INTRODUCTION

The Group 2 of the class NCA from the University of Baguio,

School of Nursing under Ms. Donna Marie Tibay had duty at Baguio

General Hospital and Medical Center from 3pm to 11pm shift last

October 17-19 at Med 5 Ward.

We had the privileged to have a hands-on experience and

communicate with the staff and clients. We monitored patients’

vital signs, regulated IVF, removal and reinsertion of the IVF,

administered medicines as ordered by the doctor, assisted during

nebulization and rendered bed side care.

The group handled different cases regarding problems of the

respiratory system. A common respiratory problem encountered

today is the Chronic Obstructive Pulmonary Disease. Chronic

obstructive pulmonary disease (COPD) is a common chronic

condition associated with a rapidly increasing physical, social,

and economic burden in terms of both direct healthcare costs

including hospitalizations and medication and indirect costs. It

is estimated that approximately 210 million people worldwide have

COPD, and its incidence is believed to be rising. Mortality

predictions suggest that COPD will become the third leading cause

of death in 2020 and the fourth leading cause of death in 2030.

According to the Global Initiative for Chronic Obstructive

Lung Disease, COPD is currently the fourth leading cause of death

in the world but is projected to become the 3rd leading cause of

death by 2020 (Global Initiative for Chronic Obstructive Lung

Disease, GOLD, 2015). The Philippines, with Manila City as its

study site, ranked 3rd highest in prevalence of COPD stage II

(moderate or GOLD stage II) among the countries which

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participated in the Burden of Obstructive Lung Disease (BOLD)

study. It has a prevalence rate of 14% among Filipino adults aged

40 and above.

Goals:

 To apply the knowledge and skills gained in our concept of

Medical-Surgical Nursing and to further expand our knowledge

regarding these cases.

Specific Objectives:

 To design or formulate a nursing care plan appropriate for

the patient’s condition.

 To gain new learning experience from conducting the case

study.

 To provide quality nursing care by assisting the patient to

do ADL’s.

 To educate client on proper diet, nutrition, and rest.

 To promote and implement proper hygiene for infection

control.

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 CHAPTER 1

Patient’s Profile

Biographical Data

Patient X is a 76 year old female she was born on

December 5, 1942.Born in Sablan, Benguet and currently

lives in Calot, Sablan, Benguet. She is a Filipino and is

a Roman Catholic. She was admitted at Baguio General

Hospital and Medical Center on October 14, 2019 at 11:45

PM at the Medical 5th floor, Station 2 Female Ward-1. She

was admitted due to a complaint of cough. The diagnosis

of Patient X is CAP MR, Chronic Obstructive Pulmonary

Disease in AE, and Hypertension.

A. History of Past Illness:

According to Patient X, she has experienced Hypertension,

and Asthma. Patient X started smoking at 15 years old and

consuming 360 packs a year and stopped at the age of 66

B. History of Present Illness:

1 week prior to admission, patient noticed cough with

yellow color phlegm, with associated fever, headache,

difficulty in breathing, chest pain. There were no any

other signs and symptoms. 1 day prior to admission, the

patient experienced cough with yellow color phlegm, chest

pain, back pain, and difficulty in breathing. Paracetamol

biogesic was taken by the patient as self medication.

Persistent of symptoms prompted patient to seek consult

hence, admission.

C. Familial History

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 According to Patient X, her mother has experienced Asthma

CHAPTER 2

13 AREAS OF ASSESSMENT

1. Psychosocial Status

Patient X is 76 years old Female Housewife currently

residing at Sablan, Benguet together with her family.

Patient X is widowed and her ethnic group is Igorot and

religiously affiliated in Roman Catholic.

2. Mental Status

Patient X is fully oriented to time,place and situation but

sometimes forgot the names of person around her. She can

recall recent and remote memories she experienced. She is

responsive and answers to the questions being.

3. Environmental Status

Patient X lived in a barangay in Sablan, beguet. The room

temperature in their house is 22 degrees centigrade. Well

ventilated.

