COLEGIO SAN AGUSTIN – BACOLOD

COLLEGE OF HEALTH AND ALLIED PROFESSIONS

NURSING PROGRAM

CHRONIC OBSTRUCTIVE PULMONARY DISEASE:

EMPHYSEMA

A Medical Case Study

Presented to

The Faculty of the College of Health and Allied Professions – Nursing Program
Colegio San Agustin – Bacolod

In Partial Fulfillment of the Requirements

For the course Nursing Care Management 118 R

By:

Luga, Lourdelyn May Murillo, Arniel

Mabesa, Yedanne Grace Palic, Cheska Mae
Makilan, Den Hezron Pastrana, Mary Abegail
Mayan, Dhenmarc Patriarca, Kaye
Mercurio, Dylin

Group 3 BSN IV A

August 2021
Table of Contents
I. Case Study Objectives  1
Case Overview 2

II. Patient’s profile  3

III. Nursing History 

A. History of present illness 3

B. Past Medical History 4

C. Family History 5

D. Socio-cultural History 6

IV. Assessment  

A. Nursing Assessment  7

1. General description of the client 7

2. Systemic assessment  8

3. Nursing History (Gordon’s Assessment) 17

a. Health perception – Health management 17

pattern 

b. Nutritional – Metabolic Pattern  18

c. Elimination Pattern  19

d. Activity Pattern 20

e. Sleep – Rest Pattern  21

f. Cognitive – Perceptual Pattern  22

g Self-Perceptual – Self – Concept Pattern  22

h. Role – Relationship Pattern  23

i. Sexuality – Reproductive Pattern  24

B. Medical 24

1. Medical History 24

2. Admitting Diagnosis/Initial impression  25

3. Laboratory and Diagnostic Examinations 25

Anatomy and Physiology of The Respiratory System 39

C. Pathophysiology  42

V. Management 

A. Medical / Surgical  49

1. Doctor’s order  46
 2. Procedures done  49

3. Drug Study 51

4. Recommended diet  58

5. Prescribed activity  59

B. Nursing Care Plan

Nursing Care Plan no. 1 61

Nursing Care Plan no. 2 72

Nursing Care Plan no. 3 80

VI. Discharge plan 89

VII. Evaluation  99

VIII. References 101

 
 1

I. Case Study Objectives

Within 39.67 hours of duty in the Medical Ward of the Doctors Hospital,

the student nurses will be able to:

Knowledge:

1. Identify the objective and subjective assessment data presented completely.

2. Trace the pathophysiology of COPD correctly.

3. Formulate a nursing care plan according to the patient’s specific needs

appropriately.

4. Discuss the rationale of the nursing procedures rendered to the patient

thoroughly.

5. Evaluate the effectiveness of nursing care rendered efficiently.

Skills:

1. Gather pertinent patient data and health history from the patient and significant

others correctly. 

2. Monitor patient’s oxygen saturation accurately.

3. Demonstrate diaphragmatic breathing techniques properly.

4. Perform postural drainage effectively.

5. Conduct health teaching regarding the disease to the patient effectively.

Attitude:

1. Manifest Augustinian values in rendering nursing care at all times.  

2. Attend closely to the patient’s concern under the nursing care promptly.

3. Demonstrate problem solving attitude in dealing with the COPD patient

cautiously.

4. Show interest in the assigned tasks given in relation to the case condition

willingly.

5. Accept the criticisms shared by other members of the healthcare team

professionally.
 2

Case Overview

Mrs. L.V. is a 44-year-old housewife who lives in the slum area of Quezon City,

Manila, together with her husband and three children. Before she was diagnosed with

her present illness, the patient worked as a laundress to help her husband who is a

tricycle driver, in supporting their family financially. She had this job for almost 10 years.

It was in the year 2015 that she decided to stop her service due to her untreatable

cough.

Given her health situation, Mrs. L.V. had her check - up in their local health

center primarily for her to understand the symptoms she manifested which included

chronic cough, increased production of mucus, and chest tightness. With this, she was

consequently diagnosed with Emphysema, a type of Chronic Obstructive Pulmonary

Disease characterized by impaired oxygen and carbon dioxide exchange results from

destruction of the walls of overdistended alveoli and was prescribed to take a nebulizer

inhaler, and a mucolytic tablet.

Upon history taking, Mrs. L.V. stated that she is not smoking cigarettes or

tobacco. However, she revealed that her husband was a chain smoker, emptying 2

packs of cigarette per week. Aside from this, the patient also uses charcoal and

firewood for cooking and at the same time, frequently exposed to chemical present in

laundry and cleaning agents. Due to chronic exposure, these factors precipitated the

patient to acquire Emphysema.

On August 23, 2021, the patient was admitted to hospital with a chief complaint

of recurrent cough. The doctor diagnosed her with Emphysema and was prescribed with

hydrocortisone (Hydrocort), ipratropium + salbutamol, and fluticasone + salmeterol

puffs. During her admission the student nurses was able to implement the appropriate

interventions and helped the patient towards her discharge.

 3

II. Patient’s profile

a. Name: L.V.

b. Address: Tandang Sora, Quezon City, Manila

c. Age: 44 years old

d. Status: Married

e. Educational Status: High School

f. Occupation: Laundress

III. Nursing History 

A. History of present illness

It was in the year 2015 when Mrs. L.V. had her first check up at the local health

center due to the symptoms of uncontrolled coughing, increased production of mucus,

and chest tightness. Upon further diagnostics and laboratory examinations, she was

diagnosed with Chronic Obstructive Pulmonary Disease, specifically with

Emphysema.

Mrs. L.V. stated that she uses firewood and charcoal for cooking for several

years already and that her husband is a chain smoker who smokes 2 packs per week.

She worked as a laundress but had to stop when she first felt a tightness on her chest

last September 2014 and had a wet cough around November 2014 but did not give

immediate attention due to financial instability. She also stated that she had trouble

breathing properly when the weather is too humid. 

After her diagnosis in January 2015, she was prescribed to take a nebulizer three

(3) times a day, two to three (2-3) pumps of inhaler and a mucolytic tablet every night.

She was also highly advised to join a breathing therapy once a year and to visit the

hospital regularly. 
 4

B. Past Medical History

The patient’s occupation back in 2015 was a laundress. She didn't have any

previous illness before she got COPD. She only got hospitalized three times to give birth

for her three children wherein she had a normal recovery and didn’t have any major

complications.

She stopped her work since she cannot handle her severe cough when she

washes loads of clothes. She went to the health center and was diagnosed with

emphysema. Consequently, she underwent some medication treatment prescribed by

the doctor such as nebulizer (3x a day), inhaler (2 pumps every morning and nighttime),

and phlegm expectorant. She doesn’t smoke but she believes that she got the disease

from her husband and her as being a second-hand smoker.

Immunizations

Figure 1. Immunization Record of Patient L.V.

Patient L.V. was fully immunized with the following vaccines: BCG, DPT, OPV,

Hepatitis B, Measles, Mumps, Rubella, and Tetanus Toxoid. The patient was

administered with 3 doses of DPT and OPV at 6 weeks, 10 weeks, and 14 weeks old.
 5

Other vaccines were given before 1 year old, except for Tetanus Toxoid which she

received during pregnancy.

C. Family History (Maternal and Paternal & Siblings Diseases)

The client, Mrs. L.V., is the third child among five children. Three members of her

family were already deceased. First, Mrs. C.V. her mother died at the age of 75 due to a

stroke. Her father, Mr. M.V., is also deceased at the age of 80 due to kidney cancer. Her

brother, Mr. A.V., has also developed cancer. Unfortunately, Mr. A.V. died at the age of

55 because of kidney cancer. Moreover, Mrs. L.V.’s family does not have any history of

any respiratory disorders such as COPD.

 6

D. Socio-cultural history

Mrs. L.V. lives in a squatter area in Tandang Sora, Quezon City, Manila wherein

her way of living was a laundry worker in which she receives 200-250 pesos depending

on the load of laundry she will wash. Her husband, as the family’s main source of

income, is a tricycle driver wherein he can earn 500-600 pesos a day. The combined

salary of Mrs. L.V. and her husband were not enough to compensate for their family’s

daily needs, thus, we may conclude that the family of Mrs. L.V. has a low

socioeconomic status. In the year of 2015, Mrs. L.V. stopped working due to the

constant coughing she experienced that seems to have worsened. When she had

herself checked to a health center near them, the results showed that she had

emphysema, a type of disease that falls under COPD. Even if Mrs. L.V. was not

smoking which is the main cause of COPD, still, she can acquire this disease condition

because she is exposed to secondhand smoke, the smoke that was being emitted when

her husband is smoking and the burning fossil fuels when she is cooking their food. It is

also evident that Mrs. L.V.’s health and condition would drastically deteriorate since she

neglected her own health just to make ends meet every day. Seeing that Mrs. L.V. had

already stopped working as a laundry worker, her husband is now the sole provider for

their family; therefore, with a limited source of income, the family needed to budget

carefully for their daily food consumption. Additionally, because Mrs. L.V.'s medications

are numerous, this would consume a significant portion of their budget, leaving them

with only 1-2 meals per day, resulting to Mrs. L.V.'s nutrition becoming unbalanced

which triggered a dramatic alteration in her physical appearance.

In terms of recreation, Mrs. L.V. spends her time sitting and watching television

due to shortness of breath when doing heavy activities. She also shared that she often

walks as a form of exercise. As she said, this can help strengthen her lungs.

Furthermore, the patient also a religious person, she often goes to the church and does

novenas since fer condition got worse. This helps her somehow become hopeful

despite of her worsening condition.

 7

IV. Assessment  

A. Nursing Assessment 

1. General description of the client

Upon assessment, Patient L.V. is a middle-aged adult woman with an

ectomorphic body built. Her height is 5’3 or 161 cm and weighing 117 pounds or 53 kgs.

Her skin color is tan and minimal wrinkles may be found in some parts of it especially in

her head areas. She has multiple moles present in her face, nose, and neck. Her hair

color is black and straight with a little gray color of strands of hair in the scalp areas. Her

eyes appeared droopy, but the pupils were responsive to light. The iris of her eyes is

black, and sclera is reddish in color. Presence of eye bags were also noted. Hair length

is not so long but not too short also. Some teeth areas are incomplete in number. Lip

area is slightly cyanotic in color Patient L.V. facial expression seems grumpy when

observed. Upon looking at the neck areas, clavicles seem slightly noticeable but can be

clearly seen when she breathes. Jugular vein distention is present in the left area of the

neck. Fingernails are pinkish in color without lunula. The movement of the patient

seems slow, especially when she walks. She slouches when walking with the head tilted

forward facing down. She stops when getting tired of walking to grasp for air and

continues to walk slowly again. Patient L.V. frequently close her eyes when breathing

after an exertion of physical activity. When the weather is hot or warm, her breathing

problem worsens. There are times that her hands were always in her chest while

breathing.
 8

2. Systemic assessment

Table 2. Systemic Assessment Data of Patient L.V.

Systems Findings Book View

A. Integumentary Inspection
Inspection
System  Skin is tan in color, thin,
 Skin is based on ethnicity
dry, scaly, and pale.
 No skin lesions present 
 Skin lesions not noted
 No edema may be
 Periocular skin
present 
hyperpigmentation noted
 Skin is moist
 Skin is intact
 No wound and bruises
 Hair is thin, black, and
 Hair depends on ethnicity
straight
 Hair is thick, straight and
 Presence of mole at the
shiny 
neck, nose and forehead
 Even distribution of hair in
 No wound and bruises
the eyebrows, eyelashes,
noted
and scalp.
 Edema not present
 Redness of skin noted
 No leg swelling noted
 Leg swelling may be
 Decreased distribution of
present
hair in the eyebrows but
 Bluish tint to skin around
even distribution in
the lips or fingernails
eyelashes and scalp
 Blue tint to skin around
fingernails
Palpation
Palpation
 Firm nail base upon
 Poor skin turgor  palpation 
 Capillary refill of 4  Tenderness of upper
seconds back may be noted
 Skin is cool and clammy  Capillary refill of 1-3
when touched seconds
 Edema not noted  Dependent edema may
 Skin surfaces are non- be present
tender

B. Respiratory Chest X-Ray (August 23,
2021)
System
 Lungs are large and
hyperinflated; hyperlucent
lung fields with wall of
bleb and low-set
diaphragm
Inspection
 Hyperinflated / Barrel
chest noted
 Chronic productive cough
with clear to gray sputum
 Pursed lip breathing
observed
 Intercostal indrawing
during inspiration
 Shortness of breath
observed
 Respiratory rate of 30
cpm with O2 at 24% at 2-
3/L per minute via face
mask
 Oxygen saturation of 89%
 Slouching position during
ambulation
 Tripod position when
sitting noted
 Minimal flaring of nares
noted
 Spends most of the time
resting in high - fowler’s
position
9
Chest X-ray 
 Lung hyperinflation with
flattened
hemidiaphragms and
possible bullous
changes.  On the lateral
radiograph, a "barrel
chest" with widened
anterior-posterior
diameter may be
visualized. The "saber-
sheath trachea" sign
refers to marked coronal
narrowing of the
intrathoracic trachea
(frontal view) with
concomitant sagittal
widening (lateral view).
Inspection
 Hyperinflated/barrel
chest
 Chronic productive
cough with clear to gray
sputum
 Pursed lip and
diaphragmatic breathing
may be observed
 Intercostal indrawing
during inspiration
 Difficulty of breathing
 Respiratory rate of >20
cpm
 Oxygen at 24% (via a
Venturi mask) at 2-3

