case

Nueva Ecija University of Science and Technology
College of Nursing
General Tinio Street, Cabanatuan City


A
CASE STUDY
ABOUT

“CHRONIC OBSTRUCTIVE PULMONARY DISEASE’’

Submitted by:
Karen Katrin M. Tabunan
Ayra A. Susada
Glenda Marie D. Tadiaman
Verlinda Sampana
Lou Arden Sermonia
BSN IV-J Submitted to:
Ms. Ria May R. Velasco
Ms. Gisharmaine Turner
Head Nursing
Mrs. Loida Martinez
Clinical Instructor
I. INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a disease state in which airflow is obstructed by emphysema, chronic bronchitis or both. The airflow obstruction is usually progressive, irreversible, and associated with airway hyperactivity resulting in narrowing of peripheral airways, airway flow limitation and changes in the pulmonary vasculature. Asthma now is considered as a separate disorder overlaps with symptoms of COPD. Cigarette smoking, air pollution and occupational exposure (coal, cotton and grain) are important risk factors that contribute to its development, which may occur over a 20-30 year span. Complications of COPD vary but include respiratory insufficiency and failure (major complication) as well as pneumonia, atelectasis and pneumothorax.












II. OBJECTIVES
GENERAL OBJECTIVES
After the 32 hours of duty at the Gapan District Hospital General Ward, we will be able:
• To provide a quality nursing care for the patient with chronic obstructive pulmonary disease,
• To impart our knowledge and skills in dealing with patient’s case, and
• To enhanced more our skill in doing our actual nurse nurse-patient interaction.

SPECIFIC OBJECTIVES
A. CLIENT CENTERED
After the 32 hours of duty at the Gapan District Hospital General Ward, the patient will be able:
• To verbalized feelings and concerns about her condition,
• To participate in the activities needed in the conduction of this case, and
• To cope with her situation and live like in a normal condition.

B. NURSE CENTERED
After the 32 hours of duty at the Gapan District Hospital General Ward, the students will be able:
• To gain the trust of the patient to make her cooperative with the activities being conducted,
• To acquire/learned more knowledge about the disease process, its manifestation, medical management and the nursing responsibilities needed in dealing with the patient, and
• To impart knowledge to the patient that she will use in her daily living.
III. CASE DISCUSSION

III.1 DEFINITION
Chronic obstructive pulmonary disease is a group of disorders that affect the movement of air in and out the lungs.

TYPES OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
• Chronic Bronchitis
• Emphysema
• Bronchiectasis

CHRONIC BRONCHITIS (BLUE BLOATERS)
Chronic Bronchitis is defined as a productive cough that lasts 3 months a year for 2 consecutive years with other causes excluded. Chronic exposure to smoke or another pollutant irritates the airways resulting in hypersecretion of mucus and inflammation, thickened bronchial walls and narrow bronchial lumen. Patients have increased susceptibility to recurring infections of the lower respiratory tract.

CLINICAL MANIFESTATIONS
a. Chronic, productive cough with copious sputum in winter months.
b. Earliest sign: cough is exacerbated by cold weather, dampness and pulmonary irritants
c. Dyspnea on exertion
d. Rales/ronchi
e. Cyanosis


RISK FACTORS
a. Cigarette smoking
b. Exposure to pollution or hazardous airborne substances
c. Heredity/family history
d. Frequent respiratory infections

EMPHYSEMA (PINK PUFFERS)
Emphysema is defined as a non uniform pattern of abnormal, permanent distention of the air spaces with destruction of the alveolar walls and eventually a reduced pulmonary capillary bed. The main problem with this disease is the loss of elasticity which eventually leads to a state of CO² retention, hypoxia and respiratory acidosis.

CLINICAL MANIFESTATIONS
a. Dyspnea on exertion
b. Cough and sputum
c. Signs of respiratory distress
d. Fatigue
e. Weight loss
f. Hyper resonance on percussion

RISK FACTORS
a. cigarette smoking
b. infection
c. inhaled irritants
d. heredity
e. allergic factors
BRONCHIECTASIS
Bronchiectasis is a chronic irreversible dilatation and impaired mucociliary clearance of the bronchi and bronchioles. The result is retention of the secretions, obstructions and eventually alveolar collapse.

