
not significantly
fluctuate. Within that
broad category, the
primary cause of the
obstruction may vary;
examples include
airway inflammation,
mucous plugging,
narrowed airway
lumina, or airway
destruction.
tolerance as
evidenced by:
a) participate in
necessary or desired
activities such as
eating, sitting up on
bed, repositioning
and turning to sides;
b.) report an increase
in activity tolerance.
abdominal/diaphragmatic breathing
exercises strengthen muscles of
respiration, help minimize collapse of
small airways, and provide the
individual with means to control
dyspnea. General conditioning exercises
increase activity tolerance, muscle
strength, and sense of well-being.
3) Explain importance of rest in
treatment plan and necessity for
balancing activities with rest
® Bed rest is maintained during acute
phase to decrease metabolic demands,
thus conserving energy for healing.
Activity restrictions thereafter are
determined by individual patient
2:00 PM
“Goal Met”
Within 6 hours
span of care our
patient was able to
improve activity
tolerance as
evidenced by:
a.) participated in
necessary or
desired activities
such as eating,
sitting up on bed,
126
@
8 AM
motion
- needs
assistance in
walking
- Ataxia,
unsteady gait
noted
- muscle tone
and strength
are equally
weak
- pale nail
beds
(especially in
the toes)
C
I
S
E
P
A
T
T
E
R
Decreased
oxygenation and lack
of necessary nutrients
causes weakness,
fatigue and general
malaise that leads to
limited physical
movement of the
extremities.
Activity intolerance
is a state in which a
person has
insufficient physical;
or psychological
energy to endure or
response to activity and resolution of
respiratory insufficiency.
4.) Monitor BP, pulse, respirations
during and after activity. Note adverse
responses to increased levels of
activity(e.g., increased heart rate
[HR]/BP, dysrhythmias, dizziness,
dyspnea, tachypnea, cyanosis of
mucous membranes/nailbeds).
®Cardiopulmonary manifestations
result from attempts by the heart and
lungs to supply adequate amounts of
oxygen to the tissues.
5.) Elevate head of bed as tolerated.
repositioning and
turning to sides;
c.) reported an
increase in
activity tolerance;
patient verbalized:
“ gina try na nako
ug lihok lihok.
Hantod sa
makaya lang
nako”
127
-Hemoglobin
= 122 g/dl
(Normal
range= 135-
175 g/dl)
- VITAL
SIGNS:
Temp: 36.5°C
BP: 80/60
mmHg
PR: 96 bpm
RR: 38 cpm
N complete required or
desired daily activity
as commonly
experienced by those
having chronic
illness.
®Enhances lung expansion to maximize
oxygenation for cellular uptake
6.) Provide/recommend assistance with
activities/ambulation as necessary,
allowing patient to do as much as
possible.
®Although help may be necessary, self-
esteem is enhanced when patient does
some things for self.
7.) Identify/implement energy-saving
techniques, e.g., sitting to perform
tasks.
®Encourages patient to do as much as
possible, while conserving limited
128
energy and preventing fatigue.
8) Plan care with rest periods between
activities
® To conserve energy and reduce
fatigue.
9.) Refrain from performing
nonessential procedures.
® Patients with limited activity
tolerance need to prioritize tasks.
10. Provide positive atmosphere, while
acknowledging difficulty of the
situation for the client
® To help minimize frustration and
rechannel energy.
129
130
Date Cues Need Nursing
Diagnosis
Plan of Care Nursing Interventions Evaluation
April
19,
2010 @
8:00
A.M.
SUBJECTIVE
CUE:
Patient
verbalized,
“Upat na ko
ka-adlaw wala
na lagi”
OBJECTIVE
CUES:
Dandruff noted
Body odor
noted
A
C
T
I
V
I
T
Y
-
E
X
E
R
Self-care deficit:
bathing/ hygiene
related to body
weakness
secondary to
Chronic
Obstructive
Pulmonary
Disease
® The nurse may
encounter the
patient with a
self-care deficit in
At the end of 4 days
of nursing care, the
patient will be able
to:
Safely perform self-
care activities to
maximum ability;
and
Identify resources
that can provide
assistance in self-
care
1. Determine existing
condition affecting the
patient’s ability to do self-
care
® To develop a plan of care
appropriate to individual
situation.
2. Promote client and SO
participation in problem
identification and decision
making
® To enhance commitment
to plan and optimizing
GOAL PARTIALLY MET
April 22, 2010 @ 10:00
A.M.
At the end of 4 days of
nursing care the patient, the
patient
Was not able to
perform self-care
activities on his
maximum ability.
