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NURSING HEALTH HISTORY

DEMOGRAPHIC DATA OF THE PATIENT


Name : Gian Chand
Age/Sex : 70 years
C.R. No. : 46180
Ward/Bed No. : ICU/9
Father’s Name : Nachattar Singh
Occupation : Nil
Education : Illiterate
Religion : Sikh
Marital status : Unmarried
Address : Mukatsar, Punjab
Date of admission: Jan.9, 2010

DIAGNOSIS: COPD (Chronic Obstructive Pulmonary Disease)

CHIEF COMPLAINTS
Patient came through emergency with chief complaints of:
Sudden breathlessness
Cough, Sputum production, Restlessness since a week

HISTORY OF PRESENT ILLNESS


Patient came through the emergency after being referred by an RMP (Registered Medical
Practitioner). He developed sudden breathlessness and restlessness in the night. Patient
was already having cough with thick sputum production since a week.
History of nausea present and hence appetite had also been reduced.

PAST HISTORY
MEDICAL HISTORY
Past history of COPD present.
Patient has been admitted to AHRC, Muktsar with history of Respiratory distress and
nausea on June28, 2009; i.e. about six months back.
No past history of Tuberculosis, Bronchial asthma, Hypertension, Diabetes mellitus and
Jaundice, Typhoid fever.
SURGICAL HISTORY
No past surgical history.
PSYCHIATRIC HISTORY
No past history of any psychiatric illness.

HISTORY OF ALLERGY
Patient is not allergic to any medicine or diet.

PERSONAL HISTORY
Patient is vegetarian, non-smoker and non-alcoholic.

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FAMILY HISTORY
(a) Patient is unmarried.
(b) Patient lives in a joint family.
The socio-economic status of the family is moderate.

Father
Mother

PATIENT Brother

Family tree

(d) There is no family history of hemophilia, tuberculosis, diabetes mellitus,


hypertension, bronchial asthma.

GENERAL PHYSICAL EXAMINATION

GENERAL APPEARANCE
Nourishment- nourished
Body build- average, neither thin nor obese

MENTAL STATUS
Consciousness- Patient is conscious and well oriented to time place and person.
Look- relaxed. He is neither anxious nor worried.

POSTURE
Body curves- Absence of lordosis, kyphosis and scoliosis.
Movement- Movement of all extremities is well.

HEIGHT: 5’4” WEIGHT: 60 Kg

SKIN CONDITIONS
Color: Absence of Pallor, No jaundice and cyanosis
Texture: Normal
Temperature: Skin is warm to touch
Lesions: Absence of macules, papules and vesicles

HEAD AND FACE


Scalp: clean, black hairs, no dandruff, pediculi or any other infection
Face: Pale, absence of puffiness, there is no enlargement of parotid glands

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EYES
Patient’s eyes are normal.
No discharge from either eye, absence of infection, sty, redness and squint

EARS
External ear: no discharge
Tympanic membrane: not perforated
Hearing: Hearing acuity normal

NOSE
External nares: No crust or discharge
Nostrils: No septal deviation or inflammation

MOUTH AND PHARYNX


Lips: Normal, absence of redness, crusts, cyanosis and angular stomatitis
Odor of the mouth: No foul smell from mouth
Teeth: Absence of dental caries
Mucus membrane & gums: Absence of ulceration & bleeding, swelling & pus formation
Tongue: No lesions or redness
Throat and pharynx: Normal, no enlargement of tonsils

NECK
Lymph nodes, thyroid gland: Not enlarged
Range of motion: Can flex, extend and rotate

CHEST
Thorax: Shape and symmetry normal. On admission patient showed the use of accessory
muscles.
Heart: No enlargement in size, absence of any cardiac murmurs

ABDOMEN
Observation: absence of skin rashes, hernia, distension
Auscultation: Bowel sounds heard
Palpation: Normal, absence of abdominal distention and localized mass
Percussion: Absence of fluid or masses.

EXTREMITIES
Range of motion of all joints is well, absence of varicose veins and pedal edema, no
congenital abnormality

GENITALS AND RECTUM


Inguinal lymph glands and prostate gland are not enlarged, absence of hemorrhoids and
any other pelvic masses

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SYSTEMIC EXAMINATION

CENTRAL NERVOUS SYSTEM


No H/o seizures, parasthesias
No history of any head injury.
No history of mental illness.
Remote and recent memory intact.

