Case study on copd

case for nursing student with the nursing process

1. HIMALAYAN COLLEGE OF NURSING
SWAMI RAMA HIMALAYAN UNIVERSITY



CASE PRESENTATION
ON
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
(COPD)









SUBMITTED TO: SUBMITTED ON: SUBMITTED BY:
Dr. Achla Dagdu Gaikwad 19/01/2021 Dashmeet kaur
Associate professor MSc Nursing 1
st
year
Himalayan college of Nursing Himalayan college of Nursing
SRHU SRHU

2. IDENTIFICATION DATA OF PATIENT

Name of the patient: Mr. Sher Singh
Age: 68 yrs
Gender: Male
Religion: Sikhism
In Patient No.: 3069967
Name of the ward: Male Medicine Isolation Ward
Date of Admission: 19/01/2021
Address: Vill.-Miyawala ; Dehradun Uttarakhand
Marital Status: married
Educational Status: 10
th
pass
Occupation: farmer
Monthly Income of family : 60,000/-
Consultant Doctor: Dr. Reshma kaushik
Clinical Diagnosis: chronic obstructive pulmonary disease (COPD)

CHIEF COMPLAINTS:
The patient came to the hospital with the chief complaint of:

1. weakness since 3-4 days
2. loss of appetite since 3-5 days
3. cough with sputum since 3-4 days

HISTORY OF PRESENT ILLNESS:

Patient sher singh came to Himalayan hospital jollygrant with chief complaints of generalized edema since 3
day, weakness since 3-4 days, loss of appetite since 3-5 days ,cough with sputum since 3-4 days . after certain
investigation patient was diagnosed with COPD . where patient was admitted in male medicine ward in
isolation room and was started on ATT medications.

HISTORY OF PAST ILLNESS
 Immunization History: patient is immunized only with BCG.
 Surgeries :no significant history of any surgery
 Allergies: no history of any allergy from food, medications, etc.
● Medical History : patient has no significant h/o of diabetic mellitus, hyperthyroidism etc.
● Surgical history : patient has no significant surgical history of hysterectomy, cholesystectomy etc.

3. FAMILY TREE






Sher singh harjeet kaur
Patient wife
68yrs/M 62 yrs/F





Manpreet kaur Inderjeet singh harmeet singh harpeet kaur
Daughter in law son son Daughter in law
30 yrs/F 35 yrs /M 33yrs/M 29yrs /F








Name of family
member
Relationship with
patient
Age/
Gender
Marital Status Educational
status
Occupation Health
Status
Sher singh Patient 68yr/M Married 10
th
pass Farmer Sick
Harjeet kaur Wife 62 yr/F Married 10
th
pass Housewife Good
Inderjeet singh Son 35yr/M Married Btech

Private job in
company
Good
Manpreet kaur Daughter in law 30 yr/F Married Bsc Housewife Good
Harmeet singh son 33ys/ M Married Msc in sociology
pass
Professor Good
Harpreet kaur Daughter in law 29yrs/F Married B.E.D Teacher Good

4. PERSONAL HISTORY
● Dietary Habits: Non- Vegetarian& vegetarian both
● Bowel and bladder habit: normal urinary pattern 7-8 times a day and normal bowel pattern 2 times a day
● Physically activites and excercises : go for a walk
● Addiction: no addiction
● Sleeping and rest pattern: 8 hours sleep
● Hobbies: Reading newspaper
● Relationship with family,friends ,significant others: good interpersonal relationship
with family, friends and society
 values and spirituality: prays to god everyday

ENVIRONMENTAL HISTORY
● Housing: Well- structured bricked house with adequate lightning and ventilation.
● Environmental hygiene: adequate
● Water Supply: Adequate supply of water daily. Stored in water tanks.
● Disposal of excreta: through drainage system
● Sanitation: Maintained. Pursue regular cleaning of household and surroundings.

PHYSICAL EXAMINATION

General Appearance:

 Level of consciousness:conscious
 Orientation: oriented to time , place and person
 Pallor/cyanosis/edema/jaundice /clubbing: absent
 Mood: good
 Body built: moderate

Anthropometric measurement

 Weight –72kg
 Height -163cm
 BMI(weight in kg/height in meter)-27 (BMI) normal

Vital signs










Date Temperature Pulse (Beat/
min.)
Respiration
Breath/min.
Blood Pressure
(Mm of hg)
Spo2
19/12/21 98.6
0
F 123 24 126/87 86%
20/12/21 98
0
F 116 20 117/70 100%
21/12/21 99
0
F 124 41 148/110 90%

5. Pain Rating Scale




No pain Mild pain Moderate pain Severe pain


Pain level of patient is – 0/10 moderate pain


HEAD TO TOE EXAMINATION

Head
● Scalp- scalp are clear, no dandruff seen
● Hair distribution- equally distributed and black in colour
● Any Abnormality- No

Eyes:
● Eyebrows -equally distributed in both eyes
● Eyelashes:normal: absence of infection , sty
● Eyelids:- symmetrical ;absence of edema, lesions,ectr-pion,entr-pion
● Eyeballs: normal: absence of sunken and protruded
● Conjunctiva: pink in colour
● Sclera:-white in colour
● Cornea and iris: normal; absence of irregularities and abrasions
● Pupil:- 3mm reacted toward light
● Lens: opaque
● Visual acuity:- normal