CBB was done by
his mother. He was
131
Untrimmed
nails.
C
I
S
E
P
A
T
T
E
R
N
the hospital.The
deficit may be the
result of transient
limitations, such
as those one
might experience
while
recuperating from
surgery; or the
result of
progressive
deterioration that
erodes the
individual’s
ability or
willingness to
perform the
outcomes.
3. Assist in providing
complete bed bath.
® As the patient has
difficulty standing for a
long time, bathing in the
toilet is not feasible. Give
the patient independence as
much as possible.
4. Maintain privacy during
bathing as appropriate.
® The need for privacy is
fundamental for most
still weak. However,
he was able to trim
his nails and comb
his hair. Dandruff
was still noted on his
scalp.
Was able to identify
resources such as
comb, towel,
toothbrush and nail
cutter in order for
him to perform
132
activities required
to care for
himself or herself.
Careful
examination of
the patient’s
deficit is required
in order to be
certain that the
patient is not
failing at self-care
because of a lack
in material
resources or a
problem with
arranging the
environment to
patients.
5. Encourage patient to comb
own hair
® This enables the patient
to maintain autonomy for as
long as possible.
6. Encourage patient to
perform minimal oral-facial
hygiene as soon after rising
as possible. Assist with
brushing teeth and shaving,
as needed.
7. Assist patient with care of
fingernails and toenails as
required.
133
suit the patient’s
physical
limitations. The
nurse coordinates
services to
maximize the
independence of
the patient and to
ensure that the
environment that
the patient lives
in is safe and
supportive of his
or her special
needs.
® Patients may require
podiatric care to prevent
injury to feet during nail
trimming or because special
implements are required to
cut nails.
8. Allow sufficient time for the
patient to accomplish tasks
to fullest extent of ability.
® Avoid unnecessary
interruptions while the
patient is doing self-care
activities.
9. Provide for communication
among those who are
involved in caring
134
for/assisting the client.
® Enhances coordination
and continuity of care
10. Encourage independence,
but intervene when patient
cannot perform.
® An appropriate level of
assistive care can prevent
injury with activities
without causing frustration.
135
DISCHARGE PLAN (M.E.T.H.O.D.)
Medications
1. Inform and instruct the patient and the significant others about the medications the patient
is taking and the importance of giving the medication for the patient’s recovery.
R: For the patient and for the significant others to increase their awareness about the
importance of taking the drug correctly.
2. Provide information about taking drugs not below or over the dosage given in order to
avoid drug toxicity and adverse effects.
R: To alleviate client’s knowledge about the drug he is taking.
3. Stress the right timing of the taking the medication.
R: To maximize the effects of the drug and prevent further complications from occuring.
4. Instruct the significant others to notify the health care provider when unusualities are
noted during the course of therapy.
R: To avoid these unusualities from worsening.
5. Store medications in places that are safe, free from insects and rodents and away
from children’s reach in order for the medicine not to be contaminated.
R: To prevent contamination and accidental ingestion of drugs.
Exercise
1. Discuss to client that exercises are important to prevent muscles from tightening.
2. Encourage him to do simple exercises such as walking, stretching, active and passive
ROM.
136
R: To promote circulation.
3. Teach the client on how to do deep breathing exercises.
R: To maximize lung capacity and oxygen circulation in the body.
4. Encourage patient to pair exercise with adequate rest and sleep.
R: To promote fast recovery.
5. Encourage the patient to exercise within normal limits.
R: In order to avoid straining and weakness.
6. Instruct the patient to avoid exhausting activities until full recovery is achieved.
R: For prevention of complications.
7. Encourage stimulation, both physically and mentally, by way of performing activities of
daily living.
R: Maintenance of bodily functions.
Treatment
1. Encourage the client to comply with the doctor’s orders and instructions, especially in
taking the prescribed medications.
R: Compliance to the doctor’s order prevents complication from occurring.
2. Explain to the patient and as well as the significant others regarding the dangers of non-
compliance to the therapy.
R: For them to understand that there will be consequences of non-compliance to the
therapy.
3. If fever occurs, instruct to do tepid sponge bath. If fever still persists, take paracetamol as
prescribed by the physician.
137
R: Promotes non-pharmacologic interventions for controlling fever.
Health Teachings:
1. Teach the patient about the importance of proper hygiene and good grooming.
2. Teach patient and his significant others on how to perform hand washing and when to do
it.
R: Handwashing is the single most important step in controlling the spread of infection.
3. Explain the importance of a well-balanced diet and enumerate its benefits to the body.
R: To increase client awareness regarding its importance and its benefits to the body.