 Occasionally cannot finish
sentences because of
breathlessness
 Use of accessory muscles
during inspiration
(sternocleidomastoid and
abdominal muscles)  - 92%
Palpation
 Trachea palpated on
suprasternal notch
 No tenderness is
appreciated upon
palpation of chest wall
 Decreased chest
expansion
 Presence of tactile Palpation
fremitus
Percussion
 Symmetrical
hyperresonance sound
percussed bilaterally
Auscultation
Percussion
 Reduced breath sounds
 (+) wheezing upon
expiration heard on both
lung fields
Auscultation
10
L/minute or at 28% (via
Venturi mask, 4
L/minute) or nasal
cannula at 1-2 L/minute
may be given
 Oxygen saturation of 88
 Assumes a forward-
leaning and tripod
position 
 Nasal flaring
 Side-lying position and
high fowler’s position
assumed
 Trachea palpated on
suprasternal notch
 Tenderness may present
upon palpation of chest
 Decreased chest
expansion 
 Decreased intensity of
tactile fremitus
 Generalized and
symmetrical
hyperresonance note
 Reveals increased
percussion notes
(particularly over the
liver) 
 11

 Coarse crackles 
 Decreased breath
sounds
 Audible expiratory
wheeze

C. Gastrointestinal Inspection Inspection

System  Pale buccal mucosa  Dry mouth

 Slight bloating of stomach  Thin appearance of
stomach
Auscultation
Palpation
 10 bowel sounds per
minute  No guarding
 occasional borborygmi or  Absence of distention
refers to the characteristic  No abdominal pain
growling or rumbling
sounds that the stomach
Percussion
and intestines make as
food, fluids, and gas pass  Tympanitic sound to
through them. percussion, which is
 sounds heard upon replaced by dullness
auscultation where solid viscera, fluid,
 No guarding, distention, or stool predominate. 
and abdominal pain  Flanks are duller as
present posterior solid structures
predominate, and the
right upper quadrant is
Percussion somewhat duller over the
liver. 
 Dullness over the liver in
the right lower anterior
chest noted Palpation
 Tympany is the
 Upon bimanual palpation
predominant sound heard
with one hand over the
over the region.
patient's chest and one

 Flanks are duller.
Palpation
 Upon bimanual palpation
with one hand over the
patient's chest and one
over the abdomen, no
paradoxical movement
was observed
D. Urinary System  Approximately 2000 -
2300ml of urine output per
day
 Straw colored urine
 No pain during urination  incontinence
 Bladder not distended
 No tenderness upon
palpation
 Approximately drinks fluid
8 - 10 glasses (2000 -
2500 mL) of water per day
 Continent bladder noted
E. Reproductive  Decreased estrogen and
progesterone level seen in
System
laboratory results
 Loss of libido as
mentioned by the patient
 Periods are shorter as
mentioned by the patient
 Amount of menstrual flow
not as heavy as before as
stated by the patient
12
over the abdomen,
paradoxical abdominal
movement may be
present
 Approximately 2000 -
2500 mL of urine output
per day
 Risk for urinary
 Straw colored urine
 Approximately drinks 8
to 12 glasses (2000 -
3000 mL) of water per
day
 Signs of perimenopause
may manifest such as
more frequent periods at
first, and then occasional
missed periods, periods
that are longer or
shorter, changes in the
amount of menstrual
flow.
 Decrease in breast

 Decrease in breast tissue
noted
F. Nervous System  Mental status: awake and
alert; oriented to person,
place, and time
 Slightly slowed reflexes
noted  retrograde memory
 Intact anterograde and
retrograde memory
 Able to comprehend
questions asked
 Normal balance,
coordination, and speech
articulation
 No involuntary
movements
 No neural damage
Cranial Nerves Assessment
Olfactory function (CN I):
decreased ability to smell
Optic function (CN II):
Visual acuity of 20/10 in
Snellen’s Chart but does not
wear corrective glasses
Oculomotor function (CN III):
Pupillary size of 5 mm and are
equal in size. They dilate and
constrict when looking at
distant and nearer objects
respectively.  Trochlear function (CN IV):
13
tissue   Lower sex drive
(libido) and sexual
response
 Conscious, coherent,
and able to identify time,
place and people. 
 Intact anterograde and
 Able to comprehend
questions asked
 Normal balance and
coordination
 No involuntary
movements
 Normal speech
articulation
 Neural damage may be
present
Cranial Nerves Assessment
Olfactory function (CN I):
able to smell
Optic function (CN II):
Visual acuity decreases
Oculomotor function (CN
III):
pupils are equal in size, dilate
when when looking at distant
objects and constrict when
looking at nearer objects

Trochlear function (CN IV):
able to move eyes
(upward/medial,
upward/lateral, medial,
downward/lateral)
Trigeminal function (CN V):
Able to feel facial sensations
and chew food 
Abducens function (CN VI):
Normal lateral eye movement
Facial function (CN VII):
Able to move facial muscles
and close eyelids
Vestibulocochlear function
(CN VIII):
Can hear questions asked
clearly and can balance while
walking, standing, and sitting. 
Glossopharyngeal function
(CN IX):
Able to taste food and feel
sensation in pharynx
Vagus function (CN X):
Has no difficulty in swallowing
food
Spinal accessory (CN XI):
Able to shrug shoulders
symmetrically and raise head
to look in the ceiling
14
Opening of eyelids, eye
movement (upward/medial,
upward/lateral, medial,
downward/lateral)
Trigeminal function (CN V): 
able to feel sensation and
chewed food in a slow
manner  
Abducens function (CN VI):
Normal lateral eye movement
Facial function (CN VII):
Able to move facial muscles
and close eyelids
Vestibulocochlear function
(CN VIII):
good hearing function; can
hear voices clearly and good
balance.
Glossopharyngeal function
(CN IX):
Taste posterior ⅓ of the
tongue and feel sensation in
the pharynx 
Vagus function (CN X):
Can have a mild difficulty
swallowing food
Spinal accessory (CN XI):
Able to shrug shoulders
symmetrically and raise head
to look in the ceiling

Hypoglossal function (CN
XII):
the tongue can move freely
while speaking and swallowing
G. Musculoskeletal  Tripod sitting position
noted
System
 Body weakness noted  
 Slouch position during
ambulation
 Muscle wasting noted  
 Exhibits slow movement
in walking
 Occasionally stops
walking to catch breath
 Ribcage is prominent
 Height is 5’3 or 161 cm  coughing
 Shoulders are on level but
not in pain
 Able to flex and extend
the neck, able to abduct
and adduct the upper and
lower extremities.
 Able to do supination and
pronation of the palms
and closed fingers.
 Equal leg length, hips
symmetric
 Knees are equal and
same height
 Feet are normal in
anatomical alignment
15
Hypoglossal function (CN
XII):
the tongue can move freely
while speaking and
swallowing
 Assumes a tripod
position
Decreased muscle
strength
 Body fatigue
Gait alterations when
ambulating 
 Muscle wasting noted 
 Shoulders are on level
and may be in pain
because of persistent
 Ribcage may be
prominent
 Able to flex and extend
the neck
 Able to abduct and
adduct the upper and
lower extremities.
 Able to do supination
and pronation of the
palms and closed
fingers.
 Equal leg length, hips
symmetric
 Knees are equal and
same height
 Feet are normal in
anatomical alignment
 16

H. Lymphatic System  Increased number of  The number of lymphatic

CD8+ Type-1 T- vessels and nodes

lymphocytes and increases, as does the

macrophages in the lung concentration of the

tissue and neutrophils in chemokine ligand 21

the airway lumen. (CCL21), expressed by

 Calcified lymphatic nodes endothelial lymphatic

present in causal portion cells and one of the A

of trachea subtypes of the G-

 Enlarged lymph nodes protein coupled receptor

located in the surrounding (GPCR), and its

of the carina and the chemokine ligand

aorto-pulmonary window. receptor 7 (CCR7)

 Calcified lymphatic nodes receptor on activated

present in causal portion dendritic cells 

of trachea   In the caudal portion of

 Swollen lymph nodes the trachea, it is possible

present  to find calcified lymphatic

  particularly at the level of nodes or nodes that

the bronchi up to the have been infiltrated by

bronchioles. adipose tissue 

 Enlarged lymph nodes

located in the

surrounding of the carina

and the aorto-pulmonary

window.

 Lymphatic nodes

undergo hypertrophy,
 17

particularly at the level of

the bronchi up to the

bronchioles.

I. Cardiovascular  Difficult to palpate apex  Cardiac apex not

beat  palpable
System
 Cardiac apex beat in
COPD may not be present
at the usual location and
may be shifted to the
subxiphoid area.
 Impaired cardiac dullness
 Pulse rate of 90 bpm
 Blood pressure of 130/80
 Loss of cardiac dullness
on percussion
 Heart sounds loudest in
epigastrium
 Can cause heart failure
in your heart's lower right
chamber, or ventricle.
 Pulse rate of more than
80 bpm
 Blood pressure of below
130/90

3. Nursing History (Gordon’s assessment) 

a. Health perception – Health management pattern 

Upon assessment, Mrs. L.V. stated that she has not been feeling well most of the

time since she manifested COPD symptoms. She said that at some point, she would

experience shortness of breath, verbalizing “Palagi akong hindi makahinga maayos.

Alam mo yun? Yung parang kinakapos ako ng hangin. Yun yung nararamdaman ko.

Pero minsan naman okay naman ako. Nakakapagsalita naman ako ng maayos ng

matagal pag wala akong ginagawa. Pero meron talagang time na hindi na ako

makakapagsalita ng maayos dahil kinakapos na naman ako ng hangin. Halimbawa,

pagkatapos kong maglaba ng mga damit namin o lumakad lakad lang. Napapapikit na

lang ako minsan kasi hindi ako makahinga ng maayos.”. Moreover, Mrs. L.V. added

what she does whenever she manifest shortness of breath by stating, "Kapag hinihingal
 18

ako, ginagawa ko lang ay umupo at magpahinga muna. Tapos pinipikit ko lang ang

aking mga mata at humihinga ng malalim. Kapag nakapag pahinga na ako ng ilang

minuto, nagiging mabuti na ang pakiramdam ko ng kaunti". With this non-

pharmacological intervention such as breathing technique, it helps Mrs. L.V. to feel a

little better. Mrs. L.V. associated her difficulty of breathing with her disease condition in

general and environmental factors such as smoke and strong odors. Mrs. L.V. was a

laundress so she may be exposed to the strong odor of the laundry detergent. Also, her

husband is a smoker which made her exposed to secondhand smoke. In addition, Mrs.

L.V. usually burn coals to cook, so this may also contribute to her illness. As a child,

Mrs. L.V. has completed her immunization, so there were no problems during her

younger years. She has no known food or drug allergies. She neither smokes nor drinks

alcoholic beverages. Mrs. L.V. stated that before, she uses traditional and herbal

remedies to treat her illness or other health problems within the family. However, when

she felt that her condition was not getting better, she went to the barangay health center

for a check-up. Mrs. L.V. has frequent visits to her physician now. She currently has

several medications. She expressed that she has plenty of medications to take and

should not be forgotten to consume. Mrs. L.V. regularly follows the doctor's order of

taking her medication with the help of her husband, as she verbalized “Yung asawa ko

ang naghahanda ng aking mga gamot. Makakalimutin kasi ako minsan. Yung mga

gamot ko at sinabi ng doctor ko, sinusunod ko yan at ginagamit sa tamang oras.

Nagpapasalamat din ako sa Diyos dahil nararamdaman ko na umeepekto yung gamot

kapag nagagamit ko. Medyo gumiginhawa yung pakiramdam ko pagtapos ko gumamit

ng gamot.” His husband is very supportive in taking care of her needs. Mrs. L.V. is very

aware of her current health situation that she can recover from her present condition as

long as she complies with every order, medication, and instruction given by the doctor. 

 b. Nutritional – Metabolic Pattern 

 19

Mrs. L.V. eats healthy foods everyday. She didn't take any food supplements

before she was diagnosed with COPD. However, the doctor prescribed her a vitamin D-

3 supplement for the protection against moderate or severe flare-ups of COPD. She

always drinks 7-8 glasses of water everyday. Mrs. L.V. also said in the interview that

she usually eats kamote tops, malunggay, pechay, mustasa, etc. She rarely eats meat

but usually eats fish. Now that she is manifesting the symptoms of COPD, she eats

minimally because she has less appetite than usual due to discomfort. She typically

consumes a half cup of cooked rice, a serving of fish, cup of soup and a fresh fruit every

meal, however, she consumes less every breakfast and dinner time. Mrs. L.V. is having

difficulty in eating. She stated that every time she eats, her coughs are nonstop, and it

makes her feel nauseated. Mrs. L.V. was advised by her doctor to limit her caffeine and

salt intake. She was told that eating too much salt causes the body to keep or retain too

much water, causing breathing to be more difficult. Furthermore, Mrs. L.V. was

encouraged to include high-fiber foods such as legumes, rice, fruits, vegetables, and

grains in her diet. However, due to loss of appetite and difficulty in eating, Mrs. L.V. had

lost some weight. Her weight went from 57 kg to 53 kg in just 1 month. Her skin is thin,

dry, and pale but without any presence of edema and lesions at upper and lower

extremities. Moreover, Mrs. L.V. has incomplete teeth without tooth decay or any dental

health problems. As to Mrs. L.V.’s last dental check-up, she verbalized, “Noong high

school pa ako nakapag check-up sa dentista para mag pabunot ng ngipin, mga 1991

siguro yun , tapos wala na. Mahirap lang kami at okay pa noon yung mga ngipin ko.