Ears:
● Auricles:- normal
● Ear Drum:- normal
● Hearing aid :- hearing of both ear is appropriate towards sound

Nose:
● Discharge:- No discharge present
● Nasal septum:- Not deviated nasal septum
● Nasal polyps- absent
● Any Abnormality- No


Mouth and pharynx:
0 1 2 3 4 5 6 7 8 9 10
No
pain
Worst
possible
pain

6. ● Lips:-brown in color, in uniformity
● Gums:- healthy
● Teeth:- white in color
● Tongue:- coated, no sign of dehydration, moisturize tongue
● Any Abnormality- no

Neck:
● Inspection- presence of jugular vein pulse
● Palpation- presence of elasticity of carotid artery pulse

Breast/,Chest
● Inspection:-Symmetrical in both side
● Nipple:- Both nipple is symmetrical
● Palpation:- No abnormal mass palpate in chest
● Auscultation- wheezing sound is present
● Any Abnormality- No
Abdomen:-
● Inspection:- Symmetrical
● Palpation:- No any splenomegaly and hepatomegaly
● Percussion: no any fluid present
● Auscultation:- hypoactive bowel sound present( 8)

Back
● Colour- Brown in colour
● Shape- normal curvature ,no kyphosis present
● Lesion- on any lesion seen

Extremtities
Range of motion- normal
Symmtery- symmetrical
Any abnormality- no other sign of abnormality seen

SYSTEMIC EXAMINATION

Respiratory System:-
● Inspection- symmetrical in shape and size
● Respiratory rate- 41 breath/min.
● Auscultation- wheezing sound present
● Percussion- improper chest expansion

7. Cardiovascular System
● Inspection:-normal
● Blood pressure- 128/90 mmhg
● Auscultation:S1 and S2 sound present
● Heart rate:- 24 b/m

Musculoskeletal System
● Inspection: symmetrical
● Palpation:- no swelling
● Range of motion: good range of motion
● Muscle tone and strength:- normal not good slightly weak

Neurological System
● Level of consciousness:-conscious
● Glasgow coma scale (GCS)-E4V5M6
● Behavior:- good behavior toward family member.

BLOOD INVESTIGATIONS
Date Investigation Patient's
Value
Normal Value Remarks
16/01/2021 Creatinine 1.46 0.67- 1.17 mg/dL increased
LIVER FUNCTION TEST
Bilirubin(total)
Alanine amino
transferase
(ALT/SGPT)
Aspartate amino
transferase
(ALT/SOPT)
Alkaline
phosphatase(ALP)
Total protein
Albumin
Globulin
Potassium(K+)
Sodium(Na+)
COMPLETE
HEMOGRAM
Hemoglobin
TLC
PCV (packed cell
volume)


1.96
21


25


122

6.09
1.2
2.4
4.11
149.6


14.7
16
44.14


0.3-1.2mg/dl
<50IU/L


<50IU/L


30-120IU/L

6-8g/dl
3.5-5.2g/dl
2-3.5g/dl
3.5-5mmol/l
136-146mmol/l


12-16 g/dl
4-11thou/cumm
36- 48%



Elevated
Normal



Normal


Elevated
decreased
Normal
Normal
Elevated
Normal


Normal
Elevated
Normal

8. RADIOLOGICAL INVESTIGATIONS








ABG ANAYLSIS

Parameters

Patient value Normal value Remarks
pH
pCO2
pO2

HCO3
So2



7.40
36
25

22.1
45
7.35-7.45
35-45mmhg
80-100mmhg

22-26mmol/l
95%-100%
Normal
Normal
Low

Normal
decreased

IMMUNOLOGY AND
MOLECULAR BIOLOGY

CRP(Quantitaive )

ESR(blood)



2.04

36










0-1mg/dl

0-20 mmin 1
st
hr



Elevated

Elevated







Measurements Patient picture
Chest X-ray Consolidation was seen
2D echo Grade I dystolic dysfunction
Mild tricuspid regurgitation

9. ANATOMY AND PHYSIOLOGY OF LUNGS


The lungs consist of right and left sides. The right lung has three lobes: Upper lobe,Middle lobe, Lower lobe The
left lung has two lobes: Upper lobe, Lower lobe.The heart sits in the mid chest extending into the left side The lungs,
which is the organ forrespiration is a paired cone shaped organs lying in the thoracic cavity separated
from each other by the heart and other structures in the mediastinum.Each lung has a base resting on
the diaphragm and an apex extending superiorlyto a point approximately 2.5 cm superior to the clavicle.
It also has a medial surfaceand with three borders- anterior, posterior and inferior. The broad coastal
surfaceof the lungs is pressed against the rib cage, while the smaller mediastinal surface faces medially.
The lungs receives the bronchus, blood vessels, lymphatic vessels and nerves through a slit in the
mediastinal surface called the helium, and the structures entering the helium constitutes the lungs root.
 The right lung is larger and weighs more than the left lung. Since the heart
 tilts to the left, the left lung is
smaller than the right and has an
indentation called the
 cardiac impression to
accommodate the heart. This
indentation shapes the inferior
 and anterior parts of the
superior lobe into a thin tongue-
like process called the lingual.


