A Case Study Presented to the Faculty of The Ateneo de Davao University College of Nursing

A Case Study on Chronic Obstructive Pulmonary Disease secondary to Pulmonary Tuberculosis

Submitted to Mr. Dude Arnel Lopez, RN Clinical Instructor – Panelist of the Case Study
Submitted by:

[Group 1-A] Ampilanon, Rae Maikko Batuhan, Katherene Beltran,Maribel


Campaner, Marie Allexis

23 April 2010




Acknowledgement 4

II. Introduction ..................................................................................................................... 5

III. Objectives

(General & Specific) ..................................................................................................................... 7

IV. Patient’s

Data ..................................................................................................................... 9

V. Family

Background and Health History ..................................................................................................................... 12

VI. Developmental Data ..................................................................................................................... 17

VII. Definition





..................................................................................................................... 22

VIII. Physical Assessment ..................................................................................................................... 24

IX. Anatomy and Physiology ..................................................................................................................... 30

X. Etiology and Symptomatology ..................................................................................................................... 34

XI. Pathophysiology ..................................................................................................................... 44

XII. Doctor’s

Order ..................................................................................................................... 57

XIII. Diagnostic

Exams ..................................................................................................................... 67

5 XIV. Drug

Study ..................................................................................................................... 93

XV. Nursing Theories ..................................................................................................................... 106 XVI. Nursing Care Plan ..................................................................................................................... 111

XVII. Discharge

Plan (M. E. T. H. O. D.) ..................................................................................................................... 136

XVIII. Prognosis………………………………………..............…………………………140

XIX. Recommendation ..................................................................................................................... 144

XX. References ..................................................................................................................... 147


ACKNOWLEDGMENT In our journey toward the accomplishment of this endeavor, there were people who made this a successful one. In this case analysis, we would like to express our heartfelt gratitude to the following that made a striking contribution and helped us along the way. First and foremost is to our Almighty Father, for without the life and the wisdom that he has given us, we will not be able to accomplish this task. To our family, who has always been there for us and supporting us emotionally and financially. To our clinical instructors, Ma’am Neriza Gudoy R.N., for allowing us to improve ourselves better as student nurses by imparting knowledge and skills; and to Sir Dudes Lopez, R.N., for the guidance, support, encouragement and for sharing to us valuable lessons not just in nursing but in life as well. Our first 2 weeks of summer duties were full of learnings, fun and laughter and we couldn’t ask for more. To the staff of Ricardo Limso Medical Center and Davao Medical Center, for allowing us to practice and hone our knowledge and skills; and to DMC Medical-Communicable Pavilion for the assistance and for allowing us to get a case for our case presentation.


To the subject of this case study and to his family, for allowing us to make them as the subject of this study and for being cooperative in the whole process of assessment, interviews and interventions. To the whole group, for constantly helping and understanding each other. Through thick and thin, together we will soar higher. And lastly, to whomever inspires us at this time, for motivating us to do better and for loving us unconditionally. INTRODUCTION

Life, amidst its complexities and predicaments, is the greatest treasure a certain individual can have at his very time of subsistence. Through life, one is able to feel simple things that can give him the satisfaction and completeness that no any worldly splendor can give. Even so, illnesses are part of everyone's life, it only varies on severity. People can either let them control their lives, or they themselves can take control. Unfortunately, the human body’s homeostasis may be altered at any point of time. Chronic Obstructive Pulmonary Disease, as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) is a disease state characterized by airflow limitation that is not fully reversible. COPD may include diseases that cause airflow obstruction such as emphysema and chronic bronchitis or any combination of these disorders. People with COPD commonly become symptomatic during the middle adult years and the incidence of the disease


increase with age. Although certain aspects of lung function normally decreases with age, COPD accentuate and accelerates these physiologic changes. According to the 2007 World Health Organization estimates, there are currently 210 million people suffering from COPD worldwide. It is the 6th leading cause of death worldwide. However, the World Health Organization projected that by the year 2030, it will become the 3rd leading cause of death due to an increase in smoking rates and demographic changes in many countries. . In the Philippines, The World Health Organization (WHO) estimates that COPD, as a single cause of death, shares 4th and 5th places with HIV/AIDS (after coronary heart disease, cerebrovascular disease and acute respiratory infection) having 33, 709 or 46.10 percent per 100, 000 population as of 2003. Furthermore, Dr. Luisito Isidor, chair of Philippine College of Chest Physicians’ COPD Council mentioned that the Philippine Burden of Lung Disease study indicated that 12 percent or one in eight individuals 40 years and above suffer from COPD. In the 2007 Press Release of the Region 11 Center for Health Development, 36% of every 100,00 has COPD. And from this number, 2 out of 8 patients die daily. Last April 19-22, 2010, we had our hospital duty at the Med Communicable Pavilion of Davao Medical Center where we found many worthy cases. In this paper, the subject of our study will be addressed as “Lito”, a 41 year old who had an unlucky fate. Pulmonary Tuberculosis struck him when he was 28 years old. It was treated that year too. However, the disease came back at the year 2006. From then on, he has been living a life destined only to him. Making things worse is the current diagnosis of Chronic Obstructive Pulmonary Disease. With


these facts, we found his case substantially credible and interesting enough to be studied and presented.


OBJECTIVES General Objective: The main aim of the group is to be able to present the case presentation of our selected client that would present a comprehensive discussion of the pathological mechanism of the illness to yield significant information for the case study. Specific Objectives: In order to meet the general objective, the group aims to: Cognitive: •

Interpret the pertinent data gathered from the patient and his significant others, Evaluate the present developmental stage of the patient according to the theories of Erikson, Kohlberg and Piaget,

• • •

Define the complete diagnosis of the patient, Rationalize the doctor’s order obtained from the patient’s chart, Interpret the laboratory test results of the patient, Relate the patient’s disease with the different nursing theories specifically those of Nightingale, Orem and Henderson,

Psychomotor: • • • State the past and present health history of the client, Trace the family genogram, Present the cephalocaudal assessment obtained from the patient,


• • • •

Discuss the anatomy and physiology of the organ involved in the patient’s disease, Present the etiology and symptomatology of the patient’s disease, Trace the pathophysiology of the patient’s disease, Present the medications given to the client, including their respective modes of action, indications, contraindications, side effects, adverse reactions, nursing responsibilities, and importance to the client’s condition;

Discuss the surgical procedure performed to the patient and its important interventions in the pre, intra, and post operative phase.

Present a specific, measurable, attainable, realistic and time-bounded nursing care plans for the client,

Justify the client’s prognosis according to the different criteria,

Affective: • • • Establish rapport to the patient and the patient’s significant others, Provide the patient and family with proper discharge planning (M.E.T.H.O.D), Inform suitable recommendations to the client, his significant others and community, and the medical world, etc.



Personal Data: Patients Name: Age: Gender: Birth date: Birth Place Civil Status Occupation City Address: Family Income: Socioeconomic class: Nationality: Religion [Denomination]: Educational Attainment: Number of Siblings: Ordinal Rank: “Lito” 40 years old Male April 28, 1969 Davao City Single Unemployed Matina, Davao City. 4000-6000/month Middle class Filipino Christianity [Roman Catholic] Highschool undergrad (2nd year) 8 2nd

Clinical/ Admitting Data:


Date of admission: Time of admission: Hospital & Hospital Number: Ward [Room & Bed Numbers]: Attending Physician: Admitting Diagnosis: Vital signs on admission: Temperature: Pulse Rate: Respiratory Rate: Blood pressure: : Source of Information: Final diagnosis:

April 16, 2010 9:27 pm Davao Medical Center, Davao City [2064421] Med CP [Room 4 Bed 5] Dr. Emerson Taghoy COPD secondary to PTB

37.7 Degrees Celsius 97 Beats per Minute 45 Cycles per Minute 130/80 mmHg Patient, patient’s mother and Patient’s Chart Chronic Obstructive Pulmonary Disease secondary to Pulmonary Tuberculosis



HEALTH BACKGROUND A. Family Background “Lito” is a 40 year old male and second in a brood of 8. He is single and is currently living with his parents and siblings. In the maternal side, no known cases of COPD and PTB were reported that can be genetically influential and thereafter, be inherited. However, several cases of PTB were present in the paternal side which includes some of the patient’s grandfathers. The patient is currently unemployed since 2009 because of his illness. The family’s source of income is from the patient's mother and father who own an eatery however they had to stop their business and now they are both running a small “sari sari” store. And according to the mother, the patient’s siblings also contribute money to the household at times. From this, the family can afford eating three times a day. Their usual diet is composed of fish and vegetables. They only cook meat once or twice a week. According to the patient’s mother, PTB has been present in the paternal side of the family although she stated these relatives were not living close to them and they have not been in contact with them for a long time. She stated that one uncle died because of PTB but this happened a long time ago and that they haven’t met this certain uncle. In the maternal side, hypertension is the only diseases identified to be genetic in etiology.


B. Past Health History The patient was born via normal spontaneous vaginal delivery. There were no complications or abnormalities when he was delivered. His mother reported that the patient received complete immunization when he was an infant. According to the patient’s mother, “Lito” was admitted at DMC when he was about 5 months old due to vomiting and diarrhea but was cured after 1 week. He was also diagnosed with Typhoid fever last 1997 and was admitted at the same institution. He has no asthma, hypertension, diabetes mellitus and any known allergies to food and drug. He has been smoking since he was 12 years old with an average of 1 pack per day. He regularly drinks alcoholic beverages such as Emperador since he was 17 years old. C. History of Present Illness Last 1997, the patient has been diagnosed with PTB while working in Cavite as a construction worker. He returned to Davao, and was referred to Matina Health Center and was given DOTS treatment which he had complied with. Alongside, they also sought the help of a “quack doctor”. He felt better after the treatment and was asymptomatic. He returned to Manila to work. Then last 2006, while working as security guard at a school in Manila, the patient experienced dyspnea which prompted him to stop smoking. He also reported that he was exposed to dust and dirt frequently since he was always staying beside the road making him exposed to heat and air pollution. He consulted a private consultant and was advised to take Myril P for his tuberculosis. He took the medicine for 3 months 3 tabs a day but


stopped taking the drug because of financial reasons. According to him the dyspnea stopped but he has experienced occasional coughing since then. Then last September 2008, he experienced extreme dizziness, severe cough and weight loss which prompted his admission at San Lazaro hospital in Manila. He was diagnosed with PTB and was given DOTS treatment plus 60 injections of streptomycin. He complied with the medications for 6 months with the help of his mother. After that they returned to Davao where he was asymptomatic but had experienced occasional cough. However last April 12-14, 2010, the patient experienced fever during dawn for 3 days accompanied by dizziness and dyspnea. And last april 15, 2010, the patient and his mother proceeded to “Brigada” where he had a check up and was given herbal medications. However the following day April 16, 2010, the patient collapsed and was rushed to Davao Medical Center which prompted his present admission. D. Effects/ Expectations of Illness to Self/ Family According to the patient, he has been battling PTB for almost 13 years already and this has given disappointment to the way he sees himself as a son and as a brother. And now that he has developed another complication, he stated he wants to be cured so that they will stop spending money on his hospitalization and medication. He states he feels bad because he doesn’t have money to buy his own medicines and he hopes he will get better as soon as possible. According to his mother, she believes that his son will be cured if they will see a quack doctor for his son’s condition. She stated her desire for her son to see the quack


doctor who “cured” him last 1997. And according to her, they are running out of money and she hopes his son will recover as soon as possible because their debt is getting bigger as the days come by. She also stated that she thinks her son will get better if he will practice healthy habits such eating nutritious foods and adequate rest. She also stated that the patient’s siblings, who reside outside Davao city, are hoping that the patient will get better soon and that they are encouraging the patient to get well.