CLINICAL MANIFESTATIONS
a. chronic cough with sputum
b. hemoptysis
c. dyspnea
d. wheezing
e. fatigue
f. weight loss
g. fever

RISK FACTORS
a. recurrent lower respiratory tract infection
b. congenital defects
c. bronchial tumors

III.2 MEDICAL MANAGEMENT
a. Bronchodilators- any of a group of drugs that expand the air passages (bronchial tubes) of the lungs. Bronchodilators are used to treat asthma, bronchitis, emphysema, and other diseases that affect the lungs. They relieve symptoms such as wheezing, shortness of breath, and coughing, and restore the patient’s ability to breathe comfortably.
b. Oxygen therapy in low concentrations- essential for cells, which use this vital substance to liberate the energy needed for cellular activities.
c. Anti- microbial therapy with sputum culture and sensitivity studies- for the minimization of microorganisms invading the respiratory tract of the patient.
d. Prophylactic vaccination- used for the prevention of further complication like pneumonia and influenza.
e. Chest physiotherapy with percussion; postural drainage, expectorations or broncoscopy to remove bronchial secretions.
f. Increased oral fluid intake

PREVENTION

a. Smoking cessation
b. Minimizing exposure to pollutions and irritants

III.3 COLLABORATIVE PROBLEMS and its NURSING MANAGEMENT
a. Respiratory insufficiency or failure
b. Pneumonia
c. Pneumothorax
d. Pulmonary hypertension

a. RESPIRATORY INSUFFICIENCY/FAILURE
Respiratory insufficiency/ failure occur when the body can no longer maintain effective gas exchange. The physiologic process that ends in respiratory failure begins with hypoventilation of the alveoli. Hypoventilation occurs when the body’s need for oxygen exceeds actual oxygen intake, the airway is partially occluded or the transfer of oxygen and carbon dioxide in the alveolar is disrupted. This disruption may occur either because of malfunction of respiratory center stimulation or because the alveolar membrane is defective.

CLINICAL MANIFESTATIONS
a. irritability
b. lethargy
c. cyanosis
d. dyspnea
e. tachypnea
f. nasal flaring
g. intercostals retractions
h. Respiratory grunting which slows the expiratory flow and increases the lung volume and alveolar pressure (signs of severe disease and suggest onset of respiratory failure).

NURSING MANAGEMENT
a. Assess patient’s quality of respiration and rate, apical pulse and temperature
b. Monitor oxygen saturation with pulse oximetry
c. Place the patient in an upright position
d. Administer oxygen as ordered
e. Keep emergency respiratory equipment at bedside
f. Monitor for the level of consciousness

b. PNEUMONIA
Pneumonia is an inflammation of the lung parenchyma commonly caused by microbial agents. Pneumonia may be viral, bacterial, or mycoplasmal in origin. Those at risk for pneumonia often have chronic underlying disorders, severe acute illness, a suppressed immune system from disease or medications, immobility, and other factors that interfere with normal lung protective mechanisms.

CLINICAL MANIFESTATIONS
a. sudden chills, rapidly rising fever (38.5°C to 40.5°C) with profuse perspiration
b. Pleuritic chest pain aggravated by respiration and coughing
c. Severely ill patient has marked tachypnea (25-45 breaths/minute) and dyspnea; orthopnea when not propped up
d. Pulse is rapid and bounding; may increase 10 beats/minute per degree of temperature elevation (Celsius)
e. A relative bradycardia for the amount of fever suggests viral infections or mycoplasma or legionella species infections.
f. Sputum purulent, rusty, bloody-tinged, viscous or green depending in etiologic agent.
g. Other sign include crackles, and signs of lobar consolidation; initial upper respiratory tract symptoms (nasal congestion, sore throat).
h. Severe pneumonia: flushed cheeks: lips and nail beds demonstrating central cyanosis.

NURSING MANAGEMENT
a. Instruct the patient about chest splinting by hugging pillow to make coughing and breathing less painful.
b. Administer medications as prescribed by the physician.
c. Instruct the patient when an antibiotic is being given; make sure that it will be taken as full course at prescribed intervals.
d. Teach patient the proper administration of drugs and any side effects.
e. Teach the proper disposal of tissue being used by the patient to prevent the spread of microorganisms.


c. PNEUMOTHORAX
Pneumothorax occurs when the parietal or visceral pleura are breached and the pleural space is exposed to positive atmospheric pressure. Air enters the pleural space and a lung or portion of it collapses.