Starting from the trachea
(windpipe), two large tubes known
as bronchi (airways) separate
and distribute air to the left and
right sides of the lungs.




Pleura
Each lung is invested by and enclosed in a serous pleural sac that consists of two continuous
membranes.
 The visceral or pulmonary pleura invest the lungs,
 The parietal pleura line the pulmonary cavities and adhere to the thoracic wall, mediastinum and
diaphragm.
 The parietal pleura consist of four parts: coastal pleura which lines the internal surface of the
thoracic wall, mediastinal pleura which lines the lateral aspect of the mediastinum, diaphragmatic

10. pleura which lines the superior surface of the diaphragm
on each side of the mediastinum, cervical pleura
extends through the superior thoracic aperture into the
root of the neck, forming a cup-shaped dome over the
apex of the lung.
Pleural Cavity
The pleural cavity is the potential space between the
visceral and parietal layers of the pleural and it contains a
capillary layer of serous pleural fluid which lubricates the
pleural surfaces and allows the layers
to slide smoothly over each other during respiration.
Surface tension created by the pleural cavity
provides the cohesion that keeps the lung surface in
contact with the thoracic wall.



Lobes and Fissures of the Lungs


Each lung is divided into lobes by fissures.
 Both lungs have oblique fissure and the right is further
divided by a transverse fissure. The oblique fissure
 in the left lung separates the superior and the inferior
lobe. The oblique and horizontal fissure divides the
lungs into superior, middle and inferior lobes. Thus the
right lung has three lobes while the left has two.
 Each lobe is supplied by a lobar bronchus. The lobes are subdivided by bronchopulmonary segments
 which are supplied by the segmental bronchi.

Tracheobronchial Tree
All the respiratory passages from the trachea to the respiratory bronchioles are called the tracheobronchial
tree. The trachea divides at the sternal angle into right and left primary bronchus which goes into the
right and left lungs. Each bronchus enters the lung at a notch called the hilum. Blood vessels and nerves also
connect with the lungs here and together with the bronchus forms a region called the root of the
lungs.
The right main bronchus is larger in diameter and more vertical making it directly in line with the trachea
than the left main bronchus. Thus swallowed objects that accidentally enter the lower
respiratory tract are most likely to become lodged in the right main bronchus.

The main bronchi divide into lobar or secondary bronchi within each lung. Two lobar bronchi exist in the

11. left lung, and three exist in the right lung. The lobar bronchi, in turn give rise to segmental or tertiary
bronchi. The tertiary bronchi supply the bronchopulmonary segments.

Bronchopulomonary Segment
Functionally, the lung is divided into a series of bronchopulmonary segments. The bronchopulmonary
segments are the largest subdivision of a lobe. They are separated from adjacent segments by connective
tissue septa and are also surgically resectable. They are 10 bronchopulmonary segments in the left lung
and 8-10 in the left lung
.

The bronchi further divides, finally giving rise to the bronchioles which are less than 1mm in diameter.
Each bronchioles divides into 50 to 80 terminal bronchioles, the final branches of respiratory bronchioles.
The functional unit of the lungs which is the acinus includes the respiratory bronchioles, alveolar ducts,
and sacs and the alveolar
.
Approximately 16 generations of branching occur from the trachea to the
terminal bronchioles
.
As the air passageways of the lungs become smaller, the structure of their
walls changes.

Blood supply
The bronchial arteries arising from the aorta provide blood supply to the non-respiratory airways, pleura,
and connective tissue while the pulmonary arteries supply the respiratory units (acini) and participate
in gas exchange.
Venous drainage is mainly by the pulmonary veins (right and left superior and inferior pulmonary veins),
though the venous of drainage from the walls of the larger bronchi is carried out by the bronchial
veins. All four veins (pulmonary veins) drain into the left atrium.


Nerves supply
The lungs and airways are innervated by the branches of sympathetic trunk and vagus nerve. Sympathetic
nervous stimulation results in bronchodilation and slight vasoconstriction, while parasympathetic nervous
system stimulation results in bronchoconstriction and indirect vasodilation. The function of the lungs is
controlled through the respiratory centre with groups of neurons located at the pons and the medulla
oblongata, and complex interactions of specialized peripheral central chemoreceptors.

12. DISEASE CONDITION
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

COPD is a disease of the lung. The lungs are the organs found in the chest which are invloved in breathing.
Air enters the nose and mouth, then travels to the lungs via the trachea, which divides into smaller airways
called bronchi and, subsequently, bronchioles. (See diagram below). The lung tissue itself is a spongy material,
consisting of a series of folded membranes (the alveoli) which are located at the ends of very fine branching air
passages (bronchioles). COPD is a disease of the smaller airways in the lungs.

13. TYPES OF COPD

1. Chronic bronchitis: Defined as chronic cough with mucous production on most days for greater than three
months, for at least two consecutive years.
2. Emphysema: Defined as an enlargement of the alveoli and bronchioles, and destruction of the alveolar walls.
These disease processes affect the bronchi and alveolar walls, respectively. The end result of both is the
destruction of lung tissue and obstruction of the airways of the lung, leading to impaired gas exchange. The
two conditions usually occur together, causing chronic airflow limitation.