LEGEND: Ѳ◊ΩDeceased Hypertension Tuberculosis PATIENT

---- -


Erikson's Stages of Psychosocial Development

Erikson's stages of psychosocial development as articulated by Erik Erikson explain eight stages through which a healthily developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future. Stage Description Result Justification Our client has not achieved

According to Erik Erikson, NOT Middle Adulthood the developmental task in middle adulthood is to form a sense of

ACHIEVED generativity even though he is able to exhibit behaviors that are well acceptable for his age and has understood the responsibilities of middle –aged person but still, the client is unproductive due to his illness. Because of his illness, he quit his job and has not earned a living for his family. The client was working towards the betterment of the society. He is a good

(25 to 65 generativity, a sense of concern for years old) GENERATI VITY vs. guiding the next generation. During middle age the primary developmental task is one of contributing to society and helping to guide future generations. When a person makes a



contribution during this period, perhaps by raising a family or working toward the betterment of society, a sense of generativity- a sense of productivity and accomplishment- results. In contrast, a person who is selfcentered and unable or unwilling to help society move forward develops a feeling of stagnation- a dissatisfaction with the relative lack of productivity. Those who are successful during this phase will feel that they are contributing to the world by being active in their home and community. Those who fail to attain this skill will feel unproductive and uninvolved in the world.

citizen. But, all people have imperfections, our client has vices. He is a chain smoker and an alcoholic and that makes him a bad example for the next generations. In this way, he’s not making the society move forward. He’s not helping towards the guidance of the future generation especially to his niece and nephews.


Kohlberg's Stages of Moral Development This theory specifically addresses moral development in children and adults. The morality of an individual’s decision was not Kohlberg’s concern; rather, he focused on the reasons an individual makes a decision. Stage Conventional Stage (Law and Order Orientation) Description Result Justification In this stage of Kohlberg's Moral Development theory, the client must follow the laws in order to maintain a good functioning in the society as a good citizen. The client expressed that it is important to follow rules and regulations inculcated to us by the society. He has not violated any laws and for him, that makes him a good citizen. He added that in order for you to become a good citizen you must not commit any crime. He is in the stage four, the Conventional level, it is said that following the laws and dictums of the society is significant to maintain a good functioning in the society, so

The conventional level of moral ACHIEVED reasoning is typical of

adolescents and adults. In this stage, it is important to obey laws, dictums and social

conventions because of their importance in maintaining a functioning society; Right is being good, with the values and norms of family and society at large. The self enters society by filling social roles; therefore

society must learn to transcend individual needs. A central

ideal or ideals often prescribe what is right and wrong, such as in the case of

fundamentalism. If one person






we have concluded our client has done his role to the society.

everyone would—thus there is an obligation and a duty to uphold laws and rules. When someone does violate a law, it is morally wrong; thus a

responsibility is

significant factor in this stage as it separates the bad domains from the good ones. Most active members of society

remain at stage four, where morality is still predominantly dictated by an outside force.

Theory of Cognitive Development

The Theory of Cognitive Development is a comprehensive theory about the nature and development of human intelligence first developed. Stage Formal operational Description In this stage, individuals move beyond concrete Result Achieved Justification The client was able to reason out when there are questions asked


stage (12– Adulthood)

experiences and begin to think abstractly, reason logically and draw conclusions from the information available, as well as apply all these processes to hypothetical situations CHARACTERISTICS: • Solves abstract and

to him. He is capable of answering it all. He was high school undergraduate but for him, he had acquired knowledge from his teachers, classmates, friends and the everyday lessons he has learned through experience and that knowledge was being used everyday especially in understanding the things that’s happening. He usually talks to his friends whenever he has problems

hypothetical problems • Thinks in combinations

with other objects • Ability to acquire and

and whenever he needs someone to utilize knowledge talk to. We had also established Good activity is talk time rapport with the client despite he had difficulty speaking because he’s having shortness of breath.


DEFINITION OF COMPLETE DIAGNOSIS CHRONIC OBSTRUCTIVE PULMONARY DISEASE Chronic obstructive pulmonary disease (COPD) refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath. Charlene J. Reeves, Gayle M. Roux, Robin Lockhart. Medical-surgical nursing. Copyright © 1995. Chapter 15, page 556. COPD stands for chronic obstructive pulmonary disease. This is a term used for a number of conditions; including chronic bronchitis and emphysema. COPD leads to damaged airways in the lungs, causing them to become narrower and making it harder for air to get in and out of the lungs. Wilma J. Phipps, Judith K. Sands, Jane F. Marek. Medical-Surgical Nursing: Concepts & Clinical Practice, 6th Edition. USA. Copyright © 2000. Chronic obstructive pulmonary disease is any disorder that persistently obstructs bronchial airflow. COPD mainly involves two related diseases -- chronic bronchitis and emphysema. Both cause chronic obstruction of air flowing through the airways and in and out of the lungs. The obstruction is generally permanent and progresses over time. Barbara Janson-Cohen. Medical Terminology: An Illustrated Guide 5th edition. Copyright © 2007. page 623.


PULMONARY TUBERCULOSIS Tuberculosis (TB) is a potentially fatal contagious disease that can affect almost any part of the body but is mainly an infection of the lungs. It is caused by a bacterial microorganism, the tubercle bacillus or Mycobacterium tuberculosis. Jane Hokanson Hawks. Medical-surgical Nursing: Clinical Management for Positive Outcomes. Copyright © 2008. Chapter 39, page 975. An infectious disease of humans and animals caused by the tubercle bacillus and characterized by the formation of tubercles on the lungs and other tissues of the body, often developing long after the initial infection. Betty Davis Jones. Comprehensive Medical Terminology. Copyright © 2008. Chapter 12 page 475. An infectious disease caused by the bacterium Mycobacterium tuberculosis that is transmitted through inhalation and is characterized by cough, fever, shortness of breath, weight loss, and the appearance of inflammatory substances and tubercles in the lungs. Tuberculosis is highly contagious and can spread to other parts of the body, especially in people with weakened immune systems. Ann Ehrlich, Carol L. Schroeder. Medical Terminology for Health Professions. Copyright © 2004. page 368.



DATE AND TIME OF ASSESSMENT: April 19, 2010 @ 2:00 P.M. I. GENERAL SURVEY The client is 40 years old and male. Upon assessment, he is lying supine on bed, awake, conscious and coherent and oriented to time, person and place. He talks coherently and has a sense of reality. He has an IVF Bottle # 3 of D5LR 1L at 300 cc level at 30 drops per minute infusing well at right metacarpal vein. He is connected to supplementary oxygen of 2 liters per minute via face mask. He is not in respiratory distress but effortful breathing is noted. His hair is not well combed and is dressed in street clothes. Slight body odor is noted. He has an ectomorphic type of body built and looks according to his age. He is cooperative during the whole course of assessment.

II. VITAL SIGNS AND CLINICAL MEASURMENT The client had a body temperature of 37.2°C, afebrile. His cardiac rate was 73 beats per minute with no skip beats noted. His pulse rate was 96 beats per minute; full pulses noted and equal to both extremities. His blood pressure was 80/60 mmHg; slightly below normal range. His respiratory rate was 28 cycles per minute; tachypneic. His height measures 5 feet and 5 inches.


III. THE INTEGUMENT a. SKIN Skin color is light brown and generally uniform on all areas except on armpit and soles of the feet where it is lighter. No edema noted on any part. Moisture is noted on armpits. Temperature on all areas is uniform and within normal range. Skin turgor is good as skin springs back to previous state after being pinched. Lesions and nodules are distributed at several areas of his body. A papule is seen on his back. b. HAIR Hair is evenly distributed over the scalp. It is black in color. It is thick and oily. Dandruff is noted on the scalp hair. Hair is evenly distributed over the extremities. Facial hair is present. He has an unshaved mustache. Axillary hair is present. c. NAILS The patient has a convex curvature on his nails. Fingernails and toenails have smooth texture. The patient has pale fingernail and toenail beds. Intact epidermis is surrounding the nails. Fingernails and toenails are unclean and untrimmed. Capillary refill time of 3 seconds is noted.



a. SKULL AND FACE The patient has normocephalic head with a circumference of 48 cm. There is a smooth and uniform consistency of skull and no masses and nodules noted. There is a symmetric facial features with symmetric facial movements. The patient is able to raise his eyebrows, close his eyes, frown, and smile. Facial hairs are noted. No tenderness of frontal and maxillary sinuses upon palpation b. EYES AND VISION Hairs in the eyebrow are black. Eyebrows are symmetrically aligned and has equal. movement. Eyelids close symmetrically. No edema is noted over lacrimal gland. The eyelashes are curled outward. Skin is intact and no discoloration is noted. Eyelids close symmetrically. Sclera appears white. Conjunctiva is red. No edema or tenderness is noted over the lacrimal gland. Pupils are equally round and reactive to light accommodation with pupil size of 3 mm. Both eyes are coordinated and move in unison with parallel alignment. The patient can see objects in periphery when looking straight ahead. c. EARS AND HEARING Ears are bilaterally symmetrical with no swelling or thickening. The color of the auricles is the same as facial skin. It is symmetrical and aligned with the outer canthus of the eye. It is mobile, firm and not tender and recoils after being folded. Cerumen accumulation not noted. There are no foul smelling, serous, or purulent discharges noted. Normal voice tones are heard. He is able to hear the ticking of the wrist watch d. NOSE AND SINUSES


The nose is symmetric and straight. No discharges or flaring is noted. Skin is the same as facial skin. It is non tender are presence of lesions is not noted. Nasal mucosa was pinkish. Both left and right nares were patent, with no discharges; air could freely move in and out when the patient breathes Air moves freely as the client breathes through the nares. The maxillary and frontal sinuses are non tender. e. MOUTH AND OROPHARYNX The outer lips have a uniform pink color. It has a soft and dry texture. He is able to pursed lips. The inner lips have a uniform pink color and have soft and moist texture. Only 28 adult teeth are present with dental carries noted. The tongue is in central position and can move freely without difficulty. It has thin whitish coating. There is a smooth tongue base with prominent veins. The uvula is pinkish in color and is positioned in the midline. Tonsils are not inflamed.

V. THE NECK Muscles are equal in size with head positioned in the center. There is a coordinated and smooth movement with no discomfort as the patient flexes, hyperextend, and laterally flexes the head. Sternocleidomastoid muscle strength is equal as the patient was able to move his head against the resistance of the hand. There is also an equal strength of trapezius muscles as the


patient was able to shrug his shoulders against the resistance of the hand. Lymph nodes are not palpable.

VI. THE THORAX AND LUNGS a. ANTERIOR CHEST Patient has a respiratory rate of 28 cycles per minute, slightly above normal range. Dyspnea is noted when patient is not connected to supplemental oxygen. His chest circumference is 85 cm. The client breathes with thoracic movement as observed.. The patient’s shoulders raise upon breathing indicating an effortful breathing. Wheezing and crackles are heard upon auscultation b. POSTERIOR CHEST Spine is vertically aligned and straight. Skin is intact and uniform in temperature. There were no masses and tenderness noted. Wheezing and crackles are noted upon auscultation.

VI. HEART a. Heart and Central Blood Vessels Point of maximum impulse and beat is auscultated at the 5th intercoastal space left midclavicular line. The patient has a cardiac rate of 100 beats per minute, within normal range and no skip beats noted. Abnormal heart sounds not noted upon auscultation.


b. Carotid Arteries and Jugular Veins Symmetric pulse volumes with full pulsations and thrusting quality were noted upon inspection and palpation of the carotid artery. Presences of bruits were not noted. Presence of jugular vein distention is also not noted. c. Peripheral Vascular System There is symmetric pulse volume with full pulsations on all peripheral pulses. Limbs are not tender and are symmetric in size. Cyanosis and jaundice are not noted in any areas of the periphery. Capillary refill time is 3 seconds.

VII. Breast and Axillae Skin color is uniform that of the abdomen. The color of his areola is dark brown. Both nipples were everted. The axilla appears moist. No lesions and bruises is seen upon inspection nor masses, discharges and tenderness during palpation. Axillary, subclavicular and supraclavicular lymphs nodes are not tender.

IX. Abdomen The abdomen has uniform skin color and same as the chest. Skin is dry. Abdominal contour is flat; flat in shape. Abdominal movements are symmetric that are caused by respiration. Umbilicus is located at the center with no signs of infection and protrusions. Bowel sounds are audible. No tenderness noted and it is relaxed and has a consistent tension.