Ngayon matanda na ako,natural lang siguro na mawalan na ako ng mga ngipin.”

 c. Elimination Pattern 

Mrs. L.V. verbalized that before her hospitalization she could defecate 1-2 times

a day without experiencing any sign of discomfort. She also stated that her stool is

brown in color and is well-formed. After her hospitalization, she verbalized that she now

defecates once a day but not every day and wherein her stool is soft, is minimal in

amount and brown in color. As to her urinary elimination, Mrs. L.V. verbalized that she
 20

usually voids 6-8 times a day before her hospitalization. She also states that her urine is

yellow in color and does not experience pain when voiding. But after her hospitalization,

she stated that she voids 3-5 times a day without pain and discomfort and the color of

urine was still yellow. She also verbalized that she has no trouble holding her urine and

when she has the urge to urinate, she does so immediately. Mrs. L.V. stated that she

also utilizes a urinal every night as to avoid getting up and going to the bathroom. Mrs.

L.V.'s bowel elimination changed in terms of frequency, consistency, and amount of

stool, as well as the frequency and amount of urine elimination before and after her

hospitalization.

d. Activity Pattern

Table 3. Functional Level of Patient L.V.

Perceived Activities Functional Level

Feeding 0
Grooming 0
Bathing 0
General Mobility 1
Toileting 0
Cooking 4
Bed Mobility 0
Home Maintenance 4
Dressing 0
Shopping 2

Functional Level Code: 

Level 0 – Independent 

Level I – Requires use of equipment or device 

Level II – Requires assistance or supervision from another person 

Level III – Requires assistance or supervision from another person and use of

equipment or device  

Level IV – Dependent and unable to participate 

Mrs. L.V has a functional level code of 0 when it comes to feeding, grooming,

bathing, toileting, bed mobility, and dressing which only means that she does not
 21

require help and assistance when she is eating, she also has the ability to groom herself

by maintaining dental hygiene, nail, and hair care, she doesn’t have any issues taking a

bath or cleaning herself, she has the ability to get to and from the toilet without any

assistance, she is able to perform activities such as rolling or turning from lying on her

back to side lying, side-lying to sitting and sitting to lying down, and also she has the

ability to select appropriate clothes and put the clothes on. Mrs. L.V. has a functional

level code of 1 when it comes to general mobility which only means that she was able to

move and walk independently. However, only for shorter periods of time. She needs to

use an inhaler when walking for too long. Mrs. L.V. has a functional level of 4 when it

comes to cooking and home maintenance because after her family became aware of

her current condition, she was forbidden to cook, clean, and keep up with home

maintenance by her family to avoid straining her more. 

e. Sleep – Rest Pattern 

Mrs L.V. verbalized that before her hospitalization she already has difficulty in

sleeping wherein she stated that after falling asleep she will eventually wake up again

and will not return back to sleeping because of the recurrent cough and the shortness of

breath she was experiencing when lying down in her bed, she also expressed that she

sleeps for a short period of time about 4 hours a day. She does not use any sleeping

aids nor have any dreams but she sometimes has nightmares of herself drowning.

Therefore, Mrs. L.V. was not generally rested and was not ready to perform her daily set

of activities due to the fatigue and body weakness brought by lack of sleep. Mrs. L.V.

also included that when it’s morning, and the sun is at its peak and is scorching, this is

the time when she experiences more symptoms and physical activity limitations. Mrs.

L.V. indicated that after her hospitalization she still has difficulty in sleeping and that she

sleeps for short periods of time about 3-4 hours a day due to pain. Mrs. L.V.’s sleep and

rest pattern has not changed much before and after her hospital admission.  Pain also

contributes as a big factor for disturbances in her sleeping pattern.

 22

f. Cognitive – Perceptual Pattern 

Mrs. L.V stated that she has no problem with her sense of hearing and does not

utilize any hearing aids. She wears eyeglasses stating, “noong 40 years old ako,

nagsimulang lumabo yong mga mata ko lalo na itong kaliwa, palaging sumasakit ‘yong

ulo ko iyon pala dahil sa mga mata ko siguro dahil na rin sa pagtatanda.” She stated

that she only finished high school and was not able to proceed to college due to

financial instability. Presently, she does not have any difficulty in learning. She

emphasized that she always listens to the radio because of how informative it is. As for

her memory, she can still clearly recall her childhood and life experiences and is well

oriented to person, place, date, and time. She was able to quickly comprehend the

questions well during the interview. She participates well all throughout the assessment.

When asked about any physical pain or discomfort, she verbalized “masakit ‘yong

dibdib ko, parang may nakadagan, parang may sumasakal sa akin, siguro ngayon nasa

nasa 7” on a pain scale of 0-10. She was prescribed by her physician nebulizer, inhaler,

and mucolytics in which she abides by religiously to feel comfort and to breathe well. 

g. Self-Perceptual – Self – Concept Pattern 

Mrs. L.V verbalized that she doesn't feel good about herself lately due to the

discomforts brought about by COPD. She said that somehow it brought her self-esteem

and self-confidence down for quite some time when her body changed physically and

that it also affected her emotional and mental health. All throughout the interview, she

was not able to hold eye contact well and was hesitant in answering some questions.

When she was diagnosed with COPD, she started to take care of herself more, this

included stopping her work as a laundress and instead focused on being a housewife

more. She reached out to her relatives to help her financially especially with her

medications. She asked one of her daughters who is old enough to handle the kitchen

chores especially that they are using firewood and charcoal for cooking. She also stated

that, “Ang asawa ko tumigil na rin sa paninigarilyo simula noong nalaman namin ‘yong
 23

sakit ko. Masaya ako kasi talagang pinagtuonan niya ng pansin ang mas makakabubuti

sa kalagayan ko.” She stated that when she was diagnosed, she was anxious and

scared but with the help of her family who became her support system, she was able to

cope up with the struggles and changes brought about by her disease. 

h. Role – Relationship Pattern 

Before, when Mrs. L.V was single, she lived with her mother and father. Her

mother had cancer and her father had a stroke a year ago. There were three girls and

two boys with a total of five siblings including her and one of her sibling Ms. A.V had

cancer. Now that she had her own family, she lived with her husband who is a chain

smoker together with their three children. The common problem in the whole world is

the problem also of Mrs. L.V which is poverty, and it is very difficult to solve. Her

children need to go to school, and she needs to find a way to feed them. That's why she

works as a laundress and her husband works as a tricycle driver. The family felt sad

about what happened to the patient, especially that she was diagnosed with COPD

emphysema. It is difficult for her to do her task or work because she every time has

trouble breathing. It is very difficult for her to provide for the needs of their children

because of poverty. The patient is a very sociable individual and her friends like her

neighbor help her sometimes with the tasks she does like carrying heavy objects. She

felt lonely sometimes because of the maltreatment she had to endure. When it comes to

work, she works hard to feed her family, but it is difficult for her to move fast or to

transfer from one place to another. The income of her is 200 and it depends if she was

called to wash the clothes it is not her everyday income also her husband had 300/day

from his work as a tricycle driver.

i. Sexuality – Reproductive Pattern 

There is a change when it comes to sexuality because the patient was already

diagnosed with COPD. COPD symptoms like coughing and shortness of breath will
 24

almost certainly change the way she and her partner express themselves sexually. But

that doesn’t mean that they must bid adieu to sex or other forms of physical intimacy.

Mrs. L.V husband usually talked to her when he wants to make love because it is very

important to talked about sex with your partner openly and directly especially if your

partner had COPD. Married couples must first agree upon the steps they will take

together to overcome any sexual problems that arise.  Mrs. L.V and her husband were

not that sexually active like once a month only because of the condition of Mrs. L.V.

Sometimes Mrs. L.V cannot handle taking long in bed. 

B. Medical

1. Medical History

In the medical history of Mrs. L.V. She verbalized that before she had

COPD, she didn’t have any health problems and considers herself as a healthy

individual. She had complete vaccine shots of polio, BCG, DPT, while Tetanus Toxoid

was the only one, she couldn’t finish. Her last dental check-up was in 1991 when she

was still a high school student. 

In 2015, she noticed that there was a decline in her condition. She had a

persistent cough for several weeks and it didn’t go away. Unknowingly her condition has

progressed into a serious disease. She decided to get a check-up in 2017 at the local

health center due to her unbearable health condition where she had difficulty in

breathing and persistent coughing. After the check-up, her X-ray result showed that she

had Emphysema. She was told by the physician that her condition was caused by her

husband's years of smoking that made her a recipient for secondhand smoke and she

also confirmed that they use coals and wood for cooking. Mrs. L.V. was exposed to

these irritants for several years which had accumulated in her lungs, leading to the

progression of her disease condition.

2. Admitting Diagnosis/Initial impression 

 25

Admitting Diagnosis: Chronic Obstructive Pulmonary Disease (COPD): Emphysema

Final Diagnosis: Chronic Obstructive Pulmonary Disease (COPD): Emphysema

Mrs. L.V. was diagnosed with Chronic Obstructive Pulmonary Disease (COPD):

Emphysema which is a chronic lung disease that is caused when a person is smoking

or a second-hand smoking recipient. At the same time the exposure to lung irritants

such as fumes and dust that further irritates the lung causing it to be inflamed. Upon

admission, Mrs. L.V. can’t talk properly due to her ragged respiration. She is having

difficulty in breathing and her chest seems to be barreled. Mrs. L.V looked weak and

deprived of sleep, with her evident droopy eyes; she moved slowly while trying to

compensate for her breathing. In addition, some of her bony structures are protruding

and she lost a significant amount of weight. 

3. Laboratory and Diagnostic Examinations

A. Pulmonary Function Tests (PFS) / Spirometry

Date: August 23, 2021

Time Taken: 2pm - 3 pm

Table 3. Pulmonary Function Tests (PFS) / Spirometry Results of Patient L.V.

Exam Results Normal Values Comments

Forced expiratory 67% FEV1 is the amount

volume (FEV1) of air you can force

Based on the
from your lungs in
Pulmonary function
one second
tests of Patient L.V.,

she really

manifested COPD-
Normal:
Emphysema
80% to 120%
 26

because of the

acquired results on
Forced vital  65% Forced vital
every test that are
capacity (FVC) capacity (FVC) is
mostly below the
the total amount of
normal range
air exhaled during
values, specifically
the FEV test. 
the FEV1/FVC ratio

of 65% and FEV1 of

67% wherein both

Normal:
are below the
80% to 120%
normal ranges.

Also, the mMRCA

Absolute FEV1/FVC 65% The ratio FEV1/FVC
breathlessness
ratio is between 70% and
scale of Patient L.V.
80% in normal
indicates a grade of
adults; a value less
2 that she walks
than 70% indicates
slower than those
airflow limitation and
people with the
the possibility of
same age as her
COPD.
and have to stop for

breath when

walking at
Normal:
preferably pace. For
Within 5% of the
predicted ratio the COPD severity

assessment, the

patient may be
 Total lung capacity  83% Total lung capacity
categorized to
(TLC) (TLC) is the total
Group B COPD
volume of air in the
 27

lungs after a severity with a

maximal inspiration. mMRCA

breathlessness

grade of 2 and at

Normal: least 0-1

exacerbation history
80% to 120%
with no hospital
Functional residual  70% The functional
admission.
capacity residual capacity

(FRC) is the resting

volume at which the

elastic recoil

pressure of the lung

inward equals the

elastic recoil

pressure of the

chest wall outward,

alveolar and mouth

pressure are both

zero, and there is

no airflow.

Normal:

75% to 120%

Residual volume 122% Residual volume

(RV) (RV) the amount of

gas remaining in the

 28

lung at the end of a

maximal exhalation.

Normal:

75% to 120%

Diffusing capacity of 57% The diffusing

carbon monoxide capacity for carbon

(DLCO) monoxide (DLCO) is

also known as the

transfer factor for

carbon monoxide or

TLCO. It is a

measure of the

conductance of gas

transfer from

inspired gas to the

red blood cells.

Normal:

> 60% to < 120%

 29

B. mMRC Breathlessness Scale

Table 4. mMRC Breathlessness Scale

Grade Description of Breathlessness

0 I only get breathless with strenuous exercise 

1 I get short of breath when hurrying on level ground or walking up a slight

hill

2 On level ground, I walk slower with people with the same age because of

breathlessness, or have to stop for breath when walking at my own pace

3 I stop for breath after walking about 100 yards or after a few minutes on

level ground 

4 I am too breathless to leave the house or I am breathless when dressing

Date of Assessment: August 23, 2021

 Patient Grade: 2

C. COPD Severity Assessment Tool

Figure 2. COPD Severity Assessment Tool

 30

Results:

mMRC: Patient Grade no. 2

Exacerbation history: 1

Findings: Severity Group B - High Symptoms, Low Risk

D. ABG Results

Date:  August 23, 2021

Table 5. ABG Results of Patient L.V.

Exam Results Normal Values Comments

RR 23 Normal: 12-20 cpm

less than 12: bradypnea Respiratory acidosis with no

compensation.
greater than 20: tachypnea

There is respiratory acidosis

pH 7.32 7.35-7.45
because in Emphysema,
less than 7.35: acidosis
there is alveolar destruction
(respiratory acidosis or
 31

metabolic acidosis) thus, alveolar gas exchange is

damaged resulting in failure of

greater than 7.45: alkalosis
the lungs to expel carbon
(respiratory alkalosis or
dioxide and causing it to retain
metabolic alkalosis)
in the body. In the human
pCO2 54 35-45 mmHg
body, carbon dioxide forms

Increased: alveolar carbonic acid causing the

hypoventilation, respiratory patient to have respiratory

acidosis acidosis. 