4. Sensory Perception

Patient X hearing ability is deficit. The sense of smell is

altered because of her age. Her tongue and oral mucous

membrane are intact and moist. She has a high tolerance when

it comes to pain.

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5. Motor Status

Patient X can mobilize from her bed to the comfort room

without assistive device. She Needs Minimal Assistance in

doing other Activity of daily living.

6. Nutritional Status

Prior to admission, patient consumes full meal 3x a day. She

eats meals on time and a balanced diet.

7. Elimination Status

Patient X stool is brown and semi formed. She usually

defacate in the afternoon. She urinated atleast 3 times

during 3-11 shift. The characteristics of her urine is

yellow approximately 300cc within the shift. Method of

elimination is at comfort room.

8. Fluid and Electrolytes

Patient X has PNSS 1L x 16 hours and was able to consume

500cc per shift. She’s consuming 300cc of oral fluid intake

per shift. Her input is proportional to her output.

9. Circulatory Status

Patient X Cardiac rate during the shift ranges from 70-80

beats per minute. Her capillary refill is 2-3 seconds.

Patient X blood pressure is 130/70 mmHg. Her oxygen

saturation is at 92-96%.

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10. Respiratory Status

Patient X respiratory rate ranges from 18-20 breaths per

minute. Upon auscultation crackles and wheezes noted. There

is use of accessory muscle.

11. Temperature Status

Patient X axillary temperature is 36.4-36.6 degrees

centigrade. Skin is warm to touch. There is no edema noted.

12. Integumentary Status

Patient X has brown skin and appropriate with the race. The

skin is normally dry and no presence of lesion. Hair color

is black and white are partially distributed. Nails are

blackish

13. Comfort and Rest Status

Patient X can sleep at night time and take a nap during day

time during her hospitalization but sometimes interrupted

due to nursing interventions like administering IV

medication.

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 CHAPTER IV

LABORATORY RESULT

COMPLETE BLOOD COUNT

TEST NAME RESULT REFERENCE RANGE

Hemoglobin 118 120-160 g/L
Hematocrit 0.35 0.37-0.47 L/L
WBC count 9.75 5.0-10.0
Differential count
Neutrophils 84 50-70%
Lymphocytes 11 20-40%
Monocytes 5 0-10%
Eosinophils 0 0-7%
Basophils 0 0-1%
RBC count 4.08 4.04-5.4 ^12/L
RBC INDICES
MCV 86.30 80-100 L
MCH 28.00 27-31 pg
MCHC 344.00 310-360

Implication: CBC is a test that evaluates the cells that make-up the

blood that reflects the body’s over-all status.

Results: The hemoglobin and hematocrit counts are lower than normal

which indicates anemia. Neutrophils is higher than normal range which

indicates acute inflammation and the lymphocytes is low which

indicates infection.

ARTERIAL BLOOD GAS RESULT

GAS RESULT NORMAL VALUES

pH 7.51 (7.35-7.45)

PCO2 34.8 (35-45)mmHg

PO2 91.6 (60-100)mmHg
HCO3 24.4 (22-26)

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 S02 95% (95-100%)
BE 1.5 (+2)mmol/L

Implication: aids in assessing the ability of the lungs to provide

adequate oxygen and remove CO2.

Interpretation: the pH is higher than normal range and the PCO2

is lower than normal range which indictes Respiratory alkalosis

ROUTINE CHEMISTRY

TEST NAME INSTRUMENT RESULT UNIT RANGE RESULT UNIT RANGE

AU480 7.22 mmol/L 4.1- 80.90 mg/DL 74-

Glucose,FBS 5.9 106

HDL AU480 1.08 mmol/L 1.03- 52.12 mg/DL 40-6o

cholesterol 1.55
LDL AU480 2.51 mmol/L <2.6 105.02 mg/DL <100

cholesterol
Triglycerides AU480 0.56 mmol/L <1.70 82.30 mg/DL <150

Total AU480 4.31 mmol/L <5.2 157.92 Mg/DL <200

cholesterol

*remarks: prediabetic A fasting blood sugar level from 4.2-5.9

mmol/L is considered prediabetes.