ETIOLOGY

RISK FACTORS
Long term exposure to things that irritate your lungs.
Cigarette pipe, bidi ,tobacco
Passive smoking
Dust, air pollution
Chemical pollution
Age >40 yrs
Genetics
Tobacco
Gender/age
Respiratory infection
Chronic bronchitic
Lung growth and development

14. PATHOPHYSIOLOGY




Noxious particles and genes
(tobacco,smoke,air pollution)


Continual bronchial irritation&inflammation

Breakdown of elastin in connective tissue
of lung


Chronic bronchitis
 Bronchial edema
 Hypersecretion of mucous
 Chronic cough
 Bronchospasm


Emphysema
 Destruction of alveolar septa
 Airway instability

Airway obstruction
Air trapping
Dyspnea
Frequent infection
Abnormal ventilation- perfusion ratio
Hypoxemia
Hypoventilation
Cor-pulmonale

15. SIGN AND SYMPTOMS

Book picture Patient picture
Early symptoms
 occasional shortness of breath, especially after
exercise
 mild but recurrent cough
 needing to clear your throat often, especially first
thing in the morning
late symptoms
 wheezing, which is a type of higher-pitched noisy
breathing, especially during exhalations
 chest tightness
 chronic cough, with or without mucus
 need to clear mucus from your lungs every day
 frequent colds, flu, or other respiratory infections
 lack of energy
 fatigue
 swelling of the feet, ankles, or legs
 weight loss



● Shortness of breath
● Wheezing sound present
● Cough with mucous



DIAGNOSTIC EVALUATION

Book picture Patient picture
History collection
Physical examination
Lung function test
Chest X-ray
CT scan
ABG
Laboratory test
History collection
Physical examination
Complete hemogram
KFT,LFT,PT,INR
Chest X-ray
ABG

16. Medical Management


In book Patient Received
Management
Oxygen therapy
If your blood oxygen level is too low, you can
receive supplemental oxygen through a mask
or nasal cannula to help you breathe better. A
portable unit can make it easier to get around.

Medications
1.Bronchodilators
Short acting bronchodilators
Albuterol
Ipratropium
levalbuterol
long-acting bronchodilators
salmeterol

2.Inhaled steroids
Fluticasone
Budesonide
3. Phosphodiesterase-4-inhibitors
Roflumilast
4. Antibiotics
azithromycin

Oxygen therapy
Bronchodilators
Antibiotics

17. SURGICAL MANAGEMENT


Book picture Patient received
1.bullectomy.
During this procedure, surgeons remove large, abnormal
air spaces (bullae) from the lungs.
Another is lung volume reduction surgery, which removes
damaged upper lung tissue. Lung volume reduction surgery
can be effective at improving breathing, but few patients
undergo this major, somewhat risky procedure.

2.Lung transplantation
it is an option in some cases. Lung transplantation can
effectively cure COPD, but has its many risks.
There is a less invasive method of improving the efficiency
of airflow in people with severe emphysema called
endobronchial valves (EBV), which are one-way valves that
divert inspired air to healthy lungs and away from non-
functioning, damaged lungs.

Not plan for any surgical treatment



COMPLICATIONS

 Secondary polycythaemia: This is an increase in the number of red blood cells in the blood to try to
 compensate for reduced oxygen levels. The blood subsequently becomes ‘thicker’ with sluggish flow which
 can lead to clotting;
 Right heart failure;
 Pneumothorax: This is leakage of air from the lung into the surrounding pleural space due to rupture of
 a bulla (dilated air space). This can lead to collapse of the lung and may require insertion of a chest drain;
 Respiratory failure: This is often caused by acute infective exacerbations. Death can sometimes occur
 from a severe decline in respiratory function.

18. Prescribed medicine for client

S.No
.
Name of
Medication
Dose

Route Frequenc
y
Indications Actions Side- effects Nurses
Responsibility
1. Inj.
Ploymexin-B
7.5IU IV BD urinary
tract, mening
es, and
bloodstream
caused by
susceptible
strains of Ps.
aeruginosa.
Antibiotic Albuminuria,
cylin-
duria, azotem
iadrowsiness,
peripheral
paresthesias
(circumoral
and stocking
glove), apnea

Baseline renal
function should
be done prior to
therapy, with
frequent
monitoring of
renal function
and blood levels
of the drug
during parenter
al therapy.

2. Tab. Vitamin
B-complex
4mg OD SOS Celiac disease
HIV
Crohn’s
disease
Alcohol
dependence
Kidney
conditions
Ulcerative
colitis
Inflammatory
bowel
disease
Multivitamin

Skin rashes
Swollen
tongue
Weakness
Nausea
Abdominal
cramps
Diarrhea
Constipation
Numbness
Assess patient
for signs
of vitamin defi
ciency before
&periodically
during
therapy.Assess
nutritional
status through
24-hr diet
recall.
Determine
frequency of
consumption
of vitamin-rich
foods.