CARDIOVASCULAR SYSTEM
No history of any cardiovascular disease
No history of arrhythmias or murmurs.
Heart not enlarged.

GASTROINTESTINAL SYSTEM
Nausea was present since five days before admission. Now no such complaints.
There is absence of abdominal distention.

RESPIRATORY SYSTEM
Rate of respiration: 22/min.
Trachea is centrally placed. Shape and symmetry of thorax is normal.
Presence of breathlessness, restlessness

MUSCULOSKELETAL SYSTEM
No musculoskeletal deformity is observed. No history of fracture, kyphosis or scoliosis.
Range of motion of upper and lower extremities is well.
Absence of pedal edema.
Varicose veins absent.

INTEGUMENTARY SYSTEM
Skin turgor is good. No history of scabies or any other skin disease.

VITALS
DATE TEMPERATURE PULSE RESPIRATION BLOOD PRESSURE
(in Fahrenheit) beats per min (beats per min) (mmHg)
09-01-10 98.8 96 26 120/70
10-01-10 98.6 88 24 110/80
11-01-10 98.2 80 22 120/80
12-01-10 98.4 78 22 120/80

LABORATORY INVESTIGATIONS-HEMATOLOGY
Date Hb WBC Lymphocytes Monocytes Gramocytes
Normal Values 13-18 4-10 m/cu 15-40% 3-10% 30-70%
gm/dL mm
Jan.09, 2010 11.8 8.33 30.6 1.9 71.5
Jan.12, 2010 11.5 8.05 28.4 1.3 85.3
Jan.14, 2010 11.4 7.38 27.2 2.2 80.8

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BLOOD GASES AND SERUM ELECTROLYTES
DATE TESTS PATIENT’s VALUE NORMAL VALUE
Jan.09, 2010 Pco2 42.1 mmHg < 50 mmHg
So2 98.9% > 100 mm Hg
Jan.10, 2010 Cl 86.4 Mmol/lt 92-110 Mmol/lt

DATE TESTS PATIENT’s NORMAL VALUE


VALUE
Jan.09, 2010 B. Sugar (Random) 72 mg/dl Up to 150 mg/dl
B. Urea 14mg/dl 5-25mg/dl
S. Creatinine 0.8mg/dl 0.4-1.6 Mg/dl
Serum Uric acid 4.7mg/dl 3.5-6 Mg/dl
Jan.10, 2010 HIV Negative Negative
HbSAg Negative Negative
HCV Negative Negative
Jan.13, 2010 B. Urea 10.8 mg/dl 5-25mg/dl
S. Creatinine 0.7 mg/dl 0.4-1.6 mg/dl

Jan.11, 2010……
ECG REPORT
Shows Tachycardia
Narrow QRS Complex
Variable PR interval

CHEST X-RAY
Shows consolidation in both of the lungs.

TREATMENT

DRUGS SALT TIME ROUTE DOSE ACTION


Inj. Monocef Ceftriaxone OD IV 2gm Broad spectrum
Sodium antibiotic

Inj. Etophylline BD IM 2ml Antiasthmatic


Deriphylline Theophylline

Inj. Hydrocortison TDS IV 200mg Corticosteroid


Hydrocortisone e Succinate
Antiulcer and
Inj. Omej Omeprazole BD IV 4O mg antisecretory

Inf.
Levofloxacin Levofloxacin OD IV 100ml Antibiotic

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COMPARATIVE STUDY

IN BOOK IN PATIENT
DEFINITION
According to Global initiative for Chronic Obstructive Lung Disease, Airflow
“COPD is a disease state characterized by airflow limitation that is not limitation
fully reversible.” present.

INCIDENCE
(a) Race Absent
COPD is more common in whites than blacks.
(b) Gender Present
COPD affects men more frequently than women. (Men)
(c) Age group Present
COPD affects middle aged and older adults. It affects 1 out of 14 (70years)
people over the age of 45years.
(d) Place of residence Absent
It is more frequent in clients living in urban environments.
(e) Socioeconomic status
COPD is found more frequent among the low socioeconomic group Absent

CAUSES/RISK FACTORS
(a) Exposure to tobacco smoke
It accounts for 80-90% of COPD cases. Absent
(b) Passive smoking
Occupational exposure to dust and chemicals. Absent
(c) Air pollution Absent
(d) Heredity Absent
Genetic abnormality including a deficiency of alpha1 antitrypsin, an
enzyme inhibitor that normally counteracts the destruction of lung
tissue by certain other enzymes.
(e) Respiratory infections/microbes Present
(f) Low socioeconomic status Absent
COPD is found more frequent among the low socioeconomic group
(g) Age Present
COPD affects middle aged and older adults
(h) Place of residence Absent
It is more frequent in clients living in urban environments.