Out-patient
1. Instruct the patient to have follow-up check -up.
R: To evaluate health status and provide a continuous care for the patient.
2. Tell the patient that regular check-ups are essential to ensure that his condition is
constantly monitored by the doctor.
R: Monitoring is important to detect any complication that may arise.
3. Encourage the patient that if he experiences any unusualities or changes in his health
status, he should notify the physician immediately.
R: Immediate actions taken decrease chances of patient’s condition to worsen.
Diet
1. A diet rich in protein, vitamins and minerals is recommended.
R: To promote healing of the body.
2. Increase oral fluid intake.
138
R: To maintain hydration and prevent dehydration.
3. Eat foods with sufficient caloric value.
R: To facilitate healing.
139
PROGNOSIS
GOOD FAIR POOR JUSTIFICATION
Onset of the
illness
√ The patient first experienced signs and symptoms
of PTB 13 years ago. He was treated and became
asymptomatic. The disease recurred last 2006 up to
now. This recurrence of PTB and its symptoms led
to the current diagnosis of the patient which is
Chronic Obstructive Pulmonary Disease.
Duration of illness √ The illness of the patient started 14 years ago when
he was diagnosed with Pulmonary Tuberculosis.
After that diagnosis, he was able to get treatment
regimen and was asymptomatic after then.
However, last 2006, a relapse happened because he
was diagnosed again with Pulmonary Tuberculosis.
He again subjected himself to TB-DOTS.
However, complications of PTB led to the
diagnosis of Chronic Obstructive Pulmonary
Disease. This 2010.
Precipitating
factors
√ Environment, smoking and infection are three
precipitating factors present in the patient. Thus,
this makes the patient more vulnerable of
developing COPD in addition to the fact that he
140
has PTB.
Willingness to
take medications
and treatment
√ During the course of his illness, he was able to
conform to the medication regimen. Last 1996, he
was able to get treatment and so he became
asymptomatic. When the disease recurred, he
participated in the DOTS treatment. There were
just times before that even though he wants to take
medication, he couldn’t do so due to financial
reasons.
Age √ The patient is currently 40 years old. This is too
early for an individual to suffer from COPD.
However, considering the fact that he also has PTB
that he acquired when he was 28 years old makes
him susceptible for this disease.
Environmental
factors
√ The patient lives in a conducive and healthy
environment. Their family has a house in Palanca
Village in Matina, Davao City. It is not near the
highway as well as not in close proximity to any
factories so the risk of pollution contributing to his
illness is lesser. Moreover, since he stays mainly in
their house after the 2nd diagnosis of PTB, he is less
exposed to environmental pollutants. No one in
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their house smokes after they found out that he has
PTB.
Family Support √ Since he was diagnosed of Pulmonary
Tuberculosis last 1996 up to this time wherein he is
currently suffering from Chronic Obstructive
Pulmonary Disease, his family never fail to attend
to his needs involving check-ups, medications,
needs during treatment. During the course of the
disease, the family has been very supportive. In
fact, his mother and his brother are the persons
who are there to attend to the patients needs in the
hospital. Family members were also seen visiting
the client within his stay in the hospital.
Total
Computation:
Poor: (4*1)/7 =4/7
Fair: (0*2)/7 = 0/7
Good: (3*3)/7 =6/7
Total: 1. 42
General Prognosis:
1-1.6 = POOR
1.7-2.3 = FAIR
2.4-3.0 = GOOD
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Rationale for a Poor Prognosis
At an early, Don Juan developed Pulmonary Tuberculosis. Even though he was prompt in
taking medications and was asymptomatic after that, a relapse developed. The return of his
illness radically changed his health and eventually led to another disease. As it name implies,
COPD is a chronic illness. Only prevention and treatment management could lead to a very good
prognosis.
We rated a poor prognosis for “Lito” due to the fact that at a young age, he
already developed a communicable disease and this disease gave him a more difficult disease to
cope up with. He may be willing to take all the medications there is and all possible treatments,
the financial capabilities of their family might hinder the possible decrease in complications of
the disease. Moreover, COPD affects individual greater than 40 years old. It is sad to note that
Don Juan has been brought in this predicament too early. Within the duration of his illness, more
symptoms appeared that makes his health more vulnerable. His age is at the risk level of COPD.
In addition, no cure has been set for COPD other than management of symptoms.