X. Genito- Urinary The patient has a diaper where he urinates freely without experiencing any difficulty. The patient has reported that there were no lesions, tenderness, and masses on his penis and anus. XII. Musculoskeletal a. Upper Extremities Upon inspection, no lesions, scars and redness is noted on arms and shoulders. No tenderness, inflammations, or masses is evident on elbows. There is no missing and deformed fingers, contractures, bone enlargements, nodules or redness. Tenderness and nodules were not noted on the left wrist, hands and fingers upon palpation. It is free from inflammation and with normal angle curvature. Client is able to extend both arms. Palm is able to stay in both prone and supine in a good manner without difficulty. Joints are able to move smoothly. He is able to exhibit strong hand grip on both arms. Reflex on the upper extremity was good. No hand tremors noted. b. Lower Extremities Upon inspection, muscles are equal on both sides of the lower extremities. No contracture and tremors noted. No deformities noted. When asked to raise his legs one at a time, the patient has difficulty doing it. The patient is able to flex and dorsiflex his feet. The patient has difficulty ambulating as he experiences pain, gets easily tired and nauseated when walking.


ANATOMY AND PHYSIOLOGY Respiratory System The respiratory system consists of all the organs involved in breathing. These include the nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important things: it brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes wrong with part of the respiratory system, such as an infection like pneumonia, chronic obstructive pulmonary diseases, it makes it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide.


The Upper Airway and Trachea When you breathe in, air enters your body through your nose or mouth. From there, it travels down your throat through the larynx (or voicebox) and into the trachea (or windpipe) before entering your lungs. All these structures act to funnel fresh air down from the outside world into your body. The upper airway is important because it must always stay open for you to be able to breathe. It also helps to moisten and warm the air before it reaches your lungs. The Lungs Structure Air travels to the lungs through a series of air tubes and passages. It enters the body through the nostrils or the mouth, passing down the throat to the larynx, or voice box, and then to the trachea, or windpipe. In the chest cavity the trachea divides into two branches, called the right and left bronchi or bronchial tubes, that enter the lungs. In the adult human, each lung is 25 to 30 cm (10 to 12 in) long and roughly conical. The left lung is divided into two sections, or lobes: the superior and the inferior. The right lung is somewhat larger than the left lung and is divided into three lobes: the superior, middle, and inferior. The two lungs are separated by a structure called the mediastinum, which contains the heart, trachea, esophagus, and blood vessels. Both right and left lungs are covered by an external membrane called the pleura. The outer layer of the pleura forms the lining of the chest cavity. The branches of the bronchi eventually narrow down to tubes of less than 1.02 mm (less than 0.04 in) in diameter. These tubes, called bronchioles, divide into even narrower tubes, called


alveolar ducts. Each alveolar duct ends in a grapelike cluster of thin-walled sacs, called alveoli (a single sac is called an alveolus). From 300 million to 400 million alveoli are contained in each lung. The air sacs of both lungs have a total surface area of about 93 sq m (about 1000 sq ft), nearly 50 times the total surface area of the skin. In addition to the network of air tubes, the lungs also contain a vast network of blood vessels. Each alveolus is surrounded by many tiny capillaries, which receive blood from arteries and empty into veins. The arteries join to form the pulmonary arteries, and the veins join to form the pulmonary veins. These large blood vessels connect the lungs with the heart. The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen into the body, which we need for our cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We each have two lungs, a left lung and a right lung. These are divided up into ‘lobes’, or big sections of tissue separated by ‘fissures’ or dividers. The right lung has three lobes but the left lung has only two, because the heart takes up some of the space in the left side of our chest. The lungs can also be divided up into even smaller portions, called ‘bronchopulmonary segments’. These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment receives its own blood supply and air supply.

Blood Supply


The lungs are very vascular organs, meaning they receive a very large blood supply. This is because the pulmonary arteries, which supply the lungs, come directly from the right side of your heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs so that the carbon dioxide can be blown off, and more oxygen can be absorbed into the bloodstream. The newly oxygen-rich blood then travels back through the paired pulmonary veins into the left side of your heart. From there, it is pumped all around your body to supply oxygen to cells and organs.

The Pleurae The lungs are covered by smooth membranes that we call pleurae. The pleurae have two layers, a ‘visceral’ layer which sticks closely to the outside surface of your lungs, and a ‘parietal’ layer which lines the inside of your chest wall (ribcage). The pleurae are important because they help you breathe in and out smoothly, without any friction. They also make sure that when your ribcage expands on breathing in, your lungs expand as well to fill the extra space.

The Diaphragm and Intercostal Muscles When you breathe in (inspiration), your muscles need to work to fill your lungs with air. The diaphragm, a large, sheet-like muscle which stretches across your chest under the ribcage, does much of this work. At rest, it is shaped like a dome curving up into your chest. When you breathe in, the diaphragm contracts and flattens out, expanding the space in your chest and


drawing air into your lungs. Other muscles, including the muscles between your ribs (the intercostal muscles) also help by moving your ribcage in and out. Breathing out (expiration) does not normally require your muscles to work. This is because your lungs are very elastic, and when your muscles relax at the end of inspiration your lungs simply recoil back into their resting position, pushing the air out as they go.

ETIOLOGY AND SYMPTOMATOLOGY A. ETIOLOGY Predisposing Present/ Absent Factors Genetics Absent A host risk factor for Although there was a COPD is a deficiency of relative diagnosed alpha enzyme protects antitrypsin, inhibitor the an with PTB there is no that medical diagnosis lung would also indicate Rationale Justification

parenchyma from injury. any genetic factor This deficiency predisposes present in the patient young people of to rapid that would predispose lobular him to such disease



emphysema, even if they condition. do not smoke. Genetically susceptible people are

sensitive to environmental factors (eg. Smoking, air pollution, infectious agents, allergens) and eventually developed obstructive chronic symptoms.

Carriers of this genetic defect must be identified so that they can modify

environmental risk factors to delay or prevent overt symptoms of disease.

Childhood respiratory Disorders


Disorders in the respiratory system during childhood can predispose an individual to be susceptible to COPD. Childhood respiratory disorders weakens the respiratory

No childhood respiratory disorders were reported by the patient.


system of an individual and making it sensitive to any irritants.

Precipitating Present/ Absent Factors Environment Present Environmental conditions such as those with high incidences of inhalational exposure to noxious substances can trigger COPD. Inhalational exposures can trigger an inflammatory response in airways and alveoli that leads to disease in genetically susceptible people. The process is thought to be mediated by The patient worked as a school security guard last 2006, wherein he stayed at the side of the road daily and according to him he was exposed to dirt and dust all the time. He also worked as a carpenter in a construction site and he was frequently exposed to dust and dirt. Rationale Justification


an increase in protease activity and a decrease in antiprotease activity



The most important risk The patient has been factor cigarette Smoking for COPD is smoking since he was

smoking.. 12 years old. depresses the

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

mechanism, which keeps breathing passages free of inhaled irritants, bacteria, and other foreign matter. When smoking damages this cleansing mechanism, airflow is obstructed and air behind becomes the trapped


The alveoli greatly distend, diminished lung capacity. Smoking also irritates the


goblet cells and mucus glands, causing an

increased accumulation of mucus, which in turn

produces more irritation, infection, and damage to the lung. In addition,

carbon monoxide (a by product of smoking)

combines with hemoglobin to carboxyhemoglobin. Hemoglobin that is bound by cannot Infection Present carboxyhemoglobin carry oxygen form

efficiently. Entry of microorganisms Sputum Culture such as H. influenza and reveals presence of pseudomonas aurginosa tuberculosis pathogen.

can cause damage to the respiratory system which can eventually turn to



B. SYMPTOMATOLOGY Symptoms Wheezing Present/Absent Present Rationale Wheezing is the highpitched sound of air passing through narrowed airways. A person with COPD may wheeze during an acute exacerbation or chronically. Sometimes the wheezing is heard only at night or with exertion. Bronchodilators can relieve wheezing quickly Wheezing indicates presence of accumulated secretions in the lungs. Dyspnea Present Obstruction of the airway and The patient is having difficulty in breathing at certain Justification Wheezing is heard upon auscultation.


accumulation of secretions contribute to difficulty in breathing. Hypoxia Absent Inadequacy of oxygen to body tissues occur in patients with COPD as impairment of airflow occur. Accessory muscle use upon breathing Present Due to impaired airflow and airway obstruction, COPD patients exert effort in breathing. In advanced cases, patients tend to use accessory muscles upon breathing in order to aid in respiration. Hoover’s sign Present It refers to inward movement of the


ABG results show no signs of hypoxia. The patient is also provided with supplemental oxygen via face mask

During physical assessment, the patient’s shoulders raise upon breathing indicating an effortful breathing, using the muscles in the neck and shoulders.

The patient is observed to display Hoover’s sign.

lower rib cage during inspiration, implying


a flat, but functioning, diaphragm, associated often with

COPD. COPD, and more specifically often to

emphysema, lead

hyperexpansion of the lungs due to air The flattened contracts instead of

trapping. resulting diaphragm inwards



paradoxically pulling the inferior with ribs its

inwards movement.

Weight loss


Patients with severe COPD work hard and burn a lot of calories just breathing. These

The patient, as reported by the SO has become thinner and apparently lost some weight.


patients also become short of breath in the very act of eating, and so may not eat enough to replace the calories they use.

Barrel Chest


When the lungs become enlarged, the diaphragm is displaced downward and is unable to contract efficiently. Consequently, chest diameter tends to widen in order to accommodate the structural changes of

The patient’s chest diameter is widened.

Pursed Lip breathing


the lungs Because airflow out of the lungs becomes limited, exhalation takes longer. Because the alveoli lose their

The patient did not manifest this symptom.


elasticity, one tries to shorten the time needed for exhalation by forcefully exhaling. Unfortunately, forced exhalation increases pressure on the lungs and causes structurally weakened airways to collapse. To prevent airways from closing during forced exhalation, pursed-lip breathing is used: The lips are narrowed together, which slows exhalation at the mouth. This keeps positive pressure in the airways, thus preventing their


collapse and allowing some forced exhalation.

Productive cough


A productive cough is caused by inflammation and excessive amounts of mucus in the airways. Coughing becomes less effective because of obstructed airflow.

The patient has productive cough.



People who have a poor supply of oxygen usually have a bluish tinge to their skin, lips, and nailbeds,

The patient is not cyanotic. Appearance of nail beds and other parts of the body appear normal, no bluish discoloration is observed. The patient did not manifest this symptom.



called cyanosis COPD is one of the more common causes of hemoptysis. It usually occurs during an acute exacerbation,


when there is a lot of coughing with purulent sputum (sputum containing pus). Usually, there are only very small amounts of blood Granulomas/ lesions Present streaking the sputum. These nodular-type lesions form from an accumulation of activated T lymphocytes and macrophages, which creates a microenvironment that limits replication and the spread of the mycobacteria.This environment destroys macrophages and produces early solid necrosis at the center of the lesion; Lesions were noted on the patient’s back.


however, the bacilli are able to adapt to survive.