PATHOPHYSIOLOGY
In COPD, the airflow limitation is both progressive and associated with
an abnormal inflammatory response of the lungs to noxious particles
and gases. COPD includes two disease conditions:
a) Chronic Bronchitis
b) Emphysema

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CHRONIC BRONCHITIS
Definition
Bronchitis is the inflammation of the bronchioles.
Chronic Bronchitis is a disease of the airways and is characterized by
the presence of cough and sputum production for at least three months
in each of the two consecutive years.

EMPHYSEMA
Definition
It is a disorder in which the alveolar walls are destroyed which leads to
permanent over distention of air spaces.

TYPES
(a) Pan lobular /Panacinar emphysema
The bronchioles, alveolar ducts and alveoli are destroyed and air spaces
within the lobule are enlarged.
(b) Centrilobular/ centroacinar emphysema
The pathologic changes are seen in the center of the secondary lobule
while the peripheral positions of the acinus are preserved.

CLINICAL MANIFESTATIONS
COPD is characterized by three primary symptoms: Present
a) Cough
b) Sputum
c) Dyspnea

EARLY STAGE
 Daily morning cough Present
 Mild shortness of breath Present
 Occasional coughing Present
 Severe cough from respiratory infection Present
 Wheezing: usually only after a respiratory infection

FURTHER STAGE
Present
 Chronic cough
Present
 Sputum: Clear, colorless Present
 Shortness of breath on exertion

LATER STAGES
INSPECTION Absent
 Nicotine stains Present
 Cough Present
 Sputum production: Mucopurulent, sometimes blood may also Present
be present Present
 Dyspnea: both on exertion and rest Absent

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 Cyanosis Absent
 Clubbing of digits Present
 Fatigue and weakness Absent
 Pursed lip breathing Absent
 Barrel chest Absent
 Use of accessory muscles of respiration
 Distended neck veins Absent
PALPATION Absent
 Pulsus Paradoxus
 Pitting peripheral edema
PERCUSSION
 Hyper resonance on percussion Present
ADVENTITIOUS BREATH SOUNDS
 Adventitious breath sounds: Rhonchi, Wheezing Present
OTHERS
 Weight loss
 Bullae
 Chest X- ray: flat diaphragm
 Heart: Enlarged, ECG shows right heart strain pattern
 Liver: Enlarged and pulsating

DIAGNOSTIC EVALUATIONS

1) THOROUGH HEALTH HISTORY


Key factors to assess in COPD patients health history are as follows:
 Exposure to risk factors- types intensity and duration.
 Past medical history – respiratory diseases/problems including Patient
asthma, allergy, sinusitis, nasal polyps, history of respiratory admitted 6
infections. months before
 Family history of COPD or other chronic obstructive diseases. also for COPD,
 Pattern of symptom development. No family
 History of exacerbations or previous hospitalizations for history
respiratory problems.
 Presence of co morbidities.
 Appropriateness of current medical treatment.
 Impact of the disease on quality of life.
 Available social and family support for patient.
 Potential for reducing risk factors. (E.g. smoking cessation)

2. PULMONARY FUNCTION TESTS (PFTs) / SPIROMETRY Not done


PFTs are performed to assess respiratory function, establish the
diagnosis and to evaluate extend and progress of COPD. Such tests
include measurements of lung volumes, ventilatory function and the
mechanics of breathing, diffusion and gas exchange.

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In COPD,
 The total lung capacity (TLC) and residual volume (RV) are
increased.
 The forced expiratory volume (FEV1) and forced vital capacity
(FVC) are decreased due to narrowed airways and resistance to
airflow. Chronic Lung Disease is a disease defined as a
FEV1/FVC ratio of less than 70%.