Decreased: alveolar In the case of the patient, the

hyperventilation, respiratory kidneys did not compensate

alkalosis (release bicarbonate) to

counteract the increasing

pO2 68 80-100 mmHg
levels of CO2 as seen in the

Decreased: respiratory data wherein it remained within

diseases (emphysema, its normal ranges. 

pneumonia and pulmonary

Client was diagnosed with
edema; in the presence of
emphysema, a type of chronic
hemoglobin; and in
obstructive pulmonary disease
polycythemia.
that causes retention of carbon

HCO3 25 22-26 meq/L dioxide resulting in respiratory

acidosis. However, the kidneys

Decreased: metabolic
did not release bicarbonate to
acidosis
compensate. 
Increased: metabolic

alkalosis

B.E. 2.9 -2 to +2 mmol/L

 32

Less than -2: acidosis

Greater than 2: alkalosis

O2 Sat 89% 95-100%

E. Radiography

Chest X-Ray

Figure 3. Films of Patient L.V.’s Chest X-Ray

Frontal Lateral

Date taken: August 23, 2021 

Remarks:

Lungs are large and hyperinflated; hyperlucent lung fields; increased AP

diameter; increased retrosternal air encroaching on heart density; multiple blebs:

avascular zones surrounded by thin wall on right portion of lung; vertical heart; low set

flat diaphragm in 12th posterior rib.

 33

Chest CT scan

Figure 4. Film of Patient L.V.’s Chest CT Scan

Date taken: August 23, 2021 

Remarks: 

Flattened hemidiaphragms; increased retrosternal airspace; right ventricular

enlargement.
 34

F. Alpha 1-Antitrypsin Screening

Table 6. Alpha 1-Antitrypsin Screening Results of Patient L.V.

Patient History Results Normal Findings Comments

 No family history of 135 Alpha-1 antitrypsin (AAT) No deficiency of Alpha-1

COPD mg/dL testing is used to help antitrypsin (AAT) noted. The

diagnose alpha-1 condition of the patient was

 Passive smoker
antitrypsin deficiency as mainly delved from passive
due to exposure of
the cause of early onset smoking or secondhand smoke
self to the husband
emphysema or chronic coming from her active smoker
which is an active
obstructive pulmonary husband. At the same time,
smoker
disease (COPD) when a she is a charcoal user in terms

 Use of charcoal in person does not have of cooking preferences.

cooking obvious risk factors such

as smoking or exposure to

lung irritants such as dust

and fumes. 

Normal:

75 to 150 milligrams per

deciliter (mg/dL)
 35

G. Complete Blood Count Results

Table 7. Complete Blood Count Results of Patient L.V.

TEST Results Normal Values

Red Blood Cells (RBCs) 10^12/L 4.8 4.5 - 5.5 

Hemoglobin (Hb) g/dL 115 120 - 160

Hematocrit (Hct) % 0. 38 0.36 - 0.42 

White Blood Cells (WBCs) 10^9/L 7 5 - 10

MCV          fL 87 80 - 100

MCHC       g/dL 29 32 - 36

DIFFERENTIAL COUNT (%)

Neutrophils 0. 55 0. 51 - 0.67

Lymphocytes 0. 26 0.21 - 0.35

Monocytes 0.05 0.04 - 0.08

Eosinophils 0.02 0.02 - 0.04

Basophils 0.01 0 - 0.01

Platelets   10^9/L 200 150 - 400

BLOOD TYPING

ABO “O”

Rh Positive

Hepatitis B Surface Antigen Non-reactive

Date: August 23, 2021

Time Taken: 10 AM
 36

Interpretation: Based on the hematology results, the patient doesn't have any infection

related. Decrease level of hemoglobin and mean corpuscular hemoglobin concentration

noted.

H. Serum Electrolytes Test

Table 8. Serum Electrolytes Test Results of Patient L.V.

Exam Name Result Normal Values

Sodium (Na) 139 meq/L 135 - 148

Potassium (K) 4.2 meq/L 3.6 - 5.4

Calcium (Ca) 9.1 mg/dL 8.5 - 10.5 (4.3 - 5.3 meq/L)

Magnesium (Mg) 1.8 meq/L 1.5 - 2.5 

Chloride (Cl) 127 meq/L 97.2 - 150.3

Phosphorus (P) 2.9 mg/dL 2.5 to 4.5 

Date: August 23, 2021

Time Taken: 10 AM

Interpretation: Normal serum electrolytes results.

I. Chemistry Test

Table 9. Chemistry Test Results of Patient L.V.

Test  Results Normal Values

Blood Urea Nitrogen (BUN) 6.5 3.2 - 7 mmol/L

Creatinine 93 71 - 133 mmol/L

SGPT (ALT) 45 13 - 61 mmol/L

SGOT 19 14 - 50 mmol/L

Total CHON 62 63 - 83 G/L

Albumin 31 35 - 50 G/L
 37

Globulin 31

A/G Ratio 1.0

Date: August 23, 2021

Time Taken: 10 AM

Interpretation: Results of the Chemistry Test are normal.

 38

J. Tissue Biopsy Test (Needle Biopsy)

Table 10. Chemistry Test Results of Patient L.V.

Description Result

A local anesthetic is given, the doctor uses a needle that is Tissue sample obtained:

guided through the chest wall into a suspicious area with

Non - cancerous
computed tomography (CT or CAT scan) or fluoroscopy (a

type of X-ray “movie”) to obtain a tissue sample. 

Date: August 24, 2021

Time Taken: 10 AM
 39

ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM

Figure 5. Respiratory System

The respiratory system has two divisions: the upper respiratory tract and the

lower respiratory tract. The upper respiratory tract includes the nose, the pharynx

(throat), and the larynx. The lower respiratory tract includes the trachea, the bronchi,

and the lungs.

The nose consists of the external nose and the nasal cavity. The external nose is

the visible structure that forms a prominent feature of the face. The next structure is the

pharynx which is the common passageway for both the respiratory and the digestive

systems. Air from the nasal cavity and air, food, and water from the mouth pass through

the pharynx. The larynx commonly called the voice box, is in the anterior throat and

extends from the base of the tongue to the trachea. It has three main functions:

maintains an open airway, protects the airway during swallowing and produces the

voice. The trachea or windpipe allows air to flow into the lungs. It is a membranous

tube attached to the larynx. The trachea is lined with a mucous membrane. This

membrane consists of pseudostratified columnar epithelium, containing numerous cilia

and goblet cells. The cilia sweep the mucus embedded with foreign particles into the

pharynx, where it is swallowed. Constant, long-term irritation of the trachea by cigarette

smoke can cause the tracheal epithelium to change to stratified squamous epithelium.

The stratified squamous epithelium has no cilia and therefore cannot clear the airway of

mucus and debris. The accumulations of mucus provide a place for microorganisms to
 40

grow, resulting in respiratory infections. Constant irritation and inflammation of the

respiratory passages stimulate the cough reflex, resulting in "smoker's cough."

Then, the trachea divides into the left and right main bronchi, or primary

bronchi, each of which connects to a lung. The lungs are the principal organs of

respiration. The tracheobronchial tree consists of the main bronchi and many branches.

Each main bronchus divides into lobar bronchi (or secondary bronchi), as they enter

their respective lungs. The bronchi continue to branch many times, finally giving rise to

bronchioles. Which subdivides until it reaches to respiratory bronchioles. Each

respiratory bronchioles subdivides to form alveolar ducts, long, branching ducts with

many openings into alveoli. Alveoli are small air-filled chambers where the air and the

blood come into close contact with each other.

The respiratory membrane of the lungs is where gas exchange between the air

and blood takes place. The elastic fibers surrounding the alveoli allow them to expand

during inspiration and recoil during expiration. The lungs are very elastic and, when

inflated, can expel the air and returning to their original, uninflated state.

The muscles associated with the ribs are responsible for ventilation. Inhaling

requires a set of muscles called the muscles of inspiration. The muscles of inspiration

include the diaphragm and the muscles that elevate the ribs and sternum, such as the

external intercostals. The diaphragm is a large dome of skeletal muscle that separates

the thoracic cavity from the abdominal cavity. Forceful exhalation requires a set of

muscles called the muscles of expiration. The muscles of exhalation include the internal

intercostals and depress the ribs and sternum.

At the end of a normal, quiet expiration, the respiratory muscles are relaxed.

During quiet inspiration, muscles of inspiration contract to increase the volume of the

thoracic cavity. Contraction of the diaphragm causes the top of the diaphragm to move

inferiorly. Contraction of the external intercostals also elevates the ribs and sternum to

increase thoracic cavity volume. Expiration occurs when the thoracic cavity volume
 41

decreases. During quiet expiration, the diaphragm and external intercostals relax. The

elastic properties of the thorax and lungs cause them to recoil into a relaxed state.
 42

C. Pathophysiology of Patient’s Disease

Precipitating Factors
Predisposing Factors
 Passive smoking (second-hand smoke)
 Gender (Female)
 Indoor and Outdoor pollution
 Low socioeconomic status
 Exposure to dust and outdoor pollution
 Indoor air pollution (chemicals from laundry
detergent and cleaning materials) and (burning
of charcoal for cooking)

Etiology
Long term exposure to lung irritants

Lung Inflammation

Complications

Free radicals produced in triggers inflammatory and immune cell

lungs recruitment within large and small
airways and in the terminal air spaces
of the lungs

Inflammatory cells release proteinases

damage the extracellular matrix

supporting airways, vasculature, and
gas exchange surfaces of the lung.

Acute Viral Infection
Exacerbation of
COPD
Acute Bacterial Infection
Death
Decrease airway elasticity
Decrease elastic recoil to
push air out of lungs
Trapping of air within lungs
43
Increase proteolytic destruction of lung
parenchyma
Destruction of alveolar walls and Medications
capillaries
hydrocortisone (100mg, IVTT, q8h)
ipratropium + salbutamol (1 neb,
Airflow obstruction nebulization inhalation, q6h)
fluticasone + salmeterol puffs (2
puffs, Oral inhalation, q12h)
Chronic Obstructive Pulmonary Disease
Emphysema
Decrease structural Increased mucus
supports for airway production
patency
Permanent enlargement /
overdistention of alveoli
Airway narrowing
Chronic productive
and collapse
cough with clear to
Increase in dead space gray sputum
(lung areas where no gas Turbulent airflow
exchange can occur) in narrow airways
Nursing Diagnosis:
Wheezing (upon Ineffective airway
auscultation) clearance
 44

PFT/Spirometry Lung Chest X-Ray Remarks: Impaired oxygen and Nursing Diagnosis:
Result: hyperinflatio Lungs are large and CO2 exchange Impaired Gas Exchange
FEV1 = 67% n hyperinflated
Normal: 80% to 120% hyperlucent lung fields
FVC = 65% Impaired Impaired CO2
Normal: 80% to 120%
More effort needed to
ventilate larger lungs oxygen diffusion elimination

mMRC
Pursed lip Breathlessness hypoxemia hypercapnia
Dyspnea
breathing Scale:
RR: 25 cpm
Tripod Sitting Normal: 12-20 cpm Patient Grade = 2
Position O2 Saturation:
ABG Result:
89%
Normal: 12-20 cpm pCO2 = 54 mmHg
Increase use of Normal: 35-45 mmHg
Barrel
accessory muscles to Respiratory Acidosis
chest
improve airflow
Decrease perfusion of
body tissues (brain,
muscles, etc.)
Nursing Diagnosis:
Impaired breathing Nursing Diagnosis: Central Cyanosis
pattern Activity Intolerance Fatigue Capillary Refill: 4 seconds
Alteration in comfort Body weakness normal = 0 – 3 seconds
Decrease exercise tolerance

Muscle wasting
 45

Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease or COPD is a preventable and treatable,

slowly progressive respiratory disease. In other words, this disease worsens over time if

not treated. This is marked by an airflow obstruction in the airways, pulmonary

parenchyma, or both, which is not fully reversible. Any form of lung tissues such as the

bronchioles, bronchi, blood vessels, interstitium, and alveoli is included in the lung

parenchyma. 

People with COPD become symptomatic during the middle years which

increases along with age. Similarly, the airflow limitation also progresses as lungs

continuously become inflamed in response to the external particles and gases. One of

the most important environmental risk factors is cigarette smoking which depresses the

activity of the scavenger cells and respiratory tract’s ciliary cleansing mechanism in

keeping the lungs free from irritants. Because of chronic inflammation and the body’s

attempt to repair such, this will result in changes including airway obstruction and

narrowing of lung airways. 

Emphysema

In emphysema, impaired oxygen and carbon dioxide exchange results from

destruction of the walls of overdistended alveoli. Emphysema is a pathologic term that

describes an abnormal distention of the airspaces beyond the terminal bronchioles and

destruction of the walls of the alveoli (GOLD, 2015). In addition, a chronic inflammatory

response may induce disruption of the parenchymal tissues. This end-stage process

progresses slowly for many years. As the walls of the alveoli are destroyed (a process

accelerated by recurrent infections), the alveolar surface area in direct contact with the

pulmonary capillaries continually decreases. This causes an increase in dead space

(lung area where no gas exchange can occur) and impaired oxygen diffusion, which

leads to hypoxemia. In the later stages of disease, carbon dioxide elimination is

 46

impaired, resulting in increased carbon dioxide tension in arterial blood (hypercapnia)

leading to respiratory acidosis.