RECOMMENDATION
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This case study has provided the proponents with important information about the
patient’s disease. In order to ensure that optimal health is restored and maintained, the group
would like to recommend the following:
To the patient
Whenever there is, the onset of a certain disease it implies one to contribute her
cooperation and willingness to be responsible for her own health. The patient himself must
present himself to the care intended for him to reduce the severity of the disease. He must be
sensitive of his own feelings, needs and must be accountable for his actions. He is encouraged to
verbalize his feelings to also help the people rendering care and for him to express his perception
and feelings regarding the condition he is undergoing. He is advised to comply strictly with the
treatment regimen, medications, and orders of the doctor for him. He must know the importance
of good compliance to medication and the benefits it would give to him. Lastly, he must not
hesitate in seeking medical assistance whenever he feels any unusualities in his body.
To the patient’s family
The family of every patient plays a very important role in the condition of the patient and
his treatment. The family themselves should understand the condition of the patient for them to
know how to care to their family member who is sick. They should make themselves physically
present so that the patient will feel their love and support so that he will feel that he is not alone
in fighting against his illness. That he has somebody to hold on to and be one of the reasons for
him to continue fighting and overcome his illness.
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To the student nurses:
Every case study that student nurses do adds to their knowledge that help them better
understand more condition thus helping them become better health care provider. Student nurses
must always be ready in whatever they will be facing in their everyday exposure. They must be
prepared and alert. Even with the clinical instructors in their side, there is still a possibility that
they can commit mistakes. Therefore, they must always be prepared, equipped with the
knowledge they learned from the lectures and skills gained from experiences for them to render
quality nursing care.
Empathy, patience, respect and genuineness are the key elements for the nurse to possess.
Every student nurses should develop these for them to assist and render quality care for the
patient and share whatever they know for the betterment of the condition of every patient they
will handle. Lastly, they must continue in studying different cases and be able to share to other
student nurses, to patients and their significant others, to people of community and especially to
their family.
To the Ateneo de Davao University- College of Nursing
The AdDU- College of Nursing has the biggest role in providing stuent nurses with
opportunities of having exposures to different clinical areas to help them apply the knowledge
they have gained from every lectures and practice the skills they gained necessary for their
profession. The faculty and staff are also encouraged to maintain improving the standards of the
Nursing Curriculum in Ateneo by providing quality education to the students. Moreover, they
themselves must be well-trained to guide the students to learn. It is of great importance that they
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will continue in inspiring generations to take up nursing and perceive this job as a noble one,
helping people who are need of care, care that only nurses dare to do.
To the Professional Medical World
COPD and PTB are kinds of diseases that can affect persons of different gender, age, and
socioeconomic status. The proponents of this study would like to recommend to the professional
world to improve their facilities and projects that were made to do researchers on how to cure
and prevent these diseases. Workers in the health team should work together to promote
optimum health, prevent the spread of illnesses, and enhance the welfare of the society most
especially. They must have projects to spread proper information to the community in order for
the community to know and be informed about the different illnesses, their information, signs
and symptoms, diagnostic exam, treatment, and how it can be prevented. Moreover, they should
teach the community techniques on how to prevent the spread of diseases. They should teach
them the proper hand washing, proper hygienic practices, proper sanitation, proper handling and
preparing of foods, and especially healthy lifestyle. Lastly, they must give more attention and do
further researches, innovation, inventions, and discoveries in the field of medicine to save more
lives. In partnership with other health sectors, attaining the goal in establishing optimum health
to the whole population is possible.
REFERENCES
BOOKS
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Ann Ehrlich, Carol L. Schroeder. Medical Terminology for Health Professions. Copyright ©
2004.
Barbara Janson-Cohen. Medical Terminology: An Illustrated Guide 5th edition. Copyright ©
2007.
Charlene J. Reeves, Gayle M. Roux, Robin Lockhart. Medical-surgical nursing. Copyright ©
1995.
Jane Hokanson Hawks. Medical-surgical Nursing: Clinical Management for Positive Outcomes.
Copyright © 2008.
Kozier and Erb’s Fundmentals of Nursing 8th Edition
Nursing Pocket Guide to Diagnoses, Prioritized Interventions and Rationale
Doenges et. al.
Wilma J. Phipps, Judith K. Sands, Jane F. Marek. Medical-Surgical Nursing: Concepts &
Clinical Practice, 6th Edition. USA. Copyright © 2000.
Understanding Medical Surgical Nursing 3rd edition; International Edition; Williams,S.L.;
Hopper, P. D.;F.A. Davis Company, 2007
Brunner and Suddarth’s Textbook of Medical Surgical Nursing, 11th edition; Smeltze, S.C.; Bare,
B.G.; Hinkle, J.L.; Cheever, K.H.; Lippincot, Williams and Wilkins; 2008