Normal values
Total lung capacity (TLC) = TV + IRV + ERV + RV
= 500ml + 3000ml + 1100ml + 1200ml
= 5800ml
Residual volume (RV) = 1200ml

3. ARTERIAL BLOOD GAS STUDIES PaCO2 and


ABG Measurements are obtained to assess the baseline oxygenation PaO2
and gas exchange. The arterial oxygen tension indicates the degree of monitored.
oxygenation of blood and the arterial CO2 tension (PaO2) indicates the
degree of oxygenation of the blood and the arterial carbon dioxide
tension. (PaCO2) indicates the adequacy of alveolar ventilation.
 Predominant chronic bronchitis and airway obstruction may
cause marked hypoxemia and hypercapnia with respiratory
acidosis. Oxygen saturation levels are low due to marked
hypoxemia.
 Clients with predominant emphysema often have mild
hypoxemia and normal or low carbon dioxide tension.
Respiratory alkalosis may be present due to an increased
respiratory rate.

Normal values
PARAMETER ARTERIAL VENOUS SAMPLE
SAMPLE
pH 7.35-7.45 7.35-7.41
PaCO2 35-45mmHg 35-40mmHg
Oxygen saturation 93-98% 65-75%
HCO3- 22-26mEq/L 24-28mEq/L
Done
4. PULSE OXIMETRY
It is a non-invasive method of continuously monitoring the oxygen
saturation of hemoglobin.
A probe or sensor is attached to the fingertip, forehead, earlobe or
bridge of the nose. The sensor detects changes in oxygen saturation
levels by monitoring high signals generated by the oximeter and
reflected by blood pulsing through the tissue at the probe. Normal
SpO2 values are 98% to 100%. Values less than 85% indicate that the
tissues are not receiving enough oxygen.

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Pulse oximetry may be continuously monitored to assess the need for
supplemental oxygen.

5. COMPLETE BLOOD EXAMINATION (CBC) WITH WHITE


BLOOD CELL (WBC) DIFFERENTIAL Done
It shows increased RBCs and hematocrit (erythrocytosis) as chronic
hypoxia stimulates increased erythropoiesis to improve the oxygen
carrying capacity of the blood.
Polycythemia, increased number of all blood cells, may be evident.
Increased WBC count and a higher percentage of immature WBCs are
often indicative of bacterial infection.
Normal values
Hematocrit: Males: 42-52%
Females: 35-47%
TLC: 4500-11000/mm3
DLC: Neutrophils: 45-73%
Eosinophils: 0-4%
Basophils: 0-1%
Lymphocytes: 20-40%,
Monocytes: 2-8%

6. VENTILATION PERFUSION SCANNING


It may be performed to determine the extent of ventilation- perfusion Not done
mismatch, i.e. the extent to which lung tissue is ventilated but not
perfused (dead space) or perfused but inadequately ventilated
(physiologic shunting). Ventilation is the flow of gas in and out of the
lungs and perfusion is the filling of the pulmonary capillaries with
blood.
A radioisotope is injected or inhaled to illustrate areas of shunting and
absent capillaries.

7. SERUM ALPHA-1 ANTITRYPSIN (α1AT) LEVELS


It may be drawn to screen for deficiency, particularly in clients with Not done
family history of obstructive airway disease, those with an early onset
(< 45 years), women and non smokers.
Normal adult serum alpha-1 antitrypsin levels range from 1.5-3.5gm/l.
Fasting is not required prior to this test.

8. CHEST X-RAY Done


Normal pulmonary tissue is radiolucent. Therefore, densities produced Shows
by fluids, tumors, foreign bodies and other pathologic conditions can be consolidation
detected by X-ray examination. in both of the
The routine X-ray consists of two views- the posterioanterior projection lungs.
and the lateral projection. In COPD, chest X-ray shows flattening of the
diaphragm due to hyperinflation and evidence of pulmonary infection,
if any.

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9. SPUTUM STUDIES Not done
Sputum is obtained to
 Identify pathogenic organisms and to determine whether
malignant cells are present.
 Assess for hypersensitivity states (in which there is an increase
in eosinophills).