Due to this process, patients with COPD manifest respiratory symptoms including

cough, sputum production and severe dyspnea which interfere with quality of life and

activities of daily living. Mrs. L.V. has been exposed to secondhand smoke, chemicals

used in doing laundry (chlorine) and pollution caused by charcoal in cooking which

contributed to the chronic inflammation and destruction of the walls of overdistended

alveoli which cumulatively posed as the factors for her to acquire emphysema. In

addition, there is impaired oxygen and carbon dioxide exchange which explains why

Mrs. L.V is having shortness of breath. Other than that, since carbon dioxide is not

expired totally and retained in the body, our patient is experiencing respiratory acidosis.

Also, there is inflammation and narrowing of the airway in any location, from your throat

out into your lungs with emphysema which results to the patient having expiratory

wheezing.

V. Management 
A. Medical / Surgical 

1. Doctor’s order 
Table 11. List of Doctor’s Orders for Patient L.V.
Time Doctor’s Orders Significance
Day 1
August 23, 2021

8 AM Admitting Diagnosis:
COPD (Emphysema)

10 AM Medications:
 hydrocortisone (Hydrocort)  hydrocortisone - used
to treat inflammation of
 47

100 mg IVTT, q8h the lungs leading to

improved lung function
 ipratropium +
 ipratropium + salbutamol salbutamol – treat
(DuoNeb) 1 neb, nebulization symptoms of COPD
inhalation, q6h such as wheezing and
shortness of breath
 fluticasone +
 fluticasone + salmeterol puffs salmeterol puffs –
(Flovent diskus) 2 puffs, oral treats inflammation of
inhalation, q12h the lungs and opens up
the medium and large
10 AM airways in the lungs.
Procedures:  Supplemental O2 is the
only pharmacologic
 Administer oxygen at 6 L/min therapy demonstrated
via face mask to unequivocally
decrease mortality
rates in patients with
COPD. This is to aid in
patient’s oxygenation.
Day 2
August 24, 2021

8 AM Lab/Diagnostic Tests:  These laboratory and

 Request for CBC, ABG,
Tissue Biopsy, Serum
Electrolytes
 Schedule patient for CXR,
Lung CT scan
diagnostic tests are
used to help confirm
the diagnosis of COPD,
determine disease
severity, and monitor
disease progression

10 AM  Sterile mixture of salt

IV Fluids and water; also called
 Start IVF PNSS 1L @ KVO isotonic solution to
promote hydration

 KVO maintains patency

of IV line so that
subsequent
intravenous solutions
or medicines can be
administered in
emergency cases.
 48

Day 3
7 AM August 25, 2021

Lab/Diagnostic Tests:  Results for chest x-ray

and CT scan were not
 Follow up results for CXR, CT
yet given by the
scan
laboratory. Informing
the department
regarding the delay is
10 AM necessary for follow
-up.

 Needle Biopsy is an
invasive procedure.
 Obtain patient’s consent for Obtaining the patient’s
biopsy consent is important to
carry out the procedure

 Early referral warrants

 Refer for episodes of DOB, urgent treatment and
increase respiratory rate >30 can avoid severe
cpm, and any significant complications.
changes in signs and
symptoms

Day 4
August 26, 2021

Decrease oxygen @ 5 L/min  Patient’s O2 saturation

slightly increased thus,
oxygen therapy is
slightly decreased. This
continuously aids
patient’s oxygenation.
 49

2. Procedures done 
Mrs. L.V. did not undergo ay surgical interventions because she only had

moderate COPD which can be managed by prescribed medicines including

corticosteroids, bronchodilators, and supplemental oxygen. The following are the

laboratory and diagnostic procedures don to the patient and its significance:

Pulmonary Function Tests (PFS)

Non-invasive tests that show how the lungs are working. Measures lung

volume, capacity, rate of flow, and gas exchange. Most effective and common

in diagnosing Chronic Obstructive Pulmonary Disease.  

mMRC Breathlessness Scale 

Quantifies the disability associated with breathlessness. Useful in

characterizing baseline dyspnea in patients with respiratory diseases.

COPD Severity Assessment Tool 

Short questionnaire designed to assess the impairment in health status of

COPD patients.

Arterial Blood Gas (ABG) 

Measure the acidity (pH) and the levels of oxygen and carbon dioxide in the

blood from an artery. Results of the test can show the severity of COPD in

patients and whether they need oxygen therapy.  

Chest X-ray 

Used to evaluate the lungs, heart, and chest wall and may be used to

diagnose dyspnea and persistent cough. Can help and support diagnosis for

advanced emphysema in COPD patients. 

Chest CT Scan 
 50

Helps in identifying problems such as infections, lung cancer, blocked blood

flow in the lung, and other lung problems. In COPD patients, this is used to

detect emphysema, chronic bronchitis and other conditions such as heart

failure causing COPD symptoms. 

Alpha 1-Antitrypsin Screening 

Used to help diagnose alpha-1 antitrypsin deficiency as the cause of early

onset emphysema or COPD.

Complete Blood Count 

Group of tests that evaluates the cells that circulate in the blood and the

overall health of an individual, detecting varieties of diseases and conditions.

Serum Electrolytes Test 

A blood test that measures the levels of the body’s main electrolytes. Helps in

determining the distribution of electrolyte imbalances in a COPD patient. 

Chemistry Test 

Group of tests that are routinely ordered to determine a person’s general

health status.

Tissue Biopsy Test (Needle Biopsy)

A medical procedure that takes a small sample of tissue to examine it closely.

Usually recommended by physicians when initial tests suggest an area of

tissue in the patient’s body is not normal. In COPD patients, a lung biopsy is

used to determine if lung cancer is present.

 51

3. DRUG STUDY

Name: Mrs. L.V. Date of Admission: August 23, 2021

Age: 44 years old Chief complaint: Recurrent cough

Room: Room 1, Medical Ward, TDH Diagnosis: COPD (Emphysema)

Attending Physician: Dr. X. Y. Z

DRUG STUDY

GENERIC BRAND CLASSIFICATION MECHANISM OF INDICATION SIDE EFFECTS NURSING CONSIDERATIONS

NAME NAME ACTION

hydrocortisone Hydrocort Pharmacologic: Enters target cells It is commonly CNS:

● Give daily before 9am to
Corticosteroids and binds to used to treat
Vertigo, headache, manic normal peak diurnal
(short acting) cytoplasmic inflammation of
paresthesias, corticosteroid levels and
Dose: 100mg receptors; initiates the lungs leading
insomnia, seizures, minimize HPA
Route: IVTT many complex to improved lung
psychosis suppression
Therapeutic: reactions that are function and
Frequency: q8h
responsible for anti- shorten the length ● Space multiple doses
 52

Anti-inflammatory inflammatory, of hospital stay. CV:

evenly throughout the day
immunosuppressive
Hypotension, shock,
(glucocorticoid), and ● Do not give IM injections if
hypertension and
salt retaining patient has
heart failure
(mineralocorticoid) thrombocytopenia purpura
secondary to fluid
actions. Some
retention,
actions may be ● Rotate sites of IM
thromboembolism,
undesirable, repository injections to
thrombophlebitis, fat
depending on drug avoid local atrophy
embolism, cardiac
use.
arrythmias secondary ● Use minimal doses for
to electrolyte minimal durations to
disturbances. minimize adverse effects

● Taper doses when

Dermatologic: discontinuing high-dose or

long-term therapy
petechiae,
ecchymoses, purpura, ● Arrange for increased
striae dosage. When patient is
subject to unusual stress

EENT: ● Ensure that adequate

amount of Ca2+ is taken if
 53

Cataracts, galucoma,
prolonged administration
increased IOP
of steroids

● Use alternate day

Endocrine:
maintenance therapy with
Amenorrhea, irregular short acting
menses, growth corticosteroids whenever
retardation, decreased possible
carbohydrate
tolerance and
diabetes mellitus

GI:

peptic or esophageal
ulcer, pancreatitis,
abdominal distention,
nausea, vomiting,
increased appetite
and weight gain
 54

Hematologic:

Hypokalemia,
hypocalcemia,
increased blood
sugar, increased
serum cholesterol

Other:
Immunosuppression,
aggravation, or
masking of infection

ipratropium + DuoNeb Pharmacologic: Anticholinergic, This is used to CNS:

● Protect solution for
salbutamol mechanically related treat and prevent
Anticholinergic + nervousness, inhalation from light. Store
to atropine, which symptoms
short-acting β2- dizziness, headache, unused vials in foil pouch
blocks vagally (wheezing and
adrenergic receptor fatigue, insomnia,
Dose: 1 neb mediated reflexes by shortness of
agonist blurred vision ● Use nebulizer mouthpiece
Route: antagonizing the breath) caused by instead of face mask to
nebulization action of ongoing lung avoid blurred vision or
inhalation Therapeutic: Long- acetylcholine. disease (chronic GI: aggravation of narrow
acting Causes obstructive angle glaucoma
Nausea, GI distress,
 55

Frequency: q6h Bronchodilators bronchodilation and pulmonary dry mouth

● Ensure adequate
inhibits secretion disease-COPD
(Respiratory hydration; control
from serous and which includes
Inhalant Combos) environment (temperature)
seromucous glands bronchitis and Respiratory:
to prevent hyperpyrexia.
lining the nasal emphysema) Dyspnea, bronchitis,
mucosa. bronchospasms, ● Have patient void before
cough, exacerbation of taking the medication to
symptoms, avoid urinary retention
hoarseness,
● Teach patient proper use
pharyngitis
of inhaler

fluticasone + Flovent Pharmacologic: Fluticasone exact Maintenance and CNS:

● Assess pulmonary
salmeterol diskus mechanism of action prophylactic
Corticosteroids headache, dizziness function periodically by
puffs is unknown. It has treatment for
measuring lung volumes,
potent anti- patients with
breath sounds, respiratory
Therapeutic: inflammatory COPD EENT:
Dose: 2 puffs rate, and other symptoms
actions. It exerts its
Anti-inflammatory dysphonia, (dyspnea, wheezing,
Route: Oral beneficial effects by
(steroidal) hoarseness, shortness of breath).
inhalation inhibiting several
oropharyngeal oral
types of cells and ● Observe paradoxical
Frequency: q12h infections, nasal
chemicals involved bronchospasm (cough,
stuffiness, rhinorrhea,
in allergic, immune wheezing, dyspnea)
 56

and inflammatory sinusitis

especially at higher doses.
responses.

● Assess muscle strength

Resp:
periodically after long-term
bronchospasm, cough, use and assess muscle
upper respiratory tract pain to rule out
infection, wheezing musculoskeletal
pathology.

GI: ● Implement resistive

exercises and weight
diarrhea
bearing activities to
minimize muscle wasting
and osteoporosis.
Endo:

adrenal suppression ● Protect skin from

(high-dose and long- breakdown, especially

term therapy), over bony prominences.

Cushing’s syndrome
● Counsel the patient and
folks on the proper use of
metered-dose inhaler or
MS:
dry-powder inhaler;
 57

muscle pain
observe use of device
whenever possible to
ensure proper technique.

● Report signs of adrenal

suppression, including
hypotension, weight loss,
weakness, nausea,
vomiting, anorexia,
lethargy, confusion, and
restlessness.
 58

4. Recommended Diet 

Mrs. L.V.’s dietician recommended the following diet guidelines aligned to her

condition, Chronic Obstructive Pulmonary Disease (Emphysema):

Total Calories per day (kcals/day): 1800 kcals/ day

Total Fat: 25 g
Calcium: 6 mg
Sodium: 1200 mg
Carbohydrates: 300 g
Protein: 65 mg
Iron: 17 mg

Chronic Obstructive Pulmonary Disease or COPD mandates a number of checks

in a patient’s eating and lifestyle habits in order to conserve energy and optimize lung

capacity and function. To maintain a COPD-friendly diet, Mrs. L.V is advised to adhere

to the following recommended diet guidelines:

1. Patient should choose the right kinds of fat when eating a higher fat diet,

avocados, nuts, seeds, coconut oil, olive oil, fatty fish and cheeses are good

choices.

2. Patient should eat complex carbohydrates that are high in fiber to help her

digestive system. This includes bran, lentils, quinoa, oats, potatoes and

barley.

3. Patient should eat the right fruits that are digestible and vegetables that do not

cause bloating. These foods are green leafy, greens, cucumbers, bell

peppers, carrots, berries, pineapple and grapes.

4. Patients should drink 6-8 glasses of water everyday because it can help to

keep the mucus thin, which means it is easier to cough up.

5. Stick to a nutrition plan to make mealtime stress-free and can form healthy

eating habits.
 59

5. Prescribed activity 

The more recent 2013 Global Initiative for Chronic Obstructive Lung Disease

(GOLD) strategy recommends that all patients with COPD should participate in daily

physical activity. One of the common problems of a person with COPD when doing

activities that require extra effort is shortness of breath. Patient is advised to manage

daily activities and it must be paced all throughout the day so that the patient can

manage to accomplish the task despite the current condition.

Pulmonary Rehabilitation

A program that can help improve breathing and quality of life. Includes breathing

retaining, exercise training, education, and counseling.

 Exercise 

o It can help the patient overcome activity intolerance; it can improve upper

and lower extremity muscles while also enhancing exercise tolerance and

endurance. 

o It can be divided into 3 basic types:

 Stretching: Helps prepare muscles for activity and prevents muscle

strain.