3. Inj.pantocid 40mg IV OD Gastroesopha
geal reflux
disease
Hepatic
impairement
Peptic ulcer

Antacid nausea,
vomiting,
headache,
dizziness,
flatulence,
diarrhea,
stomach
pain, and
thrombophle
Advice patient
to report to
their healthcare
provider if they
experience any
sign or
symptoms

19. bitis (pain,
redness, and
swelling of
the vein).
4. Salbutamol

Respule Inhaler TDS Chronic
bronchitis
Bronchial
asthma
COPD
Bronchodilator Feeling shaky
Faster
heartbeat
Headches
Muscle
cramps
Assess lung
sounds, PR
and BP before
drug
administration
and during
peak of
medication.
Observe fore
paradoxical
spasm and
withhold
medication
and notify
physician if
condition
occurs.
Administer PO
medications
with meals to
minimize
gastric
irritation
5. Tab. Folic
acid
5mg Oral BD Anemia
Stomach/
intestinal
problems ,
Kidney
dialysis
Iron
supplement
abdominal
cramps,
diarrhea,
rash, sleep
disorders,
irritability,
confusion,
nausea,
stomach
upset,
behavior
changes, skin
reactions,
seizures, gas,
excitability,
 Administer
orally if at all
possible. With
severe GI
malabsorption
or very severe
disease, give
IM, IV, or
subcutaneousl
y.
 Test using
Schilling test
and serum
vitamin B12
levels to rule
out pernicious
anemia.
Therapy may
mask signs of

20. pernicious
anemia while
the neurologic
deterioration
continues.

6. Inj.
hyrdrocortis
one
50
mg/IV
IV BD inflammatio
n, status
asthmaticus,
acute and
chronic
adrenal
insufficiency,
and as
physiologic
replacement
in pediatric
use.
Steroid  Acne
 Adrenal
suppression
 Bladder dysf
unction
 Cataract
 Cushing
syndrome
 Delayed
wound
healing
 Delirium
 Depression
 Diabetes
mellitus
 Enlarged
heart
 Fast heart
rate
 Fat
embolism

Monitor signs of
hypersensitivity
reactions or
anaphylaxis,
including
pulmonary
symptoms
(tightness in the
throat and
chest, wheezing,
cough, dyspnea)
or skin reactions
(rash, pruritus,
urticaria). Notify
physician
or nursing staff
immediately if
these reactions
occur. Assess
any muscle or
joint pain.
7. Inj.
clindamycin
600mg/
IV
IV TDS Bacterial
infections,
including
infections of
the lungs,
skin, blood,
bones,
joints,
female
reproductive
organs, and
internal
organs.
Antibiotic  hardness,
 pain, or a
soft, painful
bump in the
area where
clindamycin
was
injected.
 unpleasant
or metallic
taste in the
mouth.
 nausea.
 vomiting.
 joint pain.
 white
Do not give
IM injections of
more than 600
mg; inject deep
into large
muscle to avoid
serious
problems. Do
not use for
minor bacterial
or viral
infections.

21. patches in
the mouth.

8. Tab.doxollin 200mg Oral BD asthma and
chronic
obstructive
pulmonary
disorder
Antiasthmetic  Upset
stomach.
 Vomiting.
 Headache.
 Nausea.
 Restlessnes
s

Do not use
more than
prescribed dose.
Taking
more medication
will not improve
your symptoms;
rather they may
cause poisoning
or serious side-
effects.




DESCRIPTION OF NURSING THEORY IN BRIEF:

VIRGINIA HENDERSON’S THEORY OF NURSING

This theory was given by Virginia Henderson born in 30 november1897, in Kansas city, Missouri and died
on 17 march 1996. Henderson’s interest in nursing involved during world war 1 from her desire to care
for sick and wounded military personnel.

NURSING DEFINITION
“The unique function of the nurse is to assist the individual, sick or well, in the performance of those
activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if
he had the necessary strength, will or knowledge.”

HENDERSON’S THEORY AND NURSING PROCESS

Nursing Process Henderson’s fourteen components and definition of Nursing

Nursing Assessment
Assess needs of human being based on the 14 components of basic
nursing care:
 Breathe normally
 Eat and drink adequately
 Eliminate body wastes
 Move and maintain desirable postures
 Sleep &rest
 Select suitable clothes: dress and undress Maintaining body
temperature within normal range by adjusting clothing and modifying
environment.

22.  Keep the body clean and well groomed and protect the integument
 Avoid the dangers in environment and avoid injuring others.
 Communicate with others in expressing emotions, needs,
fears or opinions.
 Workship according to one’s faith.
 Play or participate in various forms of recreation.
 Learn, discover or satisfy the curiosity that leads to normal
development and health and use the available facilties.


Nursing Diagnosis
Analysis: compare data to knowledge base of health and disease
indentify individual’s ability to meet own needs with or without
assistance, taking into consideration strength , will , or knowledge.

Nursing Plan Document how the nurse can assist the individual ,sick or well

Nursing implementation
Assist the sick or well individual in the performance of activities in
meeting human needs to maintain health,recover from illness, or to aid
in peaceful death. Implementation based on physiological principles,
age ,cultural background , emotional balance, and physical and
intellectual capacities. Carry out the treatment prescribed by the
physician.

Nursing evaluation

Use the acceptable definition of nursing and appropriate laws related
to the practice of nursing. The quality of care is drastically affected by
the preparation and native ability of the nursing personnel rather than
the amount of hours of care. Successful outcomes of nursing care are
based on the speed with which or degree to which the patient
performs independently the activites of daily living.