PATHOPHYSIOLOGY Predisposing Factors: Genetics Childhood respiratory Disorders Precipitating Factors: Environment Smoking

Inhalation of pathogen


Droplets settle throughout the airways

Majority becomes trapped to the upper respiratory tract where mucus secreting goblet cells exist

Production of mucus

Cilia sweeps mucus upward

Mucus containing trapped microorganisms becomes expelled out of the body

Bacteria bypasses mucociliary system reaches the alveoli

Cell mediated immune response

Productive cough

Ingestion by macrophages

Production of proteolytic enzymes and cytokines to degrade bacteria

Mycobacteria continues to multiply slowly at the rate of 25-32 hours

Cytokines attract T-lymphocytes

Cell mediated immune response occur


Macrophages present mycobacterial antigens on their surface to T-cells

Skin test detection

immune process continues for 2 to 12 weeks; the microorganisms continue to grow

Skin lesions and nodules appear

Formation of granulomas around M. tuberculosis microorganisms

fibrosis and calcification of lesions ( in persons with adequate immune system)

granuloma formation is initiated yet ultimately is unsuccessful in containing the bacilli (in less immunocompetent persons)

Bacteria is contained in the dormant healed lesions

Liquefication of necrotized tissues, the fibrous wall loses structural integrity.

semiliquid necrotic material drain into a bronchus or nearby blood vessel, leaving an airfilled cavity at the original site

Destruction of alveolar/ lung structures, Accumulation of microorganisms and Hyperactivity of cells lining the bronchial tree secretions

Smooth muscle of airways constrict and narrow

Mucus plugging, mucosal edema, bronchospasm


Cilia functions poorly

Destroyed alveolar attachments

Decreased ability to eliminate secretions Wheezing hemoptysis Accumulation of secretions decreased airway support and closure during expiration

Breeding of microorganisms Airway obstruction

Loss of elastic recoil and lung hyperinflation

Increased susceptibility to other infections

Hypoxia Cyanosis Airflow limitation Dyspnea NARRATIVE PATHOPHYSIOLOGY Accessory Muscle Use Hoover’s Sign Weight Loss Once inhaled, the Barrel Chestdroplets settle throughout the airways. The majority of the infectious Pursed Lip Breathing

bacilli are trapped in the upper parts of the airways where the mucus-secreting goblet cells exist. The mucus produced catches foreign substances, and the cilia on the surface of the cells constantly beat the mucus and its entrapped particles upward for removal. This system provides


the body with an initial physical defense that prevents infection in most persons exposed to tuberculosis. Bacteria in droplets that bypass the mucociliary system and reach the alveoli are quickly surrounded and engulfed by alveolar macrophages, the most abundant immune effector cells present in alveolar spaces. These macrophages, the next line of host defense, are part of the innate immune system and provide an opportunity for the body to destroy the invading mycobacteria and prevent infection. Macrophages are readily available phagocytic cells that combat many pathogens without requiring previous exposure to the pathogens. Several mechanisms and macrophage receptors are involved in uptake of the mycobacteria. The mycobacterial lipoarabinomannan is a key ligand for a macrophage receptor. The complement system also plays a role in the phagocytosis of the bacteria. The complement protein C3 binds to the cell wall and enhances recognition of the mycobacteria by macrophages. Opsonization by C3 is rapid, even in the air spaces of a host with no previous exposure to M tuberculosis. The subsequent phagocytosis by macrophages initiates a cascade of events that results in either successful control of the infection, followed by latent tuberculosis, or progression to active disease, called primary progressive tuberculosis. The outcome is essentially determined by the quality of the host defenses and the balance that occurs between host defenses and the invading mycobacteria. After being ingested by macrophages, the mycobacteria continue to multiply slowly, with bacterial cell division occurring every 25 to 32 hours. Regardless of whether the infection becomes controlled or progresses, initial development involves production of proteolytic enzymes and cytokines by macrophages in an attempt to degrade the bacteria. Released cytokines attract T lymphocytes to the site, the cells that constitute cell-mediated immunity. Macrophages


then present mycobacterial antigens on their surface to the T cells. This initial immune process continues for 2 to 12 weeks; the microorganisms continue to grow until they reach sufficient numbers to fully elicit the cell-mediated immune response, which can be detected by a skin test. For persons with intact cell-mediated immunity, the next defensive step is formation of granulomas around the M tuberculosis organisms. These nodular-type lesions form from an accumulation of activated T lymphocytes and macrophages, which creates a micro-environment that limits replication and the spread of the mycobacteria. This environment destroys macrophages and produces early solid necrosis at the center of the lesion; however, the bacilli are able to adapt to survive. In fact, M tuberculosis organisms can change their phenotypic expression, such as protein regulation, to enhance survival. By 2 or 3 weeks, the necrotic environment resembles soft cheese, often referred to caseous necrosis, and is characterized by low oxygen levels, low pH, and limited nutrients. This condition restricts further growth and establishes latency. Lesions in persons with an adequate immune system generally undergo fibrosis and calcification, successfully controlling the infection so that the bacilli are contained in the dormant, healed lesions. Lesions in persons with less effective immune systems progress to primary progressive tuberculosis.

For less immunocompetent persons, granuloma formation is initiated yet ultimately is unsuccessful in containing the bacilli. The necrotic tissue undergoes liquefaction, and the fibrous wall loses structural integrity. The semiliquid necrotic material can then drain into a bronchus or nearby blood vessel, leaving an air-filled cavity at the original site. In patients infected with M tuberculosis, droplets can be coughed up from the bronchus and infect other persons. If discharge into a vessel occurs, occurrence of extrapulmonary tuberculosis is likely. Bacilli can also drain


into the lymphatic system and collect in the tracheobronchial lymph nodes of the affected lung, where the organisms can form new caseous granulomas. When these bacilli are not effectively contained by the body’s cell mediated immune response, many different complications commence. Primary reaction is inflammation. Inhalational exposures can trigger an inflammatory response in airways and alveoli that leads to disease in genetically susceptible people. The process is thought to be mediated by an increase in protease activity and a decrease in antiprotease activity. Lung proteases, such as neutrophil elastase, matrix metalloproteinases, and cathepsins, break down elastin and connective tissue in the normal process of tissue repair. Their activity is normally balanced by antiproteases, such as α1-antitrypsin, airway epithelium–derived secretory leukoproteinase inhibitor, elafin, and matrix metalloproteinase tissue inhibitor. In patients with COPD, activated neutrophils and other inflammatory cells release proteases as part of the inflammatory process; protease activity exceeds antiprotease activity, and tissue destruction and mucus hypersecretion result. Neutrophil and macrophage activation also leads to accumulation of free radicals, superoxide anions, and hydrogen peroxide, which inhibit antiproteases and cause bronchoconstriction, mucosal edema, and mucous hypersecretion. Neutrophil-induced oxidative damage, release of profibrotic neuropeptides (eg, bombesin), and reduced levels of vascular endothelial growth factor may contribute to apoptotic destruction of lung parenchyma. The inflammation in COPD increases with increasing disease severity, and, in severe (advanced) disease, inflammation does not resolve completely with smoking cessation. Neither does this inflammation appear responsive to corticosteroids.


Bacteria, especially Haemophilus influenzae, colonize the normally sterile lower airways of about 30% of patients with COPD. In more severely affected patients (eg, those with previous hospitalizations), Pseudomonas aeruginosa colonization is common. Smoking and airflow obstruction may lead to impaired mucus clearance in lower airways, which predisposes to infection. Repeated bouts of infection increase the inflammatory burden that hastens disease progression. There is no evidence, however, that long-term use of antibiotics slows the progression of COPD.Another consequence is airflow limitation. The cardinal pathophysiologic feature of COPD is airflow limitation caused by airway obstruction, loss of elastic recoil, or both. Airway obstruction is caused by inflammation-mediated mucus hypersecretion, mucus plugging, mucosal edema, bronchospasm, peribronchial fibrosis, or a combination of these mechanisms. Alveolar attachments and alveolar septa are destroyed, contributing to loss of airway support and airway closure during expiration. Enlarged alveolar spaces sometimes consolidate into bullae, defined as airspaces ≥ 1 cm in diameter. Bullae may be entirely empty or have strands of lung tissue traversing them in areas of locally severe emphysema; they occasionally occupy the entire hemithorax. These changes lead to loss of elastic recoil and lung hyperinflation triggering signs and symptoms such as increased work of breathing, as does lung hyperinflation. Increased work of breathing may lead to alveolar hypoventilation with hypoxia and hypercapnia, although hypoxia is also caused by ventilation/perfusion. In this case, several signs commence such as dyspnea, Hoover’s sign, weight loss, pursed lip breathing and use of accessory muscles upon breathing.



Please admit patient under For close monitoring of the Admitted yellow service med cp level3. patient and proper management of his condition. Secure consent to care Consent to care is the permission Obtained. obtained from a patient/guardian to perform medical management


needed for the patient. To secure the consent of the patient is important for legal purposes. Diet as Tolerated DAT, Diet as Tolerated is a Patient particular diet that is given when informed. client can tolerate any food he desires that is nutritious, if this will not lead to any

complications. Monitor vital signs q4 then Vital signs are important for Taken record baseline assessment and to recorded. and

monitor patients condition which evaluates the whole treatment course, especially the medications he received that could be a contributing factor in the

variation results of the vital signs Laboratory Tests: Complete Blood Count with CBC with PC determines the Done, platelet quantity of each quantity of blood result cell in a given specimen of blood, to chart. often including the amount of hemoglobin, hematocrit, and the proportion of various white blood with attached


cells. This is done to know any condition of the client that may affect his medical management. Urinalysis Urinalysis is performed to screen Done, for urinary tract disorders, kidney result. disorders, urinary neoplasm and other medical conditions that produce changes in the urine. This test also is used to monitor the effects of treatment of known renal or urinary condition. This test is also used to monitor the effects of certain procedures done to patient and to check if genitourinary is in normal state or not. Chest Xray Posterior anterior An view x-ray (radiograph) is a Done, with attached without

noninvasive medical test that result helps physicians diagnose and to chart. treat medical conditions. This is done to help diagnose or monitor treatment for conditions such as pneumonia, emphysema and

other lung conditions. They are ordered for symptoms of


shortness of breath, cough, or chest pain. Serum Creatinine The test is done to evaluate Done, kidney function. Creatinine is result removed from the body entirely to chart by the kidneys. If kidney function is abnormal, creatinine levels will increase in the blood because less creatinine is released through your urine. Serum electrolytes (Na, K) This is done to measure the Done, concentration of electrolytes result with attached with attached

which are needed for both the to chart diagnosis and management of renal, endocrine, acid-base, water balance, and many other

conditions. Their importance lies in part with the serious

consequences that follow from the relatively small changes that diseases or abnormal conditions may cause. This is done for diagnosing dietary deficiencies, excess loss of nutrients due to


urination, vomiting, and diarrhea, or abnormal shifts in the location of an electrolyte within the body. Venoclysis: PNSS 1L to run at Intravenous lines provide easy Hooked 100 cc/hour access for drug administration regulated. intravenously (IVTT). Plain and

normal saline solution is isotonic to body fluid and is commonly used for rehydration. O2 inhalation 2-4 L/min Hypoxia can be a strong driving Given via face force in patients with COPD; mask. administering oxygen will reduce this drive in these patients.

Additionally, there will be a loss of physiological hypoxic

vasoconstriction which is partly protecting the patient from the effects of areas of gross alveolar hypoventilation. Meds: 1) Ceftriaxone 1g IV BID Ceftriaxone is often used (in Given combination, but not direct, with macrolide and/or aminoglycoside antibiotics) for the treatment of


community-acquired or mild to moderate health care-associated pneumonia. 2) Azithromycin 500mg 1 Azithromycin is an azalide, a Given tab OD subclass of macrolide antibiotics. It is effective against susceptible bacteria causing pneumonia and other bacterial infections. 3) Acetylcysteine 600mg+ An antioxidant drug used to Given 1glass of water reduce the thickness of mucus and ease its with removal. hydration


significantly reduces the risk of contrast nephropathy in patients with chronic renal insufficiency. Watch out for dyspnea and This is done to monitor patient Done other unusualities Refer accordingly closely and to avoid hypoxia. This may create a collaborative Done. treatment among the client and the health care providers; thus it also makes a good coordination on the treatment of the client. 4/19/10 Referred for BP 80/50 ABG now ABG testing is mainly used in Done, with


pulmonology, to determine gas result exchange levels in the blood to chart related to lung function. This is ordered since the patient has impaired lung function. Paracetamol 500mg po qid Paracetamol is ordered to reduce Given (hold) IVF PNSS @ fever.


100cc/hr- Plain normal saline solution is Regulated. isotonic to body fluid and is commonly used for rehydration.


IVF PNSS 500cc over 80mins This is done to increase the Given. now Refer for any unusualities. patient’s blood pressure. This may create a collaborative Done. treatment among the client and the health care providers; thus it also makes a good coordination on the treatment of the client. Sputum AFBx3 GSCS, Sputum AFB is done to determine Done, if the patient is positive for result tuberculosis or other kinds of to chart infection. It is done three times to check for accuracy. Gram Stain culture and sensitivity is done to detect and identify bacteria or with attached


fungi that infect the lungs or breathing passages. Continue meds This is done until desired effects Given. are met. Continue 100cc/hr IVF PNSS @ Plain normal saline solution is Regulated. isotonic to body fluid and is commonly used for rehydration. 12:50 1) Salbutamol It is used for the relief of Given. bronchospasm in conditions such as asthma and chronic obstructive pulmonary disease. 2) Continue all meds This is done until desired effects Given. are met. 3) Refer accordingly This may create a collaborative Done treatment among the client and the health care providers; thus it also makes a good coordination on the treatment of the client. 4/20/2010 4) please give paracetamol Paracetamol is ordered to reduce given fever. This is ordered since the patient is febrile. Increase caloric and protein This is because people with Patient intake COPD require 10 times as many informed.

nebulization q6

500mg q6


calories to breathe than a healthy person. And because of the added effort that it takes to breathe, people with COPD typically have a higher energy requirement than most. Protein has a high caloric value and also in tuberculosis, there is a considerable wasting of body tissues. Therefore, it is essential intake. Diagnostics: 2D Echo An echocardiogram is a test in Order given; not which ultrasound is used to done. examine the heart. This is done to check any abnormalities of the heart, assess the heart’s function and determine the presence of disease of the heart muscle. 4/21/10 Still for 2D echo Continue medications This is done until desired effects Done are met. Refer accordingly This may create a collaborative Done treatment among the client and to increase protein


the health care providers; thus it also makes a good coordination on the treatment of the client.