 Aerobic: This exercise strengthens the heart and lungs. It improves

the body's ability to use oxygen and improves breathing. (Walking,

Jogging, and Low-impact Aerobics)

 Strengthening: This strengthens the upper body through repeated

muscle contractions. It is helpful for patient with COPD. This

 60

exercise helps increase the strength of upper respiratory muscles.

 Stair Climbing

o Instruct the patient to always hold on the hand railings to maintain

balance. Always take one step at a time, while breathing out with pursed

lips. Inhale and take a rest before taking the next step.

 Breathing during activity 

o Instruct the patient to breath slowly to conserve energy while exercising or

doing activities. Tell the patient to inhale through the nose while the mouth

is closed to keep the breathed air warm and moisturized. Exhaling through

pursed lips.

Strictly impose on the patient that overstraining is not allowed. Every activity

must always be paced, and educate the patient to follow an activity regimen designed

by the physical therapist. This should be done everyday to build resistance and improve

the patient’s breathing. Through proper management and cooperation, it could make the

patient active with less shortness of breath and delay the progress of COPD, as well as

improving the patient’s quality of life.

 61

B. NURSING CARE PLAN

Name: Mrs. L.V. Date of Admission: August 23, 2021

Age: 44 years old Chief complaint: Recurrent cough
Room: Room 1, Medical Ward, TDH Diagnosis: COPD (Emphysema)
Attending Physician: Dr. X. Y. Z.

NURSING CARE PLAN NO. 1

General Objectives: To facilitate the maintenance of a supply of oxygen to all body cells.

Cues Nursing Diagnosis Rationale Specific Interventions Rationale Evaluation

Objectives
After 8 hours of
Impaired gas Within 8 hours Independent:
August 23, 2021 COPD rendering nursing
exchange related to of rendering Useful in evaluating care
8 AM Emphysema Assess and record at The
destruction of the nursing care at the degree of Doctor’s Hospital -
respiratory rate and
walls of The Doctor’s respiratory distress or Medical Ward, the
depth. Note the use
Subjective overdistended Hospital chronicity of the oxygen saturation
Long term exposure of accessory
alveoli secondary to -Medical Ward, disease process.
The following are as to lung irritants muscles, pursed-lip of the patient has
Emphysema the patient’s
verbalized by the breathing, inability to partially
oxygen
patient: speak or converse. improved as
saturation will
 62

evidence by:
 “Nahihirapan akong increase and
Lung inflammation
huminga lalo na back within the
Assess and
kapag ako’y normal range.
routinely monitor Cyanosis may be  Oxygen
naglalakad ng
. skin and mucous peripheral (noted in saturation
malayo.”
Inflammatory cells membrane color.  nail beds) or central increased from
 “Nararamdaman ko release proteinases (noted around 89% to 93%
kapag inaatake ako
lips/earlobes).  Shortness of
parang yung may
Duskiness and central breath still
huni sa dibdib ko.”
cyanosis indicate noted as
 “Tapos pakiramdam
advanced hypoxemia. evidenced by
ko para akong
RR of 22
nalulunod na may
Increase proteolytic  Shows signs of
nakadagan sa dibdib destruction of lung Monitor changes in Restlessness, improved
ko at nahihirapan parenchyma
the level of agitation, and anxiety respiratory
akong huminga.”
consciousness and are common effort as
 “‘Pag ganyang mainit
mental status. manifestations of verbalized by
ang panahon, lalo na
hypoxia. Worsening of the patient
pag sobra Destruction of
alveolar walls and ABGs accompanied by  “Kapag may
pakiramdam ko
capillaries confusion/somnolence oxygen
parangn laging
are indicative of gumagaan po
naninikip ang dibdib
cerebral dysfunction yung paghinga
ko. Parang gusto mo
 63

lagi kang nasa lalo na kapag

due to hypoxemia.
preskong lugar.” Overdistention of nakaupo.”
alveoli
 “Tapos ang  Improved
pakiramdam ko ay arterial blood
sinasakal ako.”  gas or pulse

Monitor vital signs Tachycardia, oximetry with

The following are as
Increase dead pCO2 of 44
space and cardiac rhythm. dysrhythmias, and
verbalized by the folks:
changes in the blood mmHg
 “Nahihirapan siyang pressure can reflect  Demonstrate
huminga at hinihingal the effect of systemic proper
siya at umuupo siya hypoxemia on cardiac diaphragmatic
‘pag hindi niya na Impaired oxygen breathing and
and CO2 exchange function.
kaya.” coughing
 “Minsan nag reklamo  Capillary refill
rin siya sa akin na di of 3 seconds
Breath sounds may be
siya makahinga ng
Nursing Diagnosis: faint because of
Auscultate breath
maayos at naninikip
Impaired Gas decreased airflow or
sounds, noting
ang dibdib niya dahil
Exchange areas of consolidation.
areas of decreased
sa init ng panahon,
Presence of wheezes
airflow and
kaya ang ginagawa
may indicate
adventitious
niya nagpapahinga
bronchospasm or
sounds. 
nalang siya sa bahay
Difficulty of retained secretions.
 64

namin.” Breathing r/t

destruction of the Scattered moist
 “Mas nahihirapan
walls of crackles may indicate
siyang huminga sa overdistended
alveoli 2 to interstitial fluid or
umaga. Ubo rin siya
Emphysema cardiac
ng ubo.”
decompensation

In emphysema,
Objective impaired oxygen
and carbon dioxide Pulse oximetry reading
exchange results Monitor 02 of 87% below may
Vital signs:
from destruction of saturation and titrate indicate the need for
RR: 25 cpm (Normal the walls of
Values: 12 - 20 cpm) overdistended oxygen to maintain oxygen administration
alveoli. Emphysema Sp02 between 88% while a reading of 92%
O2 Sat:  89% (Normal is a pathologic term
Values for COPD: 88 - that describes an to 92%. or higher may require
92%) abnormal distention
of the airspaces oxygen titration.
Chest X-Ray (CXR): beyond the terminal
bronchioles and
- hyperlucent and destruction of the
hyperinflated with a wall walls of the alveoli
of bleb and low-set As the patient’s
(GOLD, 2015). This
diaphragm. causes an increase condition progresses,
in dead space (lung Monitor arterial Pa02
CT Scan usually
area where no gas
exchange can blood gasses values decreases.
- damage to the walls of occur) and impaired
bronchial air sacs and as ordered.
oxygen diffusion,
gas trapping
 65

which leads to
Spirometry Test: hypoxemia.

FEV1/FVC: 60%
Elevate the head of Oxygen delivery may
Due to this process,
FEV1: 65% the bed, assist the be improved by a high
Mrs. L.V., an
emphysema patient patient to assume a fowler's position and
manifest respiratory
Arterial Blood Gas: symptom including position to ease the breathing exercises to
difficulty of breathing work of breathing. decrease airway
pH:7.32 (Normal Values:
which is precipitated
7.35 - 7.45) Include periods of collapse, dyspnea, and
by destruction of her
alveolar walls. From, time in a prone work of breathing.
this impaired gas
paCO2: 54 mmHg exchange was position as Using a prone position
(Normal Values: 35 - 45 evidenced by her tolerated. increases Pa02.
mmHg) decreased
oxygenation which Encourage deep-
triggered her to slow or pursed-lip
HCO3: 25 mEq/L have an increased
(Normal Values: 22 - 26 breathing pattern to breathing as
mEq/L) compensate with the individually needed
mEq/L decrease.
or tolerated. 

→ Respiratory Acidosis References:

with No Compensation Hinkle, J. & Thick, tenacious,
Encourage
Cheever, K.
(2018). Brunner expectoration of copious secretions are
August 23, 2021 & Suddhart’s sputum; suction a major source of
Textbook of impaired gas exchange
Medical-Surgical
 66

Nursing 14th
9 AM edition. Wolters when needed. in small airways. Deep
Kluwer suctioning may be
Objective
Yu, Y. (2013 required when the
Vital signs: January 7).
cough is ineffective for
COPD: Clinical
RR: 24 cpm (Normal expectorations of
findings.
Values: 12 - 20 cpm)
Retrieved from secretions.
O2 Sat: 86% https://calgarygui
de.ucalgary.ca/C
(Normal Values for OPD:-Clinical-
COPD: 95 - 100%) Findings
These techniques
Yu, Y. (2013
January 7). improve ventilation by
Instruct and
COPD: opening airways to
 Shortness of breath encourage patient in
Pathogenesis.
facilitate clearing the
noted Retrieved from diaphragmatic
https://calgarygui airways of sputum.
 Productive cough breathing and
de.ucalgary.ca/C Gas exchange is
and use of accessory OPD:- effective coughing.
Pathogenesis/ improved, and fatigue
breathing muscles
is minimized.
noted
 Skin Pallor
 Upon auscultation,
Lack of oxygen causes
wheezes are heard 
the lips, fingers, and
 Decreased chest
Evaluate skin color, tongue to be cyanotic;
expansion observed
temperature,
 67

and there is an
capillary refill If cyanosis happens
increased tactile
inside the mouth, it is
fremitus
considered a medical
 Minimal flaring of
emergency
nares 
 4 seconds delayed
capillary refill test
 Body weakness
noted Chronic inhalation of
 Pursed lip breathing Evaluate current both indoor and
noted. exposure to outdoor toxins causes
 Sitting in a tripod occupational toxins damage to the airways

position observed or pollutants and and impairs gas

 Occasionally cannot indoor/outdoor exchange.
finish sentences pollution.

because of
breathlessness

Dependent:
Prompt recognition of
Stress the need for side/adverse effects
medication allows for timely
 68

compliance. Review
intervention and
side/adverse effects
change in drug
with the patient. 
regimen.

Administer
medications as
prescribed.

Administer anti-
inflammatory drugs Corticosteroids are It is
such as commonly used to
corticosteroids treat inflammation of
the lungs leading to

hydrocortisone improved lung function

100mg and shorten the length

IV route of hospital stay

q8 hours

fluticasone +
 69

salmeterol puffs

2 puffs
q12 hours

Administer
bronchodilators as Bronchodilators dilate
prescribed. the airways. The
medication dosage is
ipratropium+salbut carefully adjusted for
amol each patient in
nebulizer accordance with
q6h clinical response.

Administer oxygen Oxygen will correct the

by the method hypoxemia. Careful
prescribed. observation of the liter
flow or the percentage
O2 at 2-3 L/min via
given and its effect on
face mask
 70

the patient is
important.

Collaborative:

Collaborate with
laboratory medical In order the patient to
technologists for understand the result
monitoring of and for the doctor to be
needed laboratory notified about the
tests and patient’s current
diagnostics and condition.
refer laboratory

results of the patient

to the physician to
interpret.

Collaborate with the

respiratory unit for The respiratory unit is
the proper support the expert for
 71

maintaining and
of the patient’s
troubleshooting
condition.
respiratory support
machines for patient’s
proper oxygenation if
the patient needs one
during severe signs
and symptoms.

Additional referrals
May be indicated to
may be given, such
optimize treatment. A
as to pulmonary
multidisciplinary
specialist or
approach including
pulmonary
education and exercise
rehabilitation, as
training may be helpful
appropriate.
in improving the
function and quality of
life.
 72

NURSING CARE PLAN NO. 2

General Objectives: To facilitate the maintenance of a supply of oxygen to all body cells.

Cues Nursing Diagnosis Rationale Specific Interventions Rationale Evaluation

Objectives

Ineffective airway Within 8 hours Auscultate breath Some degree of Within 8 hours of
August 23, 2021 COPD
clearance related to of rendering sounds. Note bronchospasm is rendering nursing
8 AM Emphysema
increased mucus nursing care at adventitious breath present with care at The
production The Doctor’s sounds such as obstructions in airway Doctor’s Hospital
Subjective secondary to Hospital - wheezes, crackles and may be - Medical Ward,
Emphysema Medical Ward, or rhonchi. manifested in the COPD
The following are as
Long term exposure the COPD adventitious breath patient’s
verbalized by the to llung irritants
patient’s sounds, such as faint breathing pattern
patient:
breathing sounds, with expiratory was partially
 “Nahihirapan akong pattern will be wheezes effective as
huminga lalo na effective and manifested by:
kapag ako’y Lung inflammation
back to normal.
Assess and monitor
naglalakad ng  Decreased
respiratory rate. Tachypnea is usually
malayo.” respiratory
Note inspiratory-to- present to some
 “Tapos pakiramdam rate from 30
degree and may be
 73

ko para akong Inflammatory cells

release proteinases expiratory ratio. pronounced on cpm to 22
nalulunod na may
admission, or during cpm.
nakadagan sa dibdib
stress. Respirations
ko at nahihirapan  Cough still
may be shallow and
akong huminga.” noted with
rapid, with prolonged
 “Tapos ang effective
expiration in
pakiramdam ko ay sputum
comparison to
sinasakal ako.”  Increase proteolytic expectoration
destruction of lung inspiration.
 “Noong panahon na parenchyma approximatel
nagkasakit ako, ubo y 15 cc per
lang ako ng ubo at Note presence and episode
Respiratory
pawang nahihirapan degree of dyspnea.
dysfunction is variable  As verbalized
na akong huminga, Use a 0 - 10 scale
Destruction of depending on the
pinabayaan ko or Grade of by the
alveolar walls and
capillaries underlying process. patient,
nalang iyon. Akala ko Breathlessness
Using a scale to rate “Napakatagal
kasi hindi lalala yung Scale to rate
dyspnea aids in na nitong ubo
kalagayan ko.” breathing difficulty.
quantifying and ko. Matapos
The following are as tracking changes in kong uminom
Airflow obstruction
verbalized by the folks: respiratory distress. ng gamot,

 “Mas nahihirapan pabalik balik

siyang huminga sa pa rin.”