STAGES OF COPD

STAGE CHARACTERISTICS
0 Normal spirometry
Chronic symptoms of cough,
sputum production
I FEV1/FVC< 70%
(Mild FEV > 80% predicted
COPD) May or may not have chronic symptoms of
cough, sputum production
II FEV1/FVC< 70%
(Moderat FEV between 30% and 80% predicted
e COPD) May or may not have chronic symptoms of
cough, sputum production
III FEV1/FVC < 70%
(Severe FEV1 < 30% predicted or FEV< 50% predicted plus
COPD) respiratory failure or clinical signs of right heart failure.
MANAGEMENT

I. MEDICAL MANAGEMENT

1. REMOVE THE UNDERLYING CAUSE


 i.e. smoking cessation Patient is a non
smoker
2. PHARMACOLOGIC THERAPY
(a) Bronchodilators Given
Bronchodilators relieve bronchospasm and airway obstruction by
allowing increased oxygen distribution throughout the lungs and
improving alveolar ventilation. They may also be used prophylactically
to prevent breathlessness.
Classes of bronchodilators:
Beta- Adrenergic Agonist Agents
 salbutamol
 terbutaline
Anticholinergic Agents
 Ipratropium bromide
 Oxittropium bromide
Methylxanthines

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 aminophylline
 theophylline

(b) Corticosteroids Given


These have anti-inflammatory action. corticosteroids do not slow the
decline in the lung function but may only improve symptoms.
e.g. beclometasone

(c) Other medications


 Yearly influenza vaccine Not given
Pneumococcal vaccine every 5-7 years
 Alpha 1 antitrypsin augmentation therapy (Prolastin) Not given
 Antibiotic agents Given
E.g. Gentamycin, Amikacin, Ceftriaxone Sodium, Cifixime
Not given
 Mucolytic agents
These drugs cause liquefaction of mucopurulent sputum. These
drugs induce copious secretions. E.g. Bromhexine, Acetyl cysteine
 Antitussive agents Not given
these drugs are used for suppression of cough. Antitussives are
used mainly for
unproductive dry cough.
e.g. syrup Corex (Dextromethorphan, Chlorpheniramine
maleate)
Syrup C-KOF (Codeine phosphate, Chlorpheniramine maleate)

3. OXYGEN THERAPY Given


Oxygen therapy is administered to prevent acute dyspnea. Long term
oxygen therapy is used for severe and progressive hypoxemia. Oxygen
therapy improves oxygen tolerance, mental functioning and quality of
life in advanced COPD. closed monitoring of ABG’s during oxygen
therapy is vital.

II. SURGICAL MANAGEMENT Not done

1. BULLECTOMY
A bullectomy is a surgical option for selected patients with bullous
emphysema. bullae are enlarged airspaces that do not contribute to
ventilation but occupy space in the thorax, these areas may be
surgically incised.
many times these bullae compress areas of the lung that do not have
adequate gas exchange. Bullectomy may help reduce dyspnea and
improve lung function it can be done thoracoscopically or via a limited
thoracotomy incision.

2. LUNG VOLUME REDUCTION SURGERY

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This is a treatment option for end-stage COPD (stageIII) patients. it
involves the removal of portion of the diseased lung parenchyma. this s
allows the functional tissue to expand, resulting in improved elastic
recoil of the lung and improved chest wall and diaphragmatic
mechanics. this type of surgery does not cure the disease but it may
decrease dyspnea, improve lung function and improve the patients
overall quality of life.

3. LUNG TRANSPLANTATION
It is a viable alternative for definitive surgical treatment of end stage
emphysema. It has been shown to improve quality of life and functional
capacity. however, organs are in short supply and many patients die
while waiting for a transplant.

COMPLICATIONS

1. RESPIRATORY INSUFFICIENCY & RESPIRATORY FAILURE


2. PNEUMONIA
3. ATELECTASIS
4. PNEUMOTHORAX
5. COR PULMONALE

PROGNOSIS
- COPD is a major cause of death and illness throughout the world. in
fact, it is the Fourth leading cause of death worldwide. COPD is a
disease that slowly worsens over time, especially if the person
continues to smoke. a person with COPD has lung infections, which
can be fatal. if the lungs are severely damaged, the heart may be
affected as well.
- A person with COPD eventually dies when the lungs and heart are
unable to function and get oxygen to the body’s organs and tissues or
when a complication, such as severe infection occurs.

NURSING MANAGEMENT

SHORT TERM GOAL


 To relieve fever.
 To relieve breathlessness.
 To improve the nutritional status of the patient.
 To improve activity intolerance.

LONG TERM GOALS


 To prevent further complications.

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 To make the patient aware about the disease process.

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