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 X-RAY RESULTS

No significant interval change of the previously noted of the Koch’s

densities in both upper lobes.

Progression of the densities in both lobes more on the right probable

pneumonia with consolidation.

Heart is not enlarged.

Atherosclerotic aorta.

Pulmonary vascular are within normal.

Both hemidiaphrams and costophrenic sulci are intact.

CHAPTER 4

Anatomy & Physiology of the Respiratory System

The major organs of the respiratory system function primarily to

provide oxygen to body tissues for cellular respiration, remove

the waste product carbon dioxide, and help to maintain acid-base

balance. Portions of the respiratory system are also used for

non-vital functions, such as sensing odors, speech production,

and for straining, such as during childbirth or coughing

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Major Respiratory Structures. The major respiratory structures

span the nasal cavity to the diaphragm.

Functionally, the respiratory system can be divided into a

conducting zone and a respiratory zone. The conducting zone of

the respiratory system includes the organs and structures not

directly involved in gas exchange. The gas exchange occurs in

the respiratory zone.

The major entrance and exit for the respiratory system is through

the nose. When discussing the nose, it is helpful to divide it

into two major sections: the external nose, and the nasal cavity

or internal nose.

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 Several bones that help form the walls of the nasal cavity

have air-containing spaces called the paranasal sinuses, which

serve to warm and humidify incoming air. Sinuses are lined with a

mucosa. Each paranasal sinus is named for its associated bone:

frontal sinus, maxillary sinus, sphenoidal sinus, and ethmoidal

sinus. The sinuses produce mucus and lighten the weight of the s

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The epiglottis, attached to the thyroid cartilage, is a very

flexible piece of elastic cartilage that covers the opening of

the trachea. When in the “closed” position, the unattached end of

the epiglottis rests on the glottis. The glottis is composed of

the vestibular folds, the true vocal cords, and the space between

these folds. A vestibular fold, or false vocal cord, is one of a

pair of folded sections of mucous membrane. A true vocal cord is

one of the white, membranous folds attached by muscle to the

thyroid and arytenoid cartilages of the larynx on their outer

edges. The inner edges of the true vocal cords are free, allowing

oscillation to produce sound. The size of the membranous folds of

the true vocal cords differs between individuals, producing

voices with different pitch ranges. Folds in males tend to be

larger than those in females, which create a deeper voice. The

act of swallowing causes the pharynx and larynx to lift upward,

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allowing the pharynx to expand and the epiglottis of the larynx

to swing downward, closing the opening to the trachea. These

movements produce a larger area for food to pass through, while

preventing food and beverages from entering the trachea.

The true vocal cords and vestibular folds of the larynx are

viewed inferiorly from the laryngopharynx.

Continuous with the laryngopharynx, the superior portion of the

larynx is lined with stratified squamous epithelium,

transitioning into pseudostratified ciliated columnar epithelium

that contains goblet cells. Similar to the nasal cavity and

nasopharynx, this specialized epithelium produces mucus to trap

debris and pathogens as they enter the trachea. The cilia beat

the mucus upward towards the laryngopharynx, where it can be

swallowed down the esophagus.

The trachea (windpipe) extends from the larynx toward the lungs.

The trachea is formed by 16 to 20 stacked, C-shaped pieces of

hyaline cartilage that are connected by dense connective tissue.

The trachealis muscle and elastic connective tissue together form

the fibro elastic membrane, a flexible membrane that closes the

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posterior surface of the trachea, connecting the C-shaped

cartilages. The fibro elastic membrane allows the trachea to

stretch and expand slightly during inhalation and exhalation,

whereas the rings of cartilage provide structural support and

prevent the trachea from collapsing. In addition, the trachealis

muscle can be contracted to force air through the trachea during

exhalation. The trachea is lined with pseudostratified ciliated

columnar epithelium, which is continuous with the larynx. The

esophagus borders the trachea posteriorly.