 74

umaga. Ubo rin siya Increased mucus

production  Wheezing sill
ng ubo.”
auscultated
Assist patient to Permits maximum lung
Objective on both lung
maintain a expansion, thus
fields
Vital signs: comfortable position improving oxygenation
Accumulation of to facilitate and increasing oxygen
RR: 25 cpm (Normal  Patient is
mucus in the
values: 12 - 20 cpm) airways breathing. Place the saturation. observed to
patient in semi- assume high
fowler's or high fowler’s
August 23, 2021
Fowler's position. position to
9 AM
Leaning over the facilitate
Vital signs: bed table or sitting ease in
Chronic productive
RR: 24 cpm (Normal cough with clear to on the edge of bed breathing
Values: 12 - 20 cpm) gray sputum
can also be done.
 Shows signs
of improved
These exercises will respiratory
 Productive cough Teach the patient to
help patient’s effort as
and use of accessory cough and deep-
breathing, clear lungs, verbalized by
breathing muscle Nursing Diagnosis: breathe, and
and respiratory the patient
noted Ineffective airway encourage the
clearance r/t functioning by
 Chronic productive increased mucus patient to do so  “Kapag may
increasing lung
cough with clear to production 2 to hourly while awake.
expansion. oxygen
 75

gray sputum Emphysema

gumagaan
approximately 5cc
po yung
per episode
paghinga lalo
 Frequently coughing,
Observe persistent, Cough can be na kapag
especially during the
In patients with nakaupo.”
hacking, or moist persistent but
day. 
COPD, lung irritants
cough. Assist with ineffective. Coughing is
 Upon auscultation,
such as smoke from
measures to most effective in an
wheezes are heard 
cigarette irritates the
improve upright or in a head-
 Decreased chest goblet cells and
effectiveness of down position.
expansion observed mucous glands,
cough effort.
with an increased causing an
tactile fremitus increased
Hydration helps
accumulation of
Increase fluid intake decrease the viscosity
mucus, which in turn
to 3000 ml/day of secretions,
produces more
within cardiac facilitating
irritation, infection,
tolerance. Provide expectoration. Using
and damage to the
warm or tepid warm liquids may
lungs. This results to
liquids. decrease
airflow limitation as
Recommended bronchospasm. Fluid
lungs continuously
intake of fluids during meals can
become inflamed in
between, instead of increase gastric
response to the
 76

external particles during meals. distention and

and gases. pressure on the
diaphragm.
Mrs. L.V. has been
exposed to
secondhand smoke,
Precipitators of allergic
chemicals used in
doing laundry Limit exposure to type of respiratory
environmental reactions can trigger or
(chlorine) and
pollution caused by pollutants such as exacerbate onset of

charcoal in cooking dust, smoke, and acute episode.

which contributed to feather pillows

the chronic according to

inflammation and individual situation.

destruction of the
walls of
overdistended Dependent: Prompt recognition of
alveoli. With this side/adverse effects
Stress the need for
process, her lungs allows for timely
medication
were irritated intervention and
compliance. Review
leading to increased change in drug
side/adverse effects
mucus accumulation regimen.
with the patient. 
 77

as she was Administer

complaining of medications as
chronic productive prescribed.
cough. Due to this,
 
the patient was
evidently having Administer anti-
Corticosteroids are It is
Ineffective Airway inflammatory drugs
commonly used to
Clearance. such as
treat inflammation of
corticosteroids
References: the lungs leading to

hydrocortisone improved lung function

Hinkle, J. &
Cheever, K. 100mg and shorten the length
(2018). Brunner IVTT of hospital stay
& Suddhart’s
Textbook of q8h
Medical-
Surgical  
Nursing 14th
edition. Wolters fluticasone +
Kluwer
salmeterol puffs
2 puffs
Yu, Y. (2013 Oral inhalation
January 7).
COPD: Clinical q12h
findings.
 78

Retrieved from
https://calgaryg  
uide.ucalgary.c
a/COPD:-  
Clinical-
Findings Administer Bronchodilators dilate
bronchodilators as the airways. The
Yu, Y. (2013 prescribed. medication dosage is
January 7).
carefully adjusted for
COPD: ipratropium+salbut
Pathogenesis. each patient in
Retrieved from amol
accordance with
https://calgaryg 1 neb
uide.ucalgary.c clinical response.
nebulization
a/COPD:-
Pathogenesis/ inhalation
q6h

Administer oxygen
Oxygen will correct the
by the method
hypoxemia. Careful
prescribed.
observation of the liter
O2 at 6 L/min via flow or the percentage
face mask given and its effect on
the patient is
 79

Collaborative: important.

Collaborate with the

respiratory unit for
The respiratory unit is
the proper support
the expert for
of the patient’s
maintaining and
condition.
troubleshooting
respiratory support
machines for a
patient's proper
oxygenation if the
patient needs one
during severe signs
and symptoms.

Additional referrals
May be indicated to
may be given, such
optimize treatment. A
as to pulmonary
multidisciplinary
specialist or
approach including
pulmonary
education and exercise
rehabilitation, as
training may be helpful
appropriate
 80

in improving the
function and quality of
life.

NURSING CARE PLAN NO. 3

General Objectives: To promote optimal activity: exercise, rest, sleep.

Cues Nursing Diagnosis Rationale Specific Interventions Rationale Evaluation

Objectives
August 23, 2021 Within 8 hours of
Independent:
8 AM COPD rendering nursing
Activity intolerance Within 8 hours
related to inability to Emphysema Assess the physical Provides baseline care at
of rendering
perform activities of activity level and information for The Doctor’s
Subjective
daily living nursing care at mobility of the formulating nursing Hospital -
The following are as patient. Take the goals during goal
secondary to The Doctor’s
verbalized by the Medical Ward,
Long term exposure resting pulse, blood setting. Discontinue
 81

patient: emphysema. to llung irritants Hospital - the COPD

pressure, and the activity if the
 “Nahihirapan akong Medical Ward, respirations. If the patient has patient’s body
huminga lalo na
the COPD signs are normal, decreased pulse rate tolerance to ADLs
kapag ako’y partially improved
patient’s body have the patient and systemic blood
naglalakad ng Lung inflammation as evidenced by:
tolerance to perform the activity. pressure.
malayo.”
activities of daily
 “Pwede rin kami mag
living (ADLs) will
exercise kaya lang  Body
improve. Assess the patient’s Adequate energy
‘yung walking, 12 Inflammatory cells weakness
nutritional status. reserves are needed
release proteinases
minutes lang.” still noted 
during activity.

 Demonstrate
d energy
The following are as
Sleep deprivation and conservation
verbalized by the folks: Observe and
difficulties during sleep techniques.
monitor the
 “Nahihirapan siyang can affect the activity
Increase proteolytic patient’s sleep  While doing
huminga at hinihingal destruction of lung level of the patient and
parenchyma pattern and prescribed
siya at umuupo siya needs to be addressed
the amount activities,
‘pag hindi niya na before successful
of sleep achieved patient
kaya.” activity progression
over the past few verbalized,
can be achieved.
Objective days. “Sandali lang
Destruction of
alveolar walls and nurse,
 82

capillaries
Vital signs: hinihingal

BP: 130/80 mmHg ako. Uupo

(Normal Values: Below muna ako
120/80 mmHg)
Provide at least 90 Allotment of para
Airflow obstruction
RR: 30 cpm (Normal minutes of undisturbed rest magpahinga”
Values: 12 - 20 cpm)
undisturbed rest in reduces demand for .
Temp: 37.1 °C (Normal between activities. oxygen and allows
Values:36.5 - 37.5 °C)  Identified
adequate physiologic
Decrease airway factors that
PR: 98 bpm (Normal recovery
Values: 60 - 100 bpm) elasticity cause activity
intolerance. 

Maintain prescribed Helps in building

August 23, 2021  Patient
activity levels. tolerance and
9 AM discussed
Overdistention of minimizing episodes of
alveoli activities or
Vital signs: dyspnea. methods that
BP: 120/80 mmHg can be
(Normal Values: Below
120/80 mmHg) performed to
ease
RR: 29 cpm (Normal
Values: 12 - 20 cpm) Teach and assist shortness of
Increased dead Aids in building
space the client with an breath. 
Temp: 37 °C (Normal stamina and avoid
Values:36.5 - 37.5 °C) active range of
complications of limited
 83

PR: 95 bpm (Normal motion exercises. mobility.

Values: 60 - 100 bpm)

Impaired oxygen
 Body weakness and CO2 exchange Assisting the client with
Assist with the ADLs
noted the ADLs allows
while avoiding
conservation of
patient dependency.
 Inability to finish energy. Carefully
eating meals balance provision of
Hypoxemia
noted assistance; facilitating
progressive endurance
 Sitting in a tripod
will ultimately enhance
position
the client’s activity
observed Decrease perfusion
of body tissues tolerance and self-
esteem.
 Spends most of
the time resting
in high - fowler’s
position
Have the client
perform the activity Helps in increasing the
 Lack of energy
Body weakness more slowly, in a tolerance for the
observed
longer time with activity.
 Slow and pauses more rest or pauses,
 84

when walking or with assistance if

Nursing Diagnosis:
and easily gets necessary.
Activity Intolerance
tired r/t inability to
perform activities of
 Occasionally daily living
Instruct patient with
secondary to
cannot finish Emphysema energy conservation These techniques
sentences techniques, such as: reduce oxygen
because of consumption, allowing
 Placing frequently
breathlessness a more prolonged
It has become used items within activity.
 Decrease increasingly reach.
recognized that
tolerance to long muscle dysfunction
is common in  Sitting to do
periods of
patients with chronic tasks.
exercise obstructive
pulmonary disease
 Frequent position
(COPD). Muscle
strength and changes.
endurance are
decreased, whereas
 Working at an
muscle fatigability is
increased. Due to even pace.
this, patients with
COPD become
breathless when
they exercise, and
may stop because Refrain from
 85

of breathlessness
before they stress performing Client with limited
the exercising nonessential activity intolerance
muscle sufficiently
to develop fatigue. activities or need to prioritize
This symptom is procedures. important tasks first.
caused by the
impaired oxygen
diffusion which
consequently also
decreases the Encourage
oxygen perfusion to
body tissues verbalization of
Helps the client to
causing weakness. feelings regarding
This process is cope. Acknowledging
evident with Mrs. limitations.
that living with the
L.V., an emphysema
patient who tends to activity intolerance is
have lower
both physically and
tolerance to
prolonged periods of emotionally difficult. 
activities due to
decreased oxygen
saturation and her
condition. With Teach the client
these signs and Knowledge promotes
and/or folks to
symptoms, it can awareness to prevent
support why the recognize signs of
patient was the complication of
physical overactivity
diagnosed with overexertion.
Activity Intolerance. or exertion.
 86

References:

Mador, M. J., &

Bozkanat, E. Teach the client on These techniques

(2001). Skeletal exercises that prolong the exhalation

muscle enhance breathing period which can

dysfunction in capacity such as decrease retention of

chronic diaphragmatic and carbon dioxide.

obstructive pursed-lip breathing.

pulmonary
disease. Respir
atory
Coordinated efforts are
research, 2(4),
Evaluate the need more meaningful and
216–224.
for additional help at effective in assisting
https://doi.org/1
home. the client in conserving
0.1186/rr60
energy.
Yu, Y. (2013
January 7).
COPD: Clinical
findings.
Retrieved from Dependent:
https://calgaryg
uide.ucalgary.c
a/COPD:-
Clinical- Stress the need for Prompt recognition of
 87

Findings
medication side/adverse effects
compliance. Review allows for timely
Yu, Y. (2013
side/adverse effects intervention and
January 7).
COPD: with the client. change in drug
Pathogenesis. regimen. 
Retrieved from
https://calgaryg
uide.ucalgary.c
Administer
a/COPD:-
Pathogenesis/ medications as
prescribed.

a.Corticosteroids

hydrocortisone
Corticosteroids is

100mg commonly used to

IV route treat inflammation of
q8 hours
  the lungs leading to
improved lung function
fluticasone +
and shorten the length
salmeterol puffs
of hospital stay
2 puffs
Oral inhalation
q12 hours
 88

b. Bronchodilators

 
Bronchodilators dilate

ipratropium + the airways. The

salbutamol medication dosage is

carefully adjusted for
1 neb each patient in
Nebulization
inhalation accordance with
q6h clinical response.

Administer oxygen
by the method Oxygen will correct the
prescribed. hypoxemia. Careful
observation of the liter
O2 at 2-3 L/min via flow or the percentage
face mask given and its effect on
the patient is
important.
 89

Collaboration:

Refer client to a The respiratory unit

pulmonary has the expertise in
rehabilitation maintaining and
program.  troubleshooting
respiratory support
machines for a client’s
proper oxygenation if
the patient needs one
 90

VI. Discharge Plan

DISCHARGE PLAN

Name: Mrs. L.V. Date of Admission: August 23, 2021

Age: 44 years old Chief complaint: Recurrent cough

Room: Room 1, Medical Ward, TDH Diagnosis: COPD (Emphysema)

Attending Physician: Dr. X. Y. Z.