ASSESSMENT ACCORDING TO NURSING THEORY CONCEPT

14 human needs Patient needs
Breathe normally

Patient is unable to breathe normally where SPO2 is 90%;
heart rate 124b /min ;pulse rate 41b/min. blood pressure is
148/110 last recorded. Patient is having difficulty in
breathing.


Eat and drink adequately


Patient doesn’t feel urge to eat food , eats half chappati 3
times in a meal /day

Eliminate body wastes

Patient bowel pattern is normal,able to excrete nitrogenous
waste product out of the body ,there is proper urine
output
Move and maintain desirable postures Patient is feeling restless due difficulty in breathing
Sleep &rest Patient sleeping pattern is normal

23. Select suitable clothes: dress and undress
Maintaining body temperature within normal
range by adjusting
Wearing Hospital clothes, and body temperature is normal
clothing and modifying environment.

Patient is provided with hospital clothes , and environment
is under comfortable zone – absence of loud noises, warm
environment due to presence of central heating lines


Keep the body clean and well groomed and
protect the integument


Patient used to bath daily at home but havnt taken bath
since admitted in the hospital apart from that patient has
maintained himself properly and well groomed.
Avoid the dangers in environment and avoid
injuring others

Physically restraint due to restlessness and abnormal
breadth.
Communicate with others in expressing
emotions, needs, fears or opinions.
Patient is unable to communicate as patient is feeling
difficulty in breathing.
Workship according to one’s faith

According to patient’s attendant patient worship everyday
.

Play or participate in various forms of
recreation.

Participates in different home- activites and spends time
with relatives and friends as stated by his son
Learn, discover or satisfy the curiosity that leads
to normal development and health and use the
available facilties.

Patient is not fully aware of the available health facilities.



NURSING DIAGNOSIS

1 Ineffective airway clearance related to increased production of secretion as evidence by SPO2 -89%,
increased respiration rate 41br./min, abnormal breath sound e.g- wheezes sound
2.Impaired breathing pattern related to retained secretion as evidence by presence of non- productive
cough, wheezing sound on auscultation, increase respiration rate 41 br./min.
3. imbalance nutrition less than body requirement related to decrease food intake due to fatigue evidence by
reported as lack of interest in food, poor muscle tone.
4.Activity intolerance related to imbalanced between oxygen supply and demand due to efficient work of
breathing as evidenced by shortness of breath, tachypnea.
5. risk for infection realted to inadequate primary defenses (decreased ciliary action, stasis of secretions)

24. NURSING CARE PLAN

Nursing
Assessment
Nursing Diagnosis Expected
outcome
Planning Implementation Rationale Evaluation
Subjective
data

Patients
states that I
am not able
to breathe
properly






Objective
Data
observed
through
Increase
respiratory
efforts
,Spo2 -
90%,tachypn
ea - 41
breath/min.
ABG shows
Respiratory
acidosis








Ineffective
airway
clearance
related to
increase mucus
secretion as
evidenced by
increase
respiratory efforts
,Spo2 -
88%,tachypnea -
38 breath/mint.
And through ABG
findings which
depicts
respiratory
acidosis
,


To maintain
patency
with breath
sounds
clear/cleari
ng
Assess the
airway of the
patient.

Provide chest
physiotherapy

Provide
prescribed
bronchodilat
or through
nebulizer


Provide
oxygen
therapy
through face
mask



Reassess the
airway of
patient
Assessment of
airway done.


Chest
physiotherapy
was provided to
the patient

Provided
nebulization
(duolin) to the
patient

Oxygen therapy
given to the
patent 2 lit/min.





Reassess the
airway.
To get the
baseline
data of the
patient


Will help to
remove out
the secretion
which is c
accumulated
inside



Helps in
maintaining
oxygen
content in
the body




To check the
effectiveness
of nursing
intervention
provided to
the patient



Airway
clear to
some
extent.
spo2-96%.
Respiratory
rate is
28breath
/mint

25. Nursing
Assessment
Nursing
Diagnosis
Expected
Outcome
Planning Implementation Rationale Evaluation
Subjective Data
Patient states
that I am
having difficulty
in breathing.




Objective Data
Observed by
auscultation –
wheezing sound
,
Increased
respiration rate
-41 br./min
Impaired
breathing
pattern
related to
retained
secretion as
evidence by
presence of
non-
productive
cough,
wheezing
sound on
auscultation,
increase
respiration
rate 41
br./min
To improve
breathing
pattern.
To maintain
respiratory
rate within
normal
limits.
 Assess
patient’s
respiratory
status every
2-4 hours and
notify any
abnormal
findings.

 Auscultate
breath
sounds every
2to 4 hours.
As indicated

 Place a
pillow when
patient is lying

 Provide
respiratory
support.

