NCM 112 MEDICAL-SURGICAL NURSING

LECTURER/S: PROF. ALMA BANUA

REFERENCE/S: BRUNNER & SUDDARTH’S TEXBOOK OF MEDICAL-SURGICAL NURSING 14TH EDITION

[NCM 112 MEDICAL-SURGICAL NURSING]: OXYGENATION

OUTLINE
I HEALTH CARE SITUATION IN THE PHILIPPINES
A Universal Health Care
II REVIEW OF THE NURSING PROCESS
A Assessment
B Nursing Diagnosis
C Planning
D Nursing Intervention
E Evaluation
III THE ANATOMY AND PHYSIOLOGY OF THE
RESPIRATORY SYSTEM
A Structures
B Defenses Genetics, diet and lifestyle, stress can contribute to
C Stages of Respiration noncommunicable diseases.
D Mechanics of Pulmonary Ventilation UNIVERSAL HEALTH CARE
E Controls of Respiration A. Financial Risk Protection - avail of health
F 2 Types of Chemoreceptors services, and reimbursement of health
expenditures by PhilHealth
G Lung Volumes and Lung Capacities
• Members of PhilHealth will be reimbursed
H Assessment of Respiratory Function from expenses but not all. Allowance from
IV UPPER RESPIRATORY DISORDER- VIRAL RHINITS Philhealth is dependent on the level of the
(COMMON COLD) hospital/ procedure/ surgery. It can be
reimbursed provided that it is within the
A Viral Rhinitis allocated amount. Not all medicines will be
B Assessment reimbursed.
B. Improve Access to Quality Hospitals and
C Clinical Manifestation Health Care Facilities
D Plan and Implementation - A percentage of the reimbursed Philhealth of
V LOWER RESPIRATORY DISORDER: CHRONIC the client will also go to the hospital and
facilities.
OBSTRUCTIVE PULMONARY DISEASE - UHC is not only for the clients but the
A Assessment hospital/health facility as well that takes
B Plan and Implementation care of the client. The UHC also helps
achieve the MDG/SDG
● Upgrade government health
HEALTH CARE SITUATION IN THE PHILIPPINES facilities
● Improve facility preparedness- for
2 aspects we have to look at when we talk about trauma and other emergencies
healthcare situation: ● Treatment packs: HPN, DM
● DOH licensure and PhilHealth
● Clientele accreditation for hospitals and
○ COVID-19 health facilities
C. Attainment of Health-related MDGs- reduce
○ Lifestyle diseases (NCD) - We are number 4 among the world when it
○ Paying capacity comes to TB. SDG na ngayon, not MDG.
● Maternal and child mortality
● Healthcare (hospital) ● Morbidity mortality from
○ Facilities Tuberculosis and Malaria
● Incidence of HIV/AIDS
○ Resources (hospital supplies)
○ Manpower (health workers)