MEDICATIONS:

Instruct the patient to:

● Strictly comply with all the medications ordered by her physician or healthcare

provider to minimize or prevent exacerbations.

● Immediate notify the folks and contact her physician if severe side effects occur

after taking the following prescribed medications:

1. ipratropium + salbutamol (DuoNeb)

Tell your doctor right away if you have any serious side effects, including:

● difficult/painful urination
● muscle cramps
Get medical help right away if you have any serious side effects, including:

● chest pain
● fast/pounding/irregular heartbeat
● rapid breathing
● confusion
● eye pain/swelling/redness
● vision changes (such as seeing rainbows around lights at night, blurred
vision)

2. fluticasone + salmeterol puffs (Flovent diskus)

 91

Tell your doctor right away if you have any serious side effects, including:

● runny nose
● sneezing
● sore throat
● throat irritation
● sinus pain
● headache
● nausea
● vomiting
● diarrhea
● stomach pain
● muscle and bone pain
● dizziness
● weakness
● tiredness
● sweating
● tooth pain
● shaking of a part of your body that you cannot control
● sleep problems

● Follow the instructions regarding the medications given and demonstrate to the patient

the proper use of inhalation devices.

● ipratropium + salbutamol (DuoNeb) - Dose: 1 neb; Route: nebulization

inhalation using a nebulizer; Frequency: every 6 hours

● fluticasone + salmeterol puffs (Flovent diskus) - Dose: 2 puffs; Route: oral

inhalation; Frequency: every 12 hours

Instruct the folks to:

● Make sure that the patient fully complies with all the medications given by the

physician.

● Report to the physician for any problems to the patient in taking medications.
 92

● Assist the patient to the hospital if severe symptoms mentioned above start to

occur while ongoing medication therapy.

● Always remind and observe the patient in taking medications.

EXERCISE/ACTIVITY/SAFETY:

Instruct patient to:

● Get about 8 hours of sleep every night.

● Avoid anything stimulating (exercising, working, arguing) 2 hours before bedtime.

● Perform the pursed lip breathing exercise.

● Perform the diaphragmatic breathing exercise.

● Avoid strenuous activities.

● Use slow, steady motions when doing things.

● Sit down if she can when she is eating, dressing, and bathing.

● Get help for harder tasks.

● Not try to do too much in one day.

● Perform light exercises such as walking and jogging about 20-30 minutes, at

least 3 to 4 times a week.

● Get a flu shot every year and ask her provider about pneumonia vaccines.

● Stay away from crowds to protect self from infections.

● Instruct family members to quit smoking.

 93

HYGIENE:

Instruct the patient to:

● Take a bath everyday and use mild soap.

● Maintain oral hygiene by brushing teeth three times a day and flossing after

brushing teeth.

● Shower in well-ventilated area with warm water.

● Change clothing everyday and wear thin clothes in hot weather.

● Take short breaks when bathing, dressing, combing hair and doing hygiene -

related activities.

● Always wash hands with soap and water for 20 seconds. Wash often before

eating, after going to the bathroom and when around people who are sick.

● Keep hands away from face.

● Cover mouth and nose with tissues when coughing.

● Disinfect inhalers and nebulizers regularly

● Clean house of dust, scented perfumes and allergens that may be present and

might exacerbate her condition

● Wear masks if possible, to avoid inhalation of irritants causing exacerbation.

Instruct the folks to:

● Be readily available to assist patient when she is bathing, dressing, combing hair

or doing any hygiene - related activities

 94

● Remind and help patient in disinfecting inhalers and nebulizers after use.

● Constantly keep the house free from dust, scented perfumes and allergens that

may exacerbate patient’s condition

● Wear mask in the house when they are feeling sick especially when they are

interacting with the patient

OPD/APPOINTMENT:

Instruct patient and folks:

● For the next check-up with Dr. X.Y.Z. at Th Doctor’s Clinic – Room 207 on

September 10, 2021 at 10 am.

● Keep the doctor updated about significant changes felt by the patient

regarding her condition and signs and symptoms of exacerbation, if ever

observed.

DIET:

Instruct the patient to:

● Drink 8 - 12 glasses of water a day

● Choose complex carbohydrates such as sweet potato or potato

● Eat a variety of fresh fruits and vegetables such as carrots, red and green

peppers, broccoli, squash, tomatoes and apples.

● Limit simple carbohydrates, including table sugar, candy, cake and regular soft

drinks.

● Eat 20 to 30 grams of fiber each day, from items such as bread, fruits and

vegetables
 95

● Eat a good source of protein at least twice a day to help maintain strong

respiratory muscles such as milk, eggs, cheese, meat, fish and poultry.

● Choose protein with a higher fat content, such as whole milk

● Limit salt in the diet

● Rest just before eating.

● Eat more food early in the morning if you're usually too tired to eat later in the

day.

● Avoid foods that cause gas or bloating.

● Eat 4 to 6 small meals a day.

● If drinking liquids with meals makes you feel too full to eat, limit liquids with

meals; drink an hour after meals.

Instruct folks to:

● Assist the patient in preparing food.

● Assist the patient to eat only if she is too tired to do so

● Incorporate cheap but high - calorie food in the patient’s diet

● Encourage the patient to consume a high - calorie diet

● Avoid smoking when the patient is around

Sample Meal Plan

Breakfast:

1 boiled egg

2 slices of bread
 96

1 bowl of oatmeal

1 glass of unsweetened milk

Lunch:

175 grams (1 serving) of laswa

1 cup of brown rice

1 - 2 glasses of calamansi infused water

Afternoon Snack

1 sweet potato

Dinner:

175 grams (1 serving) of broiled fish with potatoes

1 - 2 glasses of water

SPIRITUAL:

Instruct the patient to:

● Talk about her spiritual needs in order to identify practices, spiritual beliefs

and resources that may positively impact the client’s health.

● Participate in support groups, if possible, wherein discussing her concerns

and questions with others can help resolve her feelings.

● List values that guide behavior in times of tragedy that will clarify values and

beliefs by reflecting on past behaviors because experience is a major source

for value development.

● Maintain a support network with family and their faith community.

● Pray with others or to be read to by members of own faith.

Instruct family, friends and significant others to:

● Provide support and attend her needs at all times.

 97

● Pray as a family together with the patient.

Problem Levels of Care Action Plan

Difficulty of Promotive/Preventive
● Minimized exposure to places with
Breathing excessive presence of air pollutants

● Keep away from substances with a

strong smell like paint, perfume, air
freshener

● Keep distance to people while they

are smoking

● Avoid doing vigorous activities

● Proper breathing exercise may help to

optimize lung function

● Proper body positioning may help in

breathing like the High fowler’s
position

● Use facemask if exposure to high

pollutant area cannot be prevented

● Stay longer in a cool and shaded

areas like under the trees

Curative
● ipratropium + salbutamol (DuoNeb)

Dose: 1 neb; Route: nebulization

inhalation using a nebulizer;
Frequency: every 6 hours

● fluticasone + salmeterol puffs

(Flovent diskus)

Dose: 2 puffs; Route: oral inhalation;

Frequency: every 12 hours

Rehabilitative
● Slowly engage to exercise (marching
in place or walking for 10 -12 minutes,
2x a day)
 98

● Encourage the folks to help the patient

in her recovery.

● See your doctor regularly for check-up

Chronic Cough Promotive/Preventive

● Instruct patient not to smoke or avoid
second-hand smoke.

● Explain the risks of smoking and

personalizing the “at-risk” message to
the patient.

● Keep environmental pollution to a

minimum such as dust, smoke, and
feather pillows, according to the
individual situation.

● Instruct patient to stay away from

crowds to protect self from infections.

● Encourage patient to get a flu shot

every year and ask health care
provider about pneumonia vaccines.

● Advise the client to position in comfort

by elevating the head of the bed for
about 30 degrees to prevent aspiration
of secretions.

Curative
● Encourage the patient to take
expectorants and antibiotics as
ordered.

● Encourage patient to take

bronchodilators if prescribed.

● Explain the purpose and importance of

the prescribed drugs.

● Encourage the patient to take the

medicines on time with the right dose,
route and frequency.

Rehabilitative
● Educate on good forceful coughing
techniques using the abdominal
muscles:

● Ex. Direct or controlled coughing,

which is more effective and reduces
fatigue associated with undirected
forceful coughing.
 99

● Teach and demonstrate to the folks

the chest physiotherapy, such as
bronchial tapping when in cough for
proper postural drainage.

Body Weakness Promotive/Preventive

● Take short breaks when bathing,
dressing, combing hair and doing
hygiene - related activities

● Choose complex carbohydrates such

as sweet potato or potato

● Eat a good source of protein at least

twice a day to help maintain strong
respiratory muscles such as milk,
eggs, cheese, meat, fish and poultry.

● Choose protein with a higher fat

content, such as whole milk

● Rest just before eating.

● Eat more food early in the morning if

you're usually too tired to eat later in
the day.

● Eat 4 to 6 small meals a day.

● Limit exercise for only less than 12

minutes to avoid provoking distress

● Schedule activities such as bathing,

dressing and other daily activities after
1 hour of moving around

● Encourage to sleep 8 - 10 hours every

night and practice good sleeping
habits and take 30 minute - 1-hour
naps in the afternoon

Curative
● Instruct patient to ask vitamin
supplements from physician

● Instruct patient to avail free vitamins

and supplements in health care
centers

● Advise patient to take Vitamins A, C,

E, D and iron

● Explain the purpose and benefits of

drugs according to the patient's level
of understanding.
 100

Rehabilitative
● Practice breathing exercises such as
diaphragmatic and pursed lip-
breathing in between activities

● Teach patient exercises she can do

with minimal effort such as:

1. Shoulder rotation

2. Elbow bends

3. Wrist bends and rotations

4. Knee bends

5. Ankle rotations to preserve strength

and energy

● Instruct client not to remain in one

position for a long period of time

● Educate patient to exercise and do so

thin one’s limits

● Advise patient to do walking exercises

early in the morning to avoid the
scorching sun and hot weather

● Instruct patient to do hobbies to that

make her feel rested such as listening
radio, watching television and reading
books
 101

VII. Evaluation

After 39.67 hours of rendering a thorough nursing care to the patient, we are able

to partially meet the set goals we formulated and established. Physiologically, the

patient's breathing pattern slightly improved with oxygen saturation of 93% after

properly performing breathing exercises as instructed by the nurse and with the help of

her folks. The patient still has shortness of breath as evidenced by the RR of 22 and a

capillary refill of 3 seconds but her arterial blood gas or pulse oximetry improved with

pCO2 of 44 mmHg. The patient shows signs of improved respiratory effort, verbalizing

“kapag may oxygen gumagaan po yung paghinga lalo na kapag nakaupo”. She was

able to demonstrate proper diaphragmatic breathing and coughing and observed a high

fowler’s position that facilitates ease in breathing. She was also able to identify the

hazards that can greatly affect her condition verbalizing “hindi ako lalapit sa mga taong

naninigarilyo at sa mga usok at gagamit na ako ng facemask sa tuwing lalabas,

sasabihan ko na rin ang pamilya ko na hindi na kami gagamit ng uling sa pagluto at

gasolito na lamang, at sasabihan ko ang aking asawa na hindi na manigarilyo sa loob

ng aming bahay”. The patient was able to complete her recovery while simultaneously

pursuing a healthy, safe, active, and fulfilling lifestyle. She sought consultation and went

to her doctor on time for her appointment, and she was fully engaged in the relaxation

techniques and breathing therapies that were provided to her. She also verbalizes the

need to exercise daily and demonstrate an exercise plan to be carried out at home. She

continued to use bronchodilators as prescribed by her doctor with minimal adverse

effects, including a heart rate that was close to normal, no dysrhythmias, and normal

mentation. She uses and cleans respiratory therapy equipment, when necessary, as

well as oxygen equipment when needed. She also demonstrates the correct technique

for use of pressurized metered dose inhaler (pMDI). The patient followed the healthy

diet recommendations, which included drinking 8 to 12 glasses of water per day, eating

sweet potato or potato, a variety of fresh fruits and vegetables, egg, cheese, meat, and
 102

fish, and limiting salt in the diet. She ensures that she will rest before eating and that

she will stick to her high-calorie diet, avoiding sweets during snacks.

The nursing objectives that keep the student nurses focused on achieving the

desired goals set were fulfilled since it I evident that the objective and subjective

assessment data of our patient were thoroughly identified and accurately traced the

pathophysiology of COPD. The student nurses also developed a nursing care plan

based on the patient's specific needs wherein each rationale for the nursing procedures

we provided to the patient were discussed and evaluated in terms of the nursing care's

effectiveness. The group was also able to collect relevant data and health history from

the patient and significant others, which was used to create a nursing care plan for the

patient that promoted her health and addressed her health issues. The group was able

to monitor the patient’s oxygen saturation accurately and demonstrate to her the correct

way to execute diaphragmatic and pursed lip-breathing techniques in which the patient

readily complied. Health teaching was conducted regarding the disease process and

explained the prescribed a COPD treatment regimen to the patient effectively. As

Augustinian nurses, the student nurses manifested the Augustinian values in rendering

care to the patient, seeing to it that she was closely attend. In dealing with the patient,

demonstrated a problem-solving attitude was apparent as criticisms were respectfully

accepted from other members of the healthcare team, and showed significant interest in

the assigned tasks provided to us in regard to the case condition. Overall, the objectives

set by the student nurses were fulfilled and evidently created a positive outcome to the

patient’s overall condition.

 103

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