DIAGNOSTIC EXAMS COMPLETE BLOOD COUNT AND PLATELET COUNT The CBC is a series of different tests used to evaluate the blood and the cellular components of RBC’s, WBC’s and platelets. The CBC is used to assess the patient for anemia, infection, inflammation, polycythemia, hemolytic disease, and the effects of ABO incompatibility, leukemia and dehydration status Normal Date Exam Value Hemoglobin April 16, 2010 135 – 175 The g/L test Rationale Patient that 122 the of per Low Result of Remarks Significance Hemoglobin decreased hemorrhage, bleeding, anemia, hemolytic anemia, overload, retention, fluid fluid 3. Assess the patient for any 2. Inform the patient that no fasting is needed. is in: 1. Discuss and explain the procedure and purpose of the test. Clinical Nursing Responsibilities

measures amount hemoglobin liter of blood.


Normal Date Exam Value Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance pregnancy, cirrhosis of the liver and factor that will probably affect the results of the test.

hyperthyroidism. A hemoglobin referred anemia. Hematocrit 0.36 – 0.48 Hematocrit is a 0.27 blood test that the Low A hematocrit referred anemia. to low is as 5. If patient is connected to IVF, make sure that the blood is not taken from the arm connected to the IVF. Hemodilution to low is as 4. Make sure patient is well hydrated. Dehydration

elevates the test results.


percentage of the volume of whole blood that is

causes false decrease of the test results.

made up of red


Normal Date Exam Value blood cells. This measurement depends on the number of red Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance

6. After the puncture, assess the site for bleeding or bruising. 7. If patient is from inform under an the

blood cells and the size of red blood cells.

treatment infection,

patient that the test will RBC count 4.20 – 6.10 The test measures 04.55 the circulating Normal Low RBC may indicate loss, blood anemia, 8. Any abnormality noted will be reported to the physician. and be repeated to monitor progress.

RBCs in 1 cubic millimeter blood. of

hemorrhage, bone failure, leukemia, marrow


Normal Date Exam Value WBC count 5.0 – 10.0 This is Rationale

Result Patient to 6.36 the

of Remarks

Clinical Nursing Responsibilities Significance malnutrition Normal Increased Elevated in


inflammation and for further test of any problems. It will certain with identify persons increase to

acute infectious disease, and in lymphocytic and monocytic fractions in viral disease, leukemia, following surgery trauma. or acute and


infection through measuring the

total amount of WBC in the body.


Normal Date Exam Value Neutrophil 55 – 75 Rationale

Result Patient Neutrophils serve 88 as the body's defense

of Remarks

Clinical Nursing Responsibilities Significance High Increased Indicates presence bacterial parasitic infections. of or


against infection through process phagocytosis. Neutrophils seek out bacteria or the of

necrotic tissue at the site of the injury and destroy them through the engulfment


Normal Date Exam Value process known as phagocytosis. Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance


20 – 35

Identifies invading substances, including viruses, bacteria, incompatible erythrocyte, and



Decreased Decrease associated SLE, trauma, is with burns, and

administration of corticosteroids.

tissue grafts or transplants.


Normal Date Exam Value Monocytes have phagocytic action. It removes dead or injured cells, fragments, Monocyte 2 – 10 microorganism. This test is done to diagnose such an as cell and Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance





inflammatory diseases. Eosinophils 1–8 Eosinophils initiate allergic 0 Low No eosinophil


responses and act


Normal Date Exam Value against parasitic The to Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance

infestation. test is use

diagnose infestation. Basophil 0–1


Basophils initiate 1 type 1 allergic



responses. Basophils are not well as understood other white They


appear to play a role in allergic and anaphylactic


Normal Date Exam Value reactions. Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance

Platelet count

150 – 400

The test measures 89 all platelets




count indicates a decrease circulating clotting factors in

present in 1 cubic millimeter blood. of The

platelet count is used to assess the ability of the bone marrow to

in the body of the making patient, the

patient likely to have bleeding.

produce and to identify destruction the of

loss of platelets in


Normal Date Exam Value the circulation. MCH The corpuscular hemoglobin, 25.7-32.20 "mean hemoglobin" (MCH), is the or cell Rationale

Result Patient mean 26.8

of Remarks

Clinical Nursing Responsibilities Significance Normal Normal

average mass of hemoglobin per

red blood cell in a sample of blood. It is reported as part of a standard complete count. blood MCH


Normal Date Exam Value value diminished hypochromic anemias.[1] is in Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance


32.30-36.50 The corpuscular hemoglobin

mean 32.20


Decrease: deficiency anemia,


concentration, or MCHC, is a

hypochromiclow hemoglobin concentration Normal: normochromicacute blood loss,

measure of the concentration of

hemoglobin in a given volume of packed red blood


Normal Date Exam Value cells. It is Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance aplastic anemias, acquired hemolytic anemia

reported as part of a complete count. MCV 79-92.20 The corpuscular volume, or "mean cell (MCV), volume" is a mean 83.3 normal standard blood

Low: microcytosissmall RBC High: macrocytosis— large RBC

measure of the average red blood cell volume (i.e. size) that is


Normal Date Exam Value reported as part of a complete count Chemistry The test measures Potassium 3.5 – 5.5 standard blood Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance

potassium levels 4.6 of the blood.



Low The test measures Sodium levels 136 – 155 the sodium levels 130.80 in the blood. Low body

sodium in the




Normal Date Exam Value Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance This measures

renal sufficiency. The lower the The test usually Creatinine level 53 – 115 indicates function. body, healthier kidneys are. Glucose RBS 4.10-6.60 High levels glucose 6.8 indicate High The patient is diabetic. Dili diabetic man ang the the renal 52.20 Low creatinine in the of

insufficient or no production insulin body. by of the This

patient dba???

indicates Diabetes


Normal Date Exam Value Mellitus. Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance

ABG Analysis - Often used to identify the specific acid-base disturbance and the degree of compensation that has occurred. This is done to determine the concentrations of carbon dioxide, oxygen and bicarbonate, as well as the pH of the blood. Its main use is in pulmonology, to determine gas exchange levels in the blood related to lung function It is also used in nephrology, and used to evaluate metabolic disorders such as acidosis and alkalosis. Exam Normal Rationale Value April 19, pH 2010 7.35 – 7.45 pH indicates the acid-base level of the blood, or the hydrogen ion (H+) concentration Patient 7.49 high Result of Remarks Significance Alkalosis Pretest: 1. Explain the importance of the procedure or to the Clinical Nursing Responsibilities




Inform the patient or watcher that the test


Normal Date Exam Value Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance requires blood sample. 2. Instruct the patient to breath normally during the test. 3. Warn that a brief

cramping or throbbing pain may occur at the puncture site. 4. Take note of the patient’s temperature respiratory rate.
5. If patient is receiving O2


therapy, discontinue O2 from 15 to 20 minutes before drawing the


Normal Date Exam Value Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance sample to measure ABG on room air.

Post Test: 1. Apply pressure on the puncture site. 2. After applying pressure, tape a gauze pad firmly over it. 3. Monitor VS. Observe for signs of circulatory such as

impairment swelling, pain,

discoloration, numbness or


Normal Date Exam Value Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance tingling in the bandaged arm. 4. Watch for bleeding from the punctured site.



45 PaCO2 how

indicates 36.3 much





Normal Date Exam Value oxygen the lungs are delivering to the blood. indicates efficiently lungs It how the Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance


carbon dioxide.



100 Indicates

how 134.6



much oxygen the lungs are

delivering to the blood.


Normal Date Exam Value Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance



26 Indicates whether 27.1 a problem metabolic is



present (such as ketoacidosis). low indicates metabolic acidosis high indicates metabolic alkalosis. and a A




Normal Date Exam Value Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance

BE (ecf) Base excess


2 The base excess 3.8 indicates whether the patient is or A base indicates



acidotic alkalotic. negative excess

that the patient is acidotic. A high positive excess base indicates

that the patient is alkalotic.


Normal Date Exam Value Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance


80 – 100%

This impaired

indicates 98.9%



respiratory function such as respiratory weakness or

paralysis, airway obstruction, bronchiole obstruction, asthma, emphysema, and from damaged or filled with fluid


Normal Date Exam Value because disease. of Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance



This impaired

indicates 28.3



respiratory function such as respiratory weakness or

paralysis, airway obstruction, bronchiole obstruction,


Normal Date Exam Value asthma, emphysema, and from damaged or filled with fluid because disease. of Rationale

Result Patient

of Remarks

Clinical Nursing Responsibilities Significance

Sputum Exam The purpose of a sputum analysis is to help identify microorganisms that are causing respiratory disease or infection. The most common reason for obtaining a sputum specimen is to test for infectious tuberculosis. A sputum analysis, however, is also used to identify disease-producing organisms that may be causing pneumonia, bronchitis, lung abscess, or other respiratory disease. A sputum


analysis may be used to identify conditions such as: aspiration pneumonia, histoplasmosis, cryptococcosis, blastomycosis, mycoplasma pneumonia, plague, mycobacterial infection, and pneumocystic pneumonia.

Specimen 1st 2nd Visual Apperance Mucopurulent Mucopurulent Reading 2+ 2+ Laboratory Diagnosis positive Gram Stain Culture and Sensitivity Predominant Organism Presence of 7cm gram positive cocci appearing in pairs Polymorphonuclear >25 Epithelial Cells <10

3rd Salivary 0



Generic Name: Brand Name: Classification: Dosage: Mode of Action:

Paracetamol Biogesic Non-narcotic analgesic, Antipyretic 500 mg tab qid Decreases fever by hypothalamic effect leading to sweating and vasodilation. Also inhibits the effect of pyrogens on the hypothalamic heat-regulating centers. May cause analgesia by inhibiting CNS prostaglandin synthesis; however, due to minimal effects on peripheral prostaglandin synthesis, it has no anti-inflammatory or uricosuric effects. Antipyretic and analgesic effects are comparable to those of aspirin


Control of pain due to headache, earache, dysmenorrheal, arthralgia, myalgia, musculoskeletal pain, arthritis, immunizations, teething, tonsillectomy; to reduce fever in bacterial or viral infections; as a substitute for aspirin in upper GI disease, aspirin allergy, bleeding disorders, clients on anticoagulant therapy, and gouty arthritis.


Contraindicated in patients hypersensitive to drug; renal insufficiency, anemia; clients with cardiac or pulmonary disease

Drug Interactions:

Activated absorption












rifabutim, rifampin, sulfinpyrazone: Increased risk of hepatotoxicity Hormonal contraceptives: Decreased efficacy Oral anticoagulants: Increased anticoagulant effect Phenothiazines: Severe hypothermia Zidovudine: Increased risk of granulocytopenia Hematologic: hemolytic anemia, neutropenia, leukopenia, pancytopenia Side/ Effects: Adverse Hepatic: jaundice Metabolic: hypoglycemia Skin: rash urticaria Nursing Responsibilities: 1. Assess vital signs 2. Document presence of fever. Rate pain, noting type, onset, location, duration and intensity. 3. Instruct the client to take the drug only for complaints indicated. 4. Tell the client not to exceed the recommended dose; do not take longer for 10 days. 5. Give the drug with food to avoid GI upset. 6. Encourage the client to avoid using other over-the-counter drug preparations; if the client needs an OTC preparation, instruct the client to consult the health care provider. 7. Discuss with the client the possible side effects of the drug. 8. Reassess the vital signs to evaluate the efficacy of the drug.