 Provide
medication to
the patient as
prescribed by
the doctor


 Reassess
 the patient
condition
 Respiratory
was rate was
assessed that is
41 br./min




 Wheezing
sound was
assessed in the
patient while
auscultation



 Soft pillow
was provided to
the [patient



 Oxygen
therapy was
given to the
patient

 Fluticasone
was provided to
the patient



 Reassessment
was
done,patients
respiratory
status is better
than before
resp.rate is-
28br./min
 To know for
any shortness
of
breath,tachypn
ea






 To know
decreased
breath sound
like crackles,
wheezes, and
rhonchi


 Provides
adequate lung
expansion while
patient is lying


 Aid in relieving
the patient
from dyspnea


 Act as a
bronchodilator




 To check the
effectiveness of
nursing
intervention
provided to the
patient .
After
providing
nursing
interventio
n patient
reported
with no sign
difficulty in
breathing
and
respiratory
rate is
normal
28br./min
patient
condition is
better than
before .

26. Nursing
Assessment
Nursing
Diagnosis
Expected
outcome
Intervention Implementation Rationale Evaluation
Subjective Data

Patient says
that I am not
feeling urge to
eat anything



Objective Data
Observed by

reported as
lack of interest
in food, poor
muscle tone



imbalance
nutrition less
than body
requirement
related to
decrease food
intake due to
fatigue
evidence by
reported as
lack of interest
in food, poor
muscle tone
Maintain
their
lifestyle
changes to
balance
their
healthy diet
Assess the
patient dietary
pattern.


Assess for the
bowel sounds




Give frequent
oral care,
remove
expectorated
secretions
promptly



Encourage a
rest period of
1 hr. before
and after
meals


Instruct
patient to
increase fluid
intake 2.5
litres per day
or more

Instruct the
patient to
frequently eat
high caloric
foods in
smaller
portions

Reassess the
dietary pattern
Patient eats
small meals like
half chapatti 3
times a day.

Bowel sounds
were 8




Patient was
guided to do
proper oral
care, and
expectorate
their secretions.



Patient was told
to take rest
before and after
meal .



Patient started
taking fluid
content.




Patient started
taking high
calorie food in
smaller
portions.



Reassessement
was done of the
To get the
baseline data of
the patient


Hypoactive
bowel sounds
reflects limited
fluid intake and
poor food
choices
Noxious
taste,smell,an
d sights are
primary
deterrents to
appetite and
can produce
nausea and
vomiting

Helps reducing
faigue during
mealtime and
provides an
opportunity to
increase total
caloric intake
Fluids aids in
decreasing the
viscosity of
secretions for
paitents with
chronic
increased of
production of
sputum.
COPD patients
expend an
extraordinary
amount of
energy simply
on breathing.

Patient
dietary
pattern was
improved to
some
extent as
started
taking 1
chappati at
a time.

27. HEALTH EDUCATION

1.Diet recommendations

 vegetables
 fruits
 grains
 protein
 dairy
 Liquids =Drink plenty of fluids. Drinking at least six to eight 8-ounce glasses of non-caffeinated liquids
a day can help keep mucus thinner. This may make the mucus easier to cough out.
Limit caffeinated beverages because they can interfere with medications. If you have heart problems,
you may need to drink less, so talk to your doctor.
Eating habits
A full stomach makes it harder for your lungs to expand, leaving you short of breath. If you find that this
happens to you, try these remedies:
 Clear your airways about an hour before a meal.
 Take smaller bites of food that you chew slowly before swallowing.
 Swap three meals a day for five or six smaller meals.
 Save fluids until the end so you feel less full during the meal.

Breathing Exercises with COPD

1.Pursed lip breathing
 While keeping your mouth closed, take a deep breath in through your nose, counting to 2. Follow this
pattern by repeating in your head “inhale, 1, 2.” The breath doesn’t have to be deep. A typical inhale will do.
 Put your lips together as if you’re starting to whistle or blow out candles on a birthday cake. This is known as
“pursing” your lips.
 While continuing to keep your lips pursed, slowly breathe out by counting to 4. Don’t try to force the air out,
but instead breathe out slowly through your mouth.


2.Coordinated breathing
of the patient

patient To check the
effectiveness
of the nursing
intervention
provided to
the patient

28. Feeling short of breath can cause anxiety that makes you hold your breath. To prevent this from occurring, you
can practice coordinated breathing using these two steps:
 Inhale through your nose before beginning an exercise.
 While pursing your lips, breathe out through your mouth during the most strenuous part of the exercise.
An example could be when curling upward on a bicep curl.



3.Deep breathing
 Sit or stand with your elbows slightly back. This allows your chest to expand more fully.
 Inhale deeply through your nose.
 Hold your breath as you count to 5.
 Release the air via a slow, deep exhale, through your nose, until you feel your inhaled air has been released.
Exercise tip: It’s best to do this exercise with other daily breathing exercises that can be performed for 10
minutes at a time, 3 to 4 times per day.

4. Diaphragmatic breathing

Diaphragmatic or abdominal breathing helps to retrain this muscle to work more effectively. Here’s how to
do it:
 While sitting or lying down with your shoulders relaxed, put a hand on your chest and place the other
hand on your stomach.
 Take a breath in through your nose for 2 seconds, feeling your stomach move outward. You’re doing
the activity correctly if your stomach moves more than your chest.
 Purse your lips and breathe out slowly through your mouth, pressing lightly on your stomach. This will
enhance your diaphragm’s ability to release air.
 Repeat the exercise as you are able to.
Exercise tip: This technique can be more complicated than the other exercises, so it’s best for a person with a
little more practice under their belt. If you’re having difficulty, talk to your doctor or respiratory therapist.