CLINICAL MANIFESTATIONS
a. Pleuritic pain
b. Minimal respiratory distress with small pneumothorax; acute respiratory distress if large
c. Anxiety, dyspnea, air hunger, use of accessory muscles and central cyanosis with severe hypoxemia, accompanied by tachypnea
d. Tympanic sound on percussion of the chess wall
e. Decreased or absence of breath sounds and tactile fremitus on affected side.

NURSING MANAGEMENT
a. Monitor blood oxygen level using pulse oximetry in case of hypoxia
b. Assist in chest tube insertion; maintain chest drainage or water seal.
c. Monitor respiratory status
d. Provide emotional support to the patient.


d. PULMONARY HYPERTENSION
Pulmonary hypertension is a condition that is not clinically evident until late in the disease. The systolic pulmonary arterial pressure exceeds 30 mmHg, and the mean pulmonary artery pressure is higher than 25 mmHg.


CLINICAL MANIFESTATIONS
a. Dyspnea, the main symptom, is noticed first with exacerbation and then at rest.
b. Substernal chest pain is common 25% to 50% of patients.
c. Weakness, fatigability, syncope, and occasional hemoptysis may occur
d. Signs of right sided heart failure are noted (peripheral edema, ascites, distended neck veins, liver engorgement, crackles and heart murmur).
e. ECG changes (right ventricular hypertrophy) are seen, with right axis deviation and tall peaked P waves in inferior leads and tall anterior R waves and ST segment depression or T wave inversion anteriorly.
f. PaO2 is decreased (hypoxemia).


NURSING MANAGEMENT
a. Administer prescribed oxygen therapy appropriately.
b. Be alert for signs and symptoms of the disease.
c. Prepare the emergency life saving device at bedside of the patient.
d. Administer medication as prescribed.
e. Monitor fluid intake and output carefully.
f. Promote rest for oxygen conservation.
g. Tailored sitting exercise to avoid dyspnea.






V. DISCHARGE PLANNING

1. Recommend the patient adopt a lifestyle of moderate activity, ideally in a climate with minimal shifts in temperature and humidity.
2. Demonstrate and supervise patient and family in performing all aspects of treatment regimen (chest physiotherapy and postural drainage), with return demonstration from patient before discharge.
3. Encourage patient to avoid emotional disturbances and stressful situations.
4. Recommend strategies for smoking cessation and review progress with patient.
5. Reinforce breathing exercises and restraining and exercise programs and teach patient methods to alleviate symptoms. Instruct patient in activity pacing (avoiding activities requiring arm lifting and movement until after patient has been up or moving around for an hour or more.
6. Encourage patient to begin gradually to bathe, dress, and take short walks, resting as needed to avoid fatigue and excessive dyspnea and to keep fluids readily available.
7. Educate patient about normal anatomy and physiology of the lung, pathophysiology and changes with COPD, medications and home oxygen therapy, nutrition, respiratory therapy treatments, symptom alleviation, smoking, cessation, sexuality, coping with chronic disease, communicating with the health care team and planning for the future.
8. Teach proper use of inhalers, bronchodilators.
9. Instruct patient and family about signs and symptoms of infection or other complications and to report changes in physical or cognitive status.
10. Inform patient that smoking with or near the oxygen is extremely dangerous.


VI. EVALUATION

CLIENT CENTERED
After the 32 hours of duty at the Gapan District Hospital General Ward, the patient:
• Verbalized feelings and concerns about her condition,
• Participated in the activities needed in the conduction of this case, and
• Coped with her situation and lived like in a normal condition.

NURSE CENTERED
After the 32 hours of duty at the Gapan District Hospital General Ward, the students:
• Gained the trust of the patient to make her cooperative with the activities being conducted,
• Acquired/learned more knowledge about the disease process, its manifestation, medical management and the nursing responsibilities needed in dealing with the patient, and
• Imparted knowledge to the patient that she will use in her daily living.