9. If any of the side effects occur, report it immediately to the physician.

Generic Name: Brand Name: Classification: Dosage: Mode of Action:

Ceftriaxone sodium Rocephin Antibiotic 1 g IV bid Bactericidal: Inhibits bacterial cell wall synthesis, causing cell death.








Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenza, Escherichia coli, and Proteus mirabilis. • UTI caused by E.coli, Klebsiella, Proteus vulgaris, P. mirabilis. • Meningitis caused Streptococcus pneumoniae,

Haemophilus influenza. • Dermatologic infections caused by Klebsiella, S. aureus, P. mirabilis. • Bone and joint infection caused by by Streptococcus pneumoniae, Staphylococcus aureus, Escherichia coli, Klebsiella pneumonia, Proteus mirabilis and


Enterobacter. Contraindication Contraindicated penicillins. Drug interactions: • • • Increased nephrotoxicity with aminoglycosides. Increased bleeding effects with oral anticoagulants. Disulfiram-like reaction may occur if taken within 72 hr after ceftriaxone administration. Side/ Adverse Effects: CNS: headache, dizziness, lethargy GI: nausea, vomiting, diarrhea, abdominal pain, flatulence, hepatotoxicity GU: nephrotoxicity Hematologic: decreased WBC, platelets and Hct Hypersensitivity: ranging from rash to fever to anaphylaxis Nursing Responsibilities: 1. Ask the client if he/she has any history of allergy with the drug. 2. Tell the client to take the full course of therapy as prescribed. 3. Have vitamin K available in case of with allergy to cephalosphorins or

hypoprothrombinemia occurs. 4. Do not mix it with other antimicrobial drugs.


5. Discontinue if hypersensitivity reaction occurs. 6. Discuss the possible side effects to the client like stomach upset or diarrhea. 7. Report any unusualities to the physician immediately.

Generic Name: Brand Name: Classification: Dosage: Mode of Action: Indication:

Azithromycin Zithromax Macrolide 500 mg, 1 tab OD Bacteriostatic or bactericidal in susceptible bacteria • Treatment of lower respiratory tract infections: Acute bacterial exacerbations of COPD due to H. influenza, S. pneumoniae. • Treatment of uncomplicated skin infections due S. aureus, S. pyogenes • • Treatment of acute sinusitis Treatment of mild to moderate COPD caused by S. pneumoniae, H. influenzae, Mycoplasma pneumoniae


Contraindicated with hypersensitivity to azithromycin,


erythromycin or any macrolide antibiotic. Drug interactions: • Decreased azithromycin serum with levels and effectiveness and of



containing antacids. • • Side/ Adverse Effects: Possible increased effects with theophylline Possible increased anticoagulant effects of warfarin

CNS: dizziness, headache, vertigo, somnolence, fatigue GI: diarrhea, abdominal pain, nausea, dyspepsia, flatulence, melena, vomiting Other: superinfections, photosensitivity

Nursing Responsibilities:

1. Ask the client if he/she has any history of allergy with the drug. 2. Tell the client to take the full course of therapy as prescribed. 3. Instruct the client not to take antacids. 4. Tell the client that the drug may be taken with or without food. 5. Explain to the client the possible side effects of the drug such as abdominal cramping, diarrhea, fatigue, and headache.


6. If any unusualities occur, report to the physician immediately.

Generic Name: Brand Name: Classification: Dosage: Mode of Action:

Acetylcysteine Mucomyst Mucolytic 600 mg + 1 glass of water Mucolytic activity: Splits links in the muco-proteins contained in respiratory mucus secretions, vdecreasing viscosity of the mucus.


Mucolytic adjuvant therapy for abnormal, viscid, or inspissated mucus secretions in acute and chronic

bronchopulmonary disease (emphysema with bronchitis, tuberculosis, pneumonia), in pulmonary complications of cystic fibrosis, and in tracheostomy care Contraindication Contraindicated with hypersensitivity to acetylcysteine; use caution and discontinue immediately if bronchospasm occurs. Drug interactions: Drug stability and safety of Acetylcysteine when mixed with other drugs in a nebulizer have not been established. Side/ Adverse Effects: GI: nausea, stomatitis Hypersensitivity: Urticaria


Respiratory: Bronchospasm Others: rhinorrhea Nursing Responsibilities: 1. Ask the client if he/she has any history of allergy with the drug. 2. Tell the client to take the full course of therapy as prescribed. 3. Use water to remove residual drug solution on the patient’s face after administration through face mask. 4. Inform patient that nebulisation may produce an initial disagreeable odor, but the odor will soon disappear. 5. Explain the possible side effects to the client including an increased productive cough, nausea and GI upset. 6. Report difficulty in breathing or nausea.

Generic Name: Brand Name: Classification: Dosage: Mode of Action:

Albuterol sulfate Salbutamol Bronchodilator 1 nebule q6 Acts relatively selectively at beta2- adrenergic receptors to


cause bronchodilation and vasodilation Indication: Contraindication Hypersensitivity to albuterol; tachycardia, tachyarrythmisa caused by digitalis intoxication; hypertension, coronary insufficiency, CAD, COPD patients with degenerative heart disease. Drug interactions: • Decreased bronchodilating effects with beta-adrenergic blockers • Decreased effectiveness of insulin, oral hypoglycaemic drugs • Decreased serum levels and therapeutic effects of digoxin • Increased risk of toxicity when used with theopylline and aminophylline • Increased symphatomimetic effects with other Inhalation: Treatment of acute attacks of bronchospasm

symphatomimetic drugs


Side/ Adverse Effects:

CNS: restlessness, anxiety, fear, tremor, drowsiness, weakness, vertigo, headache

CV: cardiac arrhythmias, tachycardia, palpitations, angina pain

• • Nursing Responsibilities:

GI: nausea, vomiting, heartburn Respiratory: coughing, bronchospasm

1. Ask the client if he/she has any history of allergy with the drug. 2. Instruct the client not to exceed recommended dosage of the drug because it may loss its effectiveness or may cause adverse effects. 3. Explain the possible side effects of the drug like dizziness, drowsiness, fatigue, rapid heart rate, nausea and vomiting 4. Encourage the client to eat small frequent meals to avoid vomiting. 5. Assist the client in performing his daily activities because it may cause drowsiness and dizziness. 6. Instruct the client to perform oral care to avoid changes in taste.


7. Perform gentle back tapping after the administration of the drug through inhalation.


NURSING THEORIES Florence Nightingales’s Environmental Theory Florence Nightingale, the “lady with the lamp” defined Nursing as: “The act of utilizing the environment of the patient to assist him in his recovery.” And that it involves the nurse's initiative to make up environmental settings suitable for the gradual restoration of the patient's health, and that external factors associated with the patient's surroundings affect life or biologic and physiologic processes, and his development. Nightingale formulated the environmental theory which focuses on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act. She identified 5 environmental factors: fresh air, pure water & efficient food supplies, efficient drainage, cleanliness/sanitation and light/direct sunlight. Any deficiencies in these 5 factors produce illness or lack of health, but with a nurturing environment, the body could repair itself. In the case of the client, he needs an environment that is conducive for his recovery; he needs a quiet and clean environment. Our client in DMC MED- CP does not have a clean surrounding, and the room is crowded, so sanitation and cleanliness is not well maintained. The room is quite noisy and sometimes the doors were being slammed by the watchers, and that could give the client an environment not conducive for resting. The hospital also has efficient drainage system specifically in the comfort room. The client should also eat more nutritious foods and drink adequate water to boost his immune system and restore his energy. The client has not eaten a well balanced diet as he had poor appetite and he has a difficulty in eating and


finishing the food because he’s running out of breath. The client has not gotten fresh air and direct sunlight since he has not gone out of the hospital.

Dorothea Orem’s Self-Care Theory Orem defined Nursing as, “The act of assisting others in the provision and management of self-care to maintain/improve human functioning at home level of effectiveness.” Orem’s theory centers on activities that adult individuals perform on their own behalf to maintain life, health and well-being. She determined three related concepts: (1) Self-care – activities an individual performs independently throughout life to promote and maintain personal well-being, (2) Selfcare deficit – results when self-care agency (Individual’s ability) is not adequate to meet the known self-care needs and (3) Nursing System – nursing interventions needed when individual is unable to perform the necessary self-care activities:
1. 2.

Wholly compensatory – nurse provides entire self-care for the client. Partial compensatory – nurse and client perform care; client can perform

selected self-care activities, but also accepts care done by the nurse for needs the client cannot meet independently.

Supportive-educative – nurse’s actions are to help the client develop/learn

their own self-care abilities through knowledge, support and encouragement. Our client has a self-care deficit since the client needs assistance in doing his activities of daily living. In doing his ADL’s, he’s dependent on his mother who’s with him.


As nurses it is our duty to provide care for our client but we also need to promote to the client self- sufficiency and independence. Since the client is partially compensatory, we can offer ourselves to the client in order for him to meet his needs, we can assist him in doing his ADL’s. We, as nurses should dedicate ourselves to the client and be there for him whenever he needs our help. We, as responsible care givers must do our duty and that is to render quality care for our client. It is also our job to promote independence to the client, through giving the client health teachings and encouragement as these will aid client develop his own self- care capability. We must encourage the client to be independent in doing his daily activities, just like feeding himself as the client can perform it independently but since the client is dependent in some of his activities like ambulating, we should instruct the watcher to offer themselves to the client and assist the client in doing his daily activities.

Virginia Henderson’s Definition 14 Basic Needs Henderson defined nursing as: “Assisting the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that an individual would perform unaided if he had the necessary strength, will or knowledge”. She formulated a nursing theory which focuses on person’s basic needs and she enumerated 14 basic needs that a person must possess. The following are the14 basic needs: 1. 2. 3. Breathing normally Eating and drinking adequately Eliminating body wastes


4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Moving and maintaining desirable position Sleeping and resting Selecting suitable clothes Maintaining body temperature within normal range Keeping the body clean and well-groomed Avoiding dangers in the environment Communicating with others Worshipping according to one’s faith Working in such a way that one feels a sense of accomplishment Playing/participating in various forms of recreation Learning, discovering or satisfying the curiosity that leads to normal development

and health and using available health facilities. In our client’s case, he was not able to meet some of these needs, the client is not breathing normally, he needs supplemental oxygen via face mask in order for him to breathe. The patient does not eat adequately and often does not finish his meals because he had shortness of breath. He was not able to wear suitable clothing; in fact, he doesn’t wear any shirt to cover his upper body parts for few days. The client was not able to keep himself clean; he’s not well-groomed and has unkempt hair. He was not able to avoid the dangers in the environment that’s why he had acquired his illness. He has not participated in various forms of recreation. He was not also able to maintain normal range of temperature since he had an elevated temperature last April 21, 2010.


However, the client has met some of the needs enumerated by Henderson. He was able to eliminate his body wastes and was able to maintain or move on his desired position but with assistance. The patient tried his best to communicate with us and had established rapport with him. He believes in God and never loses hope; he worshipped according to one’s faith. When he was not ill yet, he really felt that he was really an accomplished person since he was able to provide his family’s needs through working hard. He was also able to have adequate rest and sleep since most of the time the client was sleeping and resting on his bed. The client was also utilizing the services given by the health care facilities.



Date Objective & Time Cues Need Nursing Diagnosis Care of Nursing Interventions Evaluation





airway After 6 hours 1) Monitor respirations for rate, depth April 16, 2010 @ 2pm

“Maglisod ko ug C ginhawa nitukar ni sukad akong I V I T

clearance related to span of care, and ease, presence of tachypnea; note thick, secretions secondary to COPD viscous the patient deep or shallow breathing, nasal flaring,

will be able to panting, and grunting. improve airway patency as ® Reveals rate and type of respirations

sakit.”as verbalized by the patient.

(baseline for deviations) that are related GOAL to age and condition of the patient, PARTIALLY changes that indicate obstruction of MET airways and lungs resulting in extreme changes in depth of respirations which




a manifested




condition of chronic by: dyspnea with


♣ Suppresion 2010 of productive cough ♣ crackles @ noted upon



airflow a. Maintain patent airway with breath sounds clearing b) demonst rate behavior s to

are abnormal.