29. DISCHARGE PLANNING

Patient is on face mask with oxygen 2 lit/mint and having Coronary artery disease and patient having mild
infection TLC is 16 thou/ cumm. And doctors know planning for the angioplasty. So,discharge not planned
shortly. It will be planned after settlement of these issues.

PROGNOSIS

Patient had chest pain, difficulty in swallowing, shortness of breath,heart rate was increased. Patient maintained
spo2 with 2 lit/ min. patient is planned for angioplasty.


SELF- LEARNING
While studying about the case, I was able to learn in detail about the coronary artery disease . Most-
importantly, its co- relation with the patient’s condition made the learning easily retainable. I was able to
apply the assessment of the cardio vasular system onto the patient. Also, I gained knowledge about CAD sign
and symptoms, causes and its medical treatment and surgical treatment.




SUMMARY

Coronary artery disease (CAD) is the most common type of heart disease. It is the leading cause of death
in the United States in both men and women.CAD happens when the arteries that supply blood to heart
muscle become hardened and narrowed. This is due to the buildup of cholesterol and other material,
called plaque, on their inner walls. This buildup is called atherosclerosis. As it grows, less blood can flow
through the arteries. As a result, the heart muscle can't get the blood or oxygen it needs. This can lead to
chest pain (angina) or a heart attack. Most heart attacks happen when a blood clot suddenly cuts off the
hearts' blood supply, causing permanent heart damage.
Over time, CAD can also weaken the heart muscle and contribute to heart failure and arrhythmias. Heart
failure means the heart can't pump blood well to the rest of the body. Arrhythmias are changes in the
normal beating rhythm of the heart.

30. CONCLUSION

Coronary artery disease is caused by plaque buildup in the wall of the arteries that supply blood to the heart
(called coronary arteries). Plaque is made up of cholesterol deposits. Plaque buildup causes the inside of the
arteries to narrow over time. This process is called atherosclerosis.
The heart muscle needs a constant supply of oxygen-rich blood. The coronary arteries, which branch
off the aorta just after it leaves the heart, deliver this blood. Coronary artery disease that narrows
one or more of these arteries can block blood flow, causing chest pain (angina) or a heart attack
(also called myocardial infarction, or (MI).Myocardial Infarction.
Coronary artery disease was once widely thought to be a man’s disease. On average, men develop it about
10 years earlier than women because, until menopause, women are protected by high levels of estrogen.
After menopause, coronary artery disease becomes more common among women. Among people
aged 75 and older, a higher proportion of women have the disease because women live longer.



RESEARCH ARTICLE
Prognosis in Chronic Obstructive Pulmonary Disease
N. R. Anthonisen , E. C. Wright , J. E. Hodgkin etal We recruited 985 patients with COPD but without
hypoxemia or other serious disease, treated them in a standard fashion, and followed them closely for nearly
3 yr. At the time of recruitment the patients were carefully characterized as to symptom severity, lung function,
exercise tolerance, and quality of life, and studies of lung function were repeated during follow-up. Overall
mortality was 23% in 3 yr of follow-up. Patient age and the initial value of the FEV1 were the most accurate
predictors of death; when FEV1 before bronchodilator was used, the response to bronchodilators was directly
related to survival, but this relationship became nonsignificant when postbronchodilator FEV1 was used as a
primary predictor. After adjustment for age and FEV1, mortality was related positively to TLC, resting heart rate,
and perceived physical disability, and related negatively to exercise tolerance. These relationships, though
significant, were relatively weak. When standardized for age and FEV1, mortality in the present series was less
than that of a previous series (4), and the same as that of hypoxemic patients with COPD who received continuous
home O2 therapy. Changes in FEV1 with time averaged −44 ml/yr, but the standard deviation was large. Patients
with low initial values of FEV1 showed relatively little further decline, probably indicating a survivor effect. In
patients with well-preserved initial FEV1, rate of decline correlated negatively with bronchodilator response,
symptomatic wheezing, and psychological disturbances

31. REFERENCES



● Black M. joyce, Hwks hokanson jane medical surgical nursing. edition, volume 2. New delhi :Reed elsevier
india private limited:2009.p1411-1426.
● Suddarth's and brunner, Hinkle LJanice, Cheever H.Kerry, text book of medical surgical nursing.
13edition. Volume 1. New delhi: wolters Kluwer india Pvt ltd 2014.p729-759.
● Chugh N S. text book of medical surgical nursing .volume 1.delhiavichal publisher company:
2013.p303-310.
● https://www.webmd.com/heart-disease/guide/heart-disease-coronary artery
diseasetti
● http://www.heart.org/en/health-topics/consumer-healthcare/what-is-cardiovascula r-disease
● https://www.nursingtimes.net/clinical-archive/cardiovascular-clinical-archive/cardiac-system-1-anatomy-
and-physiology-29-01-2018/
● https://training.seer.cancer.gov/anatomy/cardiovascular/
● https://medlineplus.gov/coronaryarterydisease.html#:~:text=Coronary%20artery%20disease%20(CAD)%2
0is,muscle%20become%20hardened%20and%20narrowed.
● https://www.msdmanuals.com/home/heart-and-blood-vessel-disorders/coronary-artery-
disease/overview-of-coronary-artery-disease-cad