The trachea branches into the right and left primary bronchi at

the carina. These bronchi are also lined by pseudostratified

ciliated columnar epithelium containing mucus-producing goblet

cells. The carina is a raised structure that contains specialized

nervous tissue that induces violent coughing if a foreign body,

such as food, is present. Rings of cartilage, similar to those of

the trachea, support the structure of the bronchi and prevent

their collapse. The primary bronchi enter the lungs at the hilum,

a concave region where blood vessels, lymphatic vessels, and

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nerves also enter the lungs. The bronchi continue to branch into

bronchial a tree. A bronchial tree (or respiratory tree) is the

collective term used for these multiple-branched bronchi. The

main function of the bronchi, like other conducting zone

structures, is to provide a passageway for air to move into and

out of each lung. In addition, the mucous membrane traps debris

and pathogens.

A bronchiole branches from the tertiary bronchi. Bronchioles,

which are about 1 mm in diameter, further branch until they

become the tiny terminal bronchioles, which lead to the

structures of gas exchange. There are more than 1000 terminal

bronchioles in each lung. The muscular walls of the bronchioles

do not contain cartilage like those of the bronchi. This muscular

wall can change the size of the tubing to increase or decrease

airflow through the tube.

An alveolar duct is a tube composed of smooth muscle and

connective tissue, which opens into a cluster of alveoli. An

alveolus is one of the many small, grape-like sacs that are

attached to the alveolar ducts.

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An alveolar sac is a cluster of many individual alveoli that are

responsible for gas exchange. An alveolus is approximately 200 μm

in diameter with elastic walls that allow the alveolus to stretch

during air intake, which greatly increases the surface area

available for gas exchange. Alveoli are connected to their

neighbors by alveolar pores, which help maintain equal air

pressure throughout the alveoli and lung.

Mechanics of Breathing

To take a breath in, the external intercostal muscles contract,

moving the ribcage up and out. The diaphragm moves down at the

same time, creating negative pressure within the thorax. The

lungs are held to the thoracic wall by the pleural membranes, and

so expand outwards as well. This creates negative pressure within

the lungs, and so air rushes in through the upper and lower

airways.

Expiration is mainly due to the natural elasticity of the lungs,

which tend to collapse if they are not held against the thoracic

wall. This is the mechanism behind lung collapse if there is air

in the pleural space

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 PATHOPHYSIOLOGY

Predisposing Factor: Precipitating:

AGE: 76 years old Smoker for 51 years

SMOKING

QUIT SMOKING
GRADUALLY
GOBLET CELLS

ACTIVATION OF PMNs
& MACROPHAGES
SPUTUM
PRODUCTION

PROTEASES
(ELASTASE)

INFLAMMATORY
REACTION
DESTRUCTION OF
ALVEOLAR WALLS

SCAR FORMATION

LOSS OF
ELASTICITY
LOSS OF
ELASTICITY
AIR TRAPPING

LOSS OF AIRWAY
ELASTICITY NARROWING

OBSTRUCTION

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NARRATIVE PATHOPHYSIOLOGY

Cigarette smoking is the leading cause of COPD. Cigarette-

associated noxious agents injure the airway epithelium and drive

the key processes that to specific airway inflammation and

structural changes. Once these agents are removed, repair

processes should, ideally, bring the airways back to their normal

structure and function. In general, an inadequate repair process

is thought to play a key role in the development of chronic

airflow obstruction in some, but not all, smokers. Indeed, in

many subjects most of the inflammatory changes continue despite

smoking cessation. This failure of bronchial inflammation to

resolve might contribute to systemic changes and ongoing

bronchial and lung matrix degradation. In addition to persistent

airway inflammation, other major phenomena involved in the

disease initiation and progression include increased oxidative

stress and protease–ant protease imbalance. Several studies have

established that airway obstruction in COPD is due to changes

affecting small airways and lung parenchyma while the

contribution of proximal airway epithelium remodeling is less

clear. The decline in forced expiratory volume in 1s (FEV1) in

COPD is mainly related to thickening of the walls of small

conducting airways and obstruction of these airways by mucous

exudates.

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