After my 6 hours span of care my patient

limitation that does not significantly

fluctuate. It is caused by noxious particles

2). Elevate head of the bed in a SemiFowlers position.




improve airway as

auscultation ♣ nasal flaring 8:00 AM noted ♣ use accessory muscles when breathing ♣ gasping, panting grunting noted during and




most from which an

® Positioning facilitates chest expansion patency and respiratory efficiency by reducing evidenced by: pressure of abdominal organs

commonly smoking perpetuates ongoing R C I S E inflammatory

of E

a. 3) Assist in performing deep breathing exercises. ® Promotes ease and deeper breathing by enlarging tracheo-bronchial tree and would help remove secretions. 4) . Assist with measures to improve b. demonstr ation of maintena nce of a patent airway.

response that results in airway narrowing and Airways hyperactivity. become

improve and maintain

edematous, excessive mucus production


respiration ♣ labored breathing ♣ tachypnea ♣ Vital Signs: RR: 28 cpm (Normal: 16 – 20 cpm) PR: 96 bpm BP: mmHg
♣ Smoker

occurs P A T T E R n function Patients increasing clearing with


cilia weakly. face

patent airway such deep breathin g exercises as

effectiveness of cough effort. ® Cough can be persistent if or patient but is

behaviors to improve and maintain patent airways such as

ineffective, elderly,

especially ill,

difficulty secretions disease



Coughing is most effective in an upright or in a head-down position after chest percussion.

progression. Accordingly, develop a they chronic

, increase oral fluid intake and head elevated in semifowler’s 5) Encourage patient to increase oral fluid intake within level of cardiac tolerance. Provide warm/tepid liquids. Recommend intake of fluids between, instead of during meals.

performa nce deep breathing exercises, increased fluid intake and head of

productive cough and dyspnea. Increase in mucus secretion as



well as the inability to expel such can cause respiratory obstruction resulting tract thus, to

28 years (1-2 cigarette pack per day) ♣ with O2 at

a ® Hydration helps decrease the viscosity of secretions, facilitating expectoration. Using warm liquids may decrease


2lpm via face mask

ineffective airway. Luxner, Delmar’s Care edition. Thomson Karla L.


bronchospasm. Fluids during meals can increase gastric distension and pressure

elevation with semifowler’s

Nursing 3rd USA: Delmar

c. expecto rate sputum effectiv ely by

on the diaphragm.


6) Administer medications as indicated: > Ceftriaxone, Azithromycin Various antimicrobials may be indicated for control of respiratory infection/ pneumonia. > Acetylcysteine Antioxidant drugs are used to reduce the thickness of mucus and ease its removal. >Salbutamol c.


Learning. 2005. pp. 66-67.

breathin g deeply before coughin g.

expectora tion mucus secretions effectivel y by of

breathing deeply

d. verbaliz e These medications relax smooth muscles



underst anding of therape utic manage ment

and reduce local congestion, reducing airway spasm, wheezing, and mucus production. d.


verbalizat 7). Instruct to splint the chest while coughing. Splint with a towel or pillow. ion of

understan ding visa-vis therapeuti c

regimen ® Splinting reduces chest discomfort and avoids exerting too much force.

8). Instruct not to suppress a productive cough. Encourage to expectorate sputum whenever he feels the urge to cough it out. Instruct to take deep breaths before coughing and expectorating the sputum. ® Suppressing a cough would prevent

managem ent regimen as patient verbalize d, “ana


expectoration of secretions which could obstruct the airways leading to



kelangan pud dili

interference with gas exchange thus, resulting to difficulty of breathing. Taking deep breaths before coughing would facilitate easy expectoration of sputum.

lang naka higda, mas gwapo man ning jud

9) Provide information about the things he has to do, and why he has to do it such as optimal positioning (sitting position) and frequent position changes to

nakalingk od diay ta noh pag

mag ubo para maayog gawas ang

facilitate easy removal of secretions. ® Having knowledge about things will give the patient an idea on how to do such procedures and would improve


compliance with the treatment regimen.

plema. Mag inom na kog


For patients with reduced energy,

sad tubig

pace activities. Maintain planned rest periods. ® Fatigue is a contributing factor to ineffective coughing.

pirminte bisag ginagmay lang sugod

11. Explain effects of smoking, which includes second-hand smoke.

karon.. However

® Smoking contributes to bronchospasm patient’s breath and increased mucus production in the sounds were not airways. clear crackles noted and were upon





Need N U init T akong R


Plan of Care

Nursing Interventions

Evaluation GOAL MET


Diagnosis Hyperthermia At the end of 1 hour related increased

to of nursing care, the 1. Provide tepid sponge bath as April 21, 2010 1:00 P.M. patient will be able needed. At the end of 1 hours of

2010 @ “Medyo 12:00 lagi

metabolic activity to:

® Through TSB, heat is lost by nursing care, the patient:







Demonstrate a temperature within normal range

evaporation and conduction.



COPD secondary to PTB

normal temperature: 2. Increase oral fluid intake. ® To support circulating volume and tissue perfusion.
3. Promote bed rest and limit



36.8 ºC

T= 38.0 N ºC A

® An increased metabolic activity triggers the



37.5 °C;

Flushed L skin M E T A B O L I C

movements. ® To reduce metabolic

hypothalamus, the body’s thermoregulator, to increase the

Skin warm to touch

demands/oxygen consumption. 4. Promote surface cooling, by undressing or loosening the clothing of the patient ®Through this, heat is lost by radiation and conduction.
5. Administer Paracetamol

thermoregulation in the body, the and

causing temperature

other vital signs to increase



beyond P A T T E R N levels.


mg PO as ordered. ® To assist with measures that would bring body temperature

Nursing Pocket Guide to Diagnoses, Prioritized Interventions and Rationale Doenges et. al.

into normal level. 6. Monitor temperature every 30 minutes ® To assesse any change in temperature pharmacologic was given
7. Administer replacement fluids.

after management





volume and tissue perfusion. 8. Provide supplemental oxygen


®To offset increased oxygen demands and consumption. 9. Provide adequate ventilation. ®The heat in the environment may affect the increasing

temperature of the client.




Nursing Diagnosis

Objective of Care At the end of 6 hours of nursing care, the patient will be able to: • Demonstrate an increase in appetite; • Verbalize 1.

Nursing Interventions


SUBJECTIVE: A P R I L • “Wala kaayo ko’y mukaon, hangakon man gud gana


Imbalanced Nutrition: Less than Body Requirements related to decreased in appetite secondary to COPD secondary to



habits, April 20, 2010 @

including food preferences and 12:30 p.m intolerances on food. ® To assess evaluate client’s likes and dislikes. 2. Monitor or explore attitudes At the end of 6 hours span of nursing care, the patient was able to demonstrate an increase in appetite as evidenced by finishing food given to him. He was able to acknowledge the significance of proper nutrition and was able to understand its benefits to the body and verbalized, “mukaon na kog GOAL MET

dayon ko,”as verbalized by the client.

toward eating and food ®Many psychological,

psychosocial, and cultural factors determine the type, amount, and appropriateness consumed. 3. Encourage nutritious foods of food

understanding about the significance of

2 0,

PTB. ® The taste

OBJECTIVE: • Poor appetite Hemoglobin = • 122 g/L


proper nutrition and its benefits to the body.

affects the degree of appetite of a person. The

and increase in oral fluid intake. ®To facilitate in providing proper nutrition that the body needs. 4. Recommend ways to aid

2 0 1 0

Was not able to finish food given to her.

decrease in the patient with meals as needed. taste Ensure a pleasant environment, perception also facilitate proper position, and causes



Date / Cues Time A P R I L Subjective: Patient verbalized: “Maglisod man lihok, lang 20, hangakon.” As verbalized by the patient. ko ug dali


Objectives of Care

Nursing Diagnosis

Nursing Interventions




intolerance Within 6 hours span 1) Instruct rationale for breathing

April 20, 2010 @ 2:00 PM

related to shortness of of care, our patient exercises, coughing effectively, and breath secondary to will COPD ® COPD is a be able to general conditioning exercises ® Pursed-lip and breathing muscles of

improve tolerance evidenced by:

activity as

abdominal/diaphragmatic exercises strengthen

condition of chronic dyspnea expiratory with airflow

“Goal Met” Within 6 hours

ko I T Y

respiration, help minimize collapse of a) participate in small airways, with and means provide to the

span of care our patient was able to improve activity

limitation that does not significantly

necessary or desired activities such as



dyspnea. General conditioning exercises increase activity tolerance, muscle

fluctuate. Within that


2 0 1 0 Objective: E

broad category, the eating, sitting up on strength, and sense of well-being. primary cause of the bed, repositioning 3) Explain importance plan and of rest in for rest

tolerance evidenced by:


obstruction may vary; and turning to sides; examples include

b.) report an increase treatment in activity tolerance. balancing

necessity with

- generalized X body malaise noted R limited of C I needs S in E E

airway inflammation, mucous narrowed lumina, or plugging, airway airway

a.) participated in necessary desired such as or activities eating,


® Bed rest is maintained during acute phase to decrease metabolic demands, thus conserving energy for healing. Activity determined restrictions by thereafter are


range motion

destruction. Decreased oxygenation and lack of necessary nutrients causes weakness,

sitting up on bed, repositioning and turning to sides;



8 AM


response to activity and resolution of respiratory insufficiency. c.) 4.) Monitor BP, pulse, respirations during and after activity. Note adverse responses to increased levels reported an in

assistance walking -

fatigue and general malaise that leads to limited movement physical of the



activity tolerance;

unsteady gait noted

of patient verbalized:


- muscle tone P and are weak pale nail strength equally T T E R N -Hemoglobin = 122 (Normal range= 175 g/dl) 135g/dl A


activity(e.g., [HR]/BP, dyspnea,

increased dysrhythmias,


rate “ gina try na nako lihok lihok. sa lang

dizziness, ug



of Hantod makaya nako”



mucous membranes/nailbeds). ®Cardiopulmonary manifestations

is a state in which a person has

beds (especially in the toes)

insufficient physical; or psychological

result from attempts by the heart and lungs to supply adequate amounts of oxygen to the tissues. 5.) Elevate head of bed as tolerated. ®Enhances lung expansion to maximize oxygenation for cellular uptake 6.) Provide/recommend assistance with activities/ambulation as necessary,

energy to endure or complete required or desired daily activity as commonly

experienced by those having illness. chronic

allowing patient to do as much as VITAL possible.


SIGNS: Temp: 36.5°C BP: mmHg PR: 96 bpm RR: 38 cpm 80/60

®Although help may be necessary, selfesteem is enhanced when patient does some things for self.

7.) Identify/implement energy-saving techniques, e.g., sitting to perform tasks. ®Encourages patient to do as much as possible, while conserving limited

energy and preventing fatigue. 8) Plan care with rest periods between activities ® To conserve energy and reduce fatigue. 9.) Refrain from performing


nonessential procedures. ® Patients with limited activity

tolerance need to prioritize tasks. 10. Provide positive atmosphere, while acknowledging difficulty of the

situation for the client ® To help minimize frustration and rechannel energy.


Date April 19,


Need A C T I V I T Y

Nursing Diagnosis Self-care deficit: bathing/ hygiene related to body weakness secondary to Chronic Obstructive Pulmonary Disease

Plan of Care At the end of 4 days of nursing care, the patient will be able to: Safely perform self-

Nursing Interventions

Evaluation GOAL PARTIALLY MET April 22, 2010 @ 10:00 A.M.

Determine existing condition affecting the patient’s ability to do selfcare

2010 @ Patient 8:00 A.M. verbalized, “Upat na ko ka-adlaw wala na lagi”

At the end of 4 days of ® To develop a plan of care nursing care the patient, the appropriate to individual patient situation.

care activities to maximum ability; and Identify resources that can provide



Promote client and SO participation in problem identification and decision making ® To enhance commitment

Was not able to perform self-care activities on his maximum ability. CBB was done by his mother. He was

Dandruff noted X Body odor noted Untrimmed E R C

® The nurse may encounter the patient with a self-care deficit in

assistance in selfcare

to plan and optimizing




the hospital.The outcomes. deficit may be the result of transient limitations, such

still weak. However, he was able to trim Assist in providing complete bed bath. his nails and comb his hair. Dandruff was still noted on his scalp. ® As the patient has difficulty standing for a long time, bathing in the toilet is not feasible. Give the patient independence as much as possible.


as those one might experience while recuperating from surgery; or the result of progressive deterioration that erodes the individual’s ability or willingness to perform the ® The need for privacy is fundamental for most •

Was able to identify resources such as comb, towel, toothbrush and nail cutter in order for him to perform

Maintain privacy during bathing as appropriate.


activities required patients. to care for himself or herself. Careful examination of the patient’s deficit is required in order to be certain that the patient is not failing at self-care because of a lack in material resources or a problem with arranging the environment to
7. 6. 5.

Encourage patient to comb own hair ® This enables the patient to maintain autonomy for as long as possible. Encourage patient to perform minimal oral-facial hygiene as soon after rising as possible. Assist with brushing teeth and shaving, as needed. Assist patient with care of fingernails and toenails as


suit the patient’s physical

required. ® Patients may require

limitations. The podiatric care to prevent nurse coordinates injury to feet during nail services to trimming or because special maximize the implements are required to independence of cut nails. the patient and to ensure that the environment that the patient lives in is safe and supportive of his or her special needs. ® Avoid unnecessary interruptions while the patient is doing self-care activities.
9. 8.

Allow sufficient time for the patient to accomplish tasks to fullest extent of ability.

Provide for communication


among those who are involved in caring for/assisting the client. ® Enhances coordination and continuity of care
10. Encourage


but intervene when patient cannot perform. ® An appropriate level of assistive care can prevent injury with activities without causing frustration.



Medications 1. Inform and instruct the patient and the significant others about the medications the patient is taking and the importance of giving the medication for the patient’s recovery. R: For the patient and for the significant others to increase their awareness about the importance of taking the drug correctly. 2. Provide information about taking drugs not below or over the dosage given in order to avoid drug toxicity and adverse effects. R: To alleviate client’s knowledge about the drug he is taking. 3. Stress the right timing of the taking the medication. R: To maximize the effects of the drug and prevent further complications from occuring. 4. Instruct the significant others to notify the health care provider when unusualities are noted during the course of therapy. R: To avoid these unusualities from worsening. 5. Store medications in places that are safe, free from insects and rodents and away

from children’s reach in order for the medicine not to be contaminated. R: To prevent contamination and accidental ingestion of drugs. Exercise 1. Discuss to client that exercises are important to prevent muscles from tightening.



Encourage him to do simple exercises such as walking, stretching, active and

passive ROM. R: To promote circulation. 3. Teach the client on how to do deep breathing exercises.

R: To maximize lung capacity and oxygen circulation in the body. 4. Encourage patient to pair exercise with adequate rest and sleep. R: To promote fast recovery. 5. Encourage the patient to exercise within normal limits. R: In order to avoid straining and weakness. 6. Instruct the patient to avoid exhausting activities until full recovery is achieved. R: For prevention of complications. 7. Encourage stimulation, both physically and mentally, by way of performing activities of daily living. R: Maintenance of bodily functions. Treatment 1. Encourage the client to comply with the doctor’s orders and instructions, especially in

taking the prescribed medications. R: Compliance to the doctor’s order prevents complication from occurring. 2. Explain to the patient and as well as the significant others regarding the dangers of noncompliance to the therapy.


R: For them to understand that there will be consequences of non-compliance to the therapy. 3. If fever occurs, instruct to do tepid sponge bath. If fever still persists, take paracetamol as prescribed by the physician. R: Promotes non-pharmacologic interventions for controlling fever.

Health Teachings: 1. Teach the patient about the importance of proper hygiene and good grooming. 2. Teach patient and his significant others on how to perform hand washing and when to do it. R: Handwashing is the single most important step in controlling the spread of infection. 3. Explain the importance of a well-balanced diet and enumerate its benefits to the body. R: To increase client awareness regarding its importance and its benefits to the body. Out-patient 1. Instruct the patient to have follow-up check -up. R: To evaluate health status and provide a continuous care for the patient. 2. Tell the patient that regular check-ups are essential to ensure that his condition is constantly monitored by the doctor. R: Monitoring is important to detect any complication that may arise.


3. Encourage the patient that if he experiences any unusualities or changes in his health status, he should notify the physician immediately. R: Immediate actions taken decrease chances of patient’s condition to worsen. Diet 1. A diet rich in protein, vitamins and minerals is recommended. R: To promote healing of the body. 2. Increase oral fluid intake. R: To maintain hydration and prevent dehydration. 3. Eat foods with sufficient caloric value. R: To facilitate healing.



GOOD FAIR POOR JUSTIFICATION Onset illness of the √ The patient first experienced signs and symptoms of PTB 13 years ago. He was treated and became asymptomatic. The disease recurred last 2006 up to now. This recurrence of PTB and its symptoms led to the current diagnosis of the patient which is Chronic Obstructive Pulmonary Disease.


Duration of illness

The illness of the patient started 14 years ago when he was diagnosed with Pulmonary Tuberculosis. After that diagnosis, he was able to get treatment regimen and was asymptomatic after then.

However, last 2006, a relapse happened because he was diagnosed again with Pulmonary Tuberculosis. He again subjected himself to TB-DOTS.

However, complications of PTB led to the diagnosis of Chronic Obstructive Pulmonary Disease. This Precipitating factors √ 2010.

Environment, smoking and infection are three precipitating factors present in the patient. Thus, this makes the patient more vulnerable of developing COPD in addition to the fact that he has PTB.

Willingness take

to √

During the course of his illness, he was able to conform to the medication regimen. Last 1996, he was able to get treatment and so he became asymptomatic. When the disease recurred, he participated in the DOTS treatment. There were just times before that even though he wants to take medication, he couldn’t do so due to financial reasons.


and treatment



The patient is currently 40 years old. This is too early for an individual to suffer from COPD. However, considering the fact that he also has PTB that he acquired when he was 28 years old makes him susceptible for this disease.

Environmental factors

The patient lives in a conducive and healthy environment. Their family has a house in Palanca Village in Matina, Davao City. It is not near the highway as well as not in close proximity to any factories so the risk of pollution contributing to his illness is lesser. Moreover, since he stays mainly in their house after the 2nd diagnosis of PTB, he is less exposed to environmental pollutants. No one in their house smokes after they found out that he has PTB.

Family Support

Since he was diagnosed of Pulmonary Tuberculosis last 1996 up to this time wherein he is currently suffering from Chronic Obstructive Pulmonary Disease, his family never fail to attend to his needs involving check-ups, medications, needs during treatment. During the course of the disease, the family has been very supportive. In fact, his mother and his brother are the persons who are there to attend to the patients needs in the hospital. Family


members were also seen visiting the client within his stay in the hospital. Computation:  Poor: (4*1)/7  Fair: (0*2)/7 =4/7 = 0/7 =6/7

 Good: (3*3)/7



1. 42

General Prognosis: 1-1.6 = POOR

1.7-2.3 = FAIR 2.4-3.0 = GOOD

Rationale for a Poor Prognosis At an early, Don Juan developed Pulmonary Tuberculosis. Even though he was prompt in taking medications and was asymptomatic after that, a relapse developed. The return of his illness radically changed his health and eventually led to another disease. As it name implies, COPD is a chronic illness. Only prevention and treatment management could lead to a very good prognosis. We rated a poor prognosis for “Lito” due to the fact that at a young age, he already developed a communicable disease and this disease gave him a more difficult disease to cope up with. He may be willing to take all the medications there is and all possible treatments,


the financial capabilities of their family might hinder the possible decrease in complications of the disease. Moreover, COPD affects individual greater than 40 years old. It is sad to note that Don Juan has been brought in this predicament too early. Within the duration of his illness, more symptoms appeared that makes his health more vulnerable. His age is at the risk level of COPD. In addition, no cure has been set for COPD other than management of symptoms.

RECOMMENDATION This case study has provided the proponents with important information about the patient’s disease. In order to ensure that optimal health is restored and maintained, the group would like to recommend the following: To the patient Whenever there is, the onset of a certain disease it implies one to contribute her cooperation and willingness to be responsible for her own health. The patient himself must present himself to the care intended for him to reduce the severity of the disease. He must be sensitive of his own feelings, needs and must be accountable for his actions. He is encouraged to verbalize his feelings to also help the people rendering care and for him to express his perception and feelings regarding the condition he is undergoing. He is advised to comply strictly with the


treatment regimen, medications, and orders of the doctor for him. He must know the importance of good compliance to medication and the benefits it would give to him. Lastly, he must not hesitate in seeking medical assistance whenever he feels any unusualities in his body.

To the patient’s family The family of every patient plays a very important role in the condition of the patient and his treatment. The family themselves should understand the condition of the patient for them to know how to care to their family member who is sick. They should make themselves physically present so that the patient will feel their love and support so that he will feel that he is not alone in fighting against his illness. That he has somebody to hold on to and be one of the reasons for him to continue fighting and overcome his illness. To the student nurses: Every case study that student nurses do adds to their knowledge that help them better understand more condition thus helping them become better health care provider. Student nurses must always be ready in whatever they will be facing in their everyday exposure. They must be prepared and alert. Even with the clinical instructors in their side, there is still a possibility that they can commit mistakes. Therefore, they must always be prepared, equipped with the knowledge they learned from the lectures and skills gained from experiences for them to render quality nursing care. Empathy, patience, respect and genuineness are the key elements for the nurse to possess. Every student nurses should develop these for them to assist and render quality care for the


patient and share whatever they know for the betterment of the condition of every patient they will handle. Lastly, they must continue in studying different cases and be able to share to other student nurses, to patients and their significant others, to people of community and especially to their family.

To the Ateneo de Davao University- College of Nursing The AdDU- College of Nursing has the biggest role in providing stuent nurses with opportunities of having exposures to different clinical areas to help them apply the knowledge they have gained from every lectures and practice the skills they gained necessary for their profession. The faculty and staff are also encouraged to maintain improving the standards of the Nursing Curriculum in Ateneo by providing quality education to the students. Moreover, they themselves must be well-trained to guide the students to learn. It is of great importance that they will continue in inspiring generations to take up nursing and perceive this job as a noble one, helping people who are need of care, care that only nurses dare to do.

To the Professional Medical World COPD and PTB are kinds of diseases that can affect persons of different gender, age, and socioeconomic status. The proponents of this study would like to recommend to the professional world to improve their facilities and projects that were made to do researchers on how to cure and prevent these diseases. Workers in the health team should work together to promote optimum health, prevent the spread of illnesses, and enhance the welfare of the society most


especially. They must have projects to spread proper information to the community in order for the community to know and be informed about the different illnesses, their information, signs and symptoms, diagnostic exam, treatment, and how it can be prevented. Moreover, they should teach the community techniques on how to prevent the spread of diseases. They should teach them the proper hand washing, proper hygienic practices, proper sanitation, proper handling and preparing of foods, and especially healthy lifestyle. Lastly, they must give more attention and do further researches, innovation, inventions, and discoveries in the field of medicine to save more lives. In partnership with other health sectors, attaining the goal in establishing optimum health to the whole population is possible.

REFERENCES BOOKS Ann Ehrlich, Carol L. Schroeder. Medical Terminology for Health Professions. Copyright © 2004. Barbara Janson-Cohen. Medical Terminology: An Illustrated Guide 5th edition. Copyright © 2007. Charlene J. Reeves, Gayle M. Roux, Robin Lockhart. Medical-surgical nursing. Copyright © 1995. Jane Hokanson Hawks. Medical-surgical Nursing: Clinical Management for Positive Outcomes. Copyright © 2008. Kozier and Erb’s Fundmentals of Nursing 8th Edition


Nursing Pocket Guide to Diagnoses, Prioritized Interventions and Rationale Doenges et. al. Wilma J. Phipps, Judith K. Sands, Jane F. Marek. Medical-Surgical Nursing: Concepts & Clinical Practice, 6th Edition. USA. Copyright © 2000. Understanding Medical Surgical Nursing 3rd edition; International Edition; Williams,S.L.; Hopper, P. D.;F.A. Davis Company, 2007 Brunner and Suddarth’s Textbook of Medical Surgical Nursing, 11th edition; Smeltze, S.C.; Bare, B.G.; Hinkle, J.L.; Cheever, K.H.; Lippincot, Williams and Wilkins; 2008

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