Healthcare system: the reality

Whatever program/protocol the DOH they implement,

this is according to the WHO’s but they can modify it
according to the situation of the philippines.
It is written in the constitution that health is a basic
right.
If the health situation of the client changes, the UHC
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must adjust to the needs of the clients. f. Pattern (What makes it better?
What makes it worse?)
PATIENT SATISFACTION: A QUALITY METRIC g. Associated factors (What other
Measurement of Patient’s Satisfaction symptoms do you have with it?
● Quality of Nursing care received Will you be able to continue
● Responsiveness of hospital staff doing your work or other
● Quietness of environment activities [leisure or exercise]?)
● Pain management
● communication/Information ii. Past Health History
- Medication, discharge, instructions ⎯ Start: Client’s history then to family
● Evaluation: Overall rating of the hospital history
a. Problems at birth
REVIEW OF THE NURSING PROCESS b. Childhood illness
Nursing Process c. Immunizations
• systematic guide to client-centered care d. Surgeries
• organizational framework for nursing practice e. Illnesses in the family
i. Parents
• Developed by Ida Jean Orlando in 1958
ii. Aunts and uncles
iii. Siblings
Phases/STEPS of the NURSING PROCESS (ADPIE)
iv. Grandparents
1. Assessment - Collecting data (subjective and
objective) ⎯ Family health history- assess for
2. Diagnosis - Analyzing data to make a professional a. Genetically based
nursing judgment (nursing diagnosis) diseases
3. Planning - Determining outcome criteria and b. Risk factors
developing a plan (target outcome) c. Example: Smoking
4. Implementation - Carrying out the plan members- can affect other
5. Evaluation - Assessing whether outcome criteria members (effect of second
have been met and revising plan as necessary hand smoke)
PHYSICAL EXAMINATION
ASSESSMENT ⎯ Based on findings of history taking decide which
• Collection of Data system will be assessed (Focused assessment)
o Subjective Data- inside (felt) – ASK ⎯ Example: Chief complaint: cough 3 days ago What
o Objective Data – outide;observed (use system will be assessed? Answer: Respiratory
senses) System
o Inspection
HEALTH HISTORY ▪ involves use of senses: vision,
smell, and hearing
⎯ Present Health History ▪ observe and detect any normal or
▪ Purpose: Identify chief complaint (cc) and abnormal findings
etiology of health problem. ▪ sample: Respiratory rate - Normal:
▪ Start: present history (most recent) 12 and 20bpm; Even and easy
• chief complaint movements of respiratory muscles
• personal history of client & chest expansion
• family history. o Palpation
▪ Example: ▪ Touching body part you have just
• Cc: cough and fever accompanied by inspected
loss of smell and taste ▪ Possible to feel an abnormal from a
• (S/S of COVID 19?) normal body part
i. History of present health concern (Chief o Percussion
complaint) ▪ tapping fingers &
⎯ Assess chief complaint using the hands quickly &
mnemonic: COLD SPA sharply against
a. CHARACTER: How does it parts of the body
feel, look, smell, sound, etc.? ▪ Purposes:
b. ONSET (When did it begin; is it • Eliciting
better, worse, or the same pain
since it began?)
c. Location (Where is it? Does it • Determining location, size,
radiate?) and shape
d. Duration (How long does it • Determining density
last? Does it recur?) • Detecting abnormal
e. Severity (How bad is it on a masses
scale of 1 [barely noticeable] to • Eliciting reflexes
10 [worst pain ever
exprienced]?)
LABORATORY EXAMINATION

⎯ In focused assessment, lab. exams are based on

results of history and P.E.
⎯ Example:
o Cc: Productive Cough for 1 month
o P.E. with rales
o Lab Ex: Chest Xray, sputum exam
o CBC –check for infection
⎯ Pause
o History + P.E. = Impression/initial Diagnosis
(R/O)

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o History + P.E. + Lab Exams = Final
Diagnosis
o Ensure alignment of History, P.E. and Lab
exam
NURSING DIAGNOSIS
⎯ Data analysis-
✓ Identifies a problem or a potential problem
✓ Focus of care/intervention
⎯ Nursing diagnosis – NANDA
TYPES OF NURSING DIAGNOSIS
A. Actual Diagnosis
• evidence of signs & symptoms of
disease
• Format: 3-part-statement PES
(Problem + etiology + signs and
symptoms)
o Problem is in negative
statement (impaired,
ineffective, altered, etc):
Ineffective airway clearance
o Etiology: written as related
to= is often part of the
medical diagnosis
o Signs and Symptoms
written as: “as evidenced by"
(AEB)
o Example: Ineffective airway
clearance/ related to
physiologic effects of
pneumonia/ as evidenced by
increased sputum, coughing,
abnormal breath sounds,
tachypnea, and dyspnea
B. Risk Diagnosis
• evidence of related risk factors of
disease
• but no evidence of signs and
symptoms
• Format: 2-part-statement Problem +
etiology
o Example: Risk for impaired
skin integrity/ related to
obesity, prolonged
confinement to bed,
immobility
o Risk: prolonged confinement
to bed, immobility
C. Wellness Diagnosis
• healthy client indicate desire to
achieve a higher level of functioning
in specific area
• Format: 1- part-statement Uses
word potential for enhanced
o Example: Wellness
Diagnosis
o Client verbalized: “I wish I
were a better parent.”
o Nursing diagnosis: Potential
for enhanced parenting
Criteria Actual Potential Wellness
Problem YES NO
Signs & YES NO
Symptoms
Format PES PE (Risk for) Potential for
enhanced
Number of 3 2 1
parts
statement
PLANNING
⎯ Development of goals for care
o Long term & short term
o Expected Outcome of care
⎯ Goals/Expected Outcome: Use SMART goals
o Sample:
▪ Client will walk with a cane at least
to end of the hall & back in 1 week
▪ Specific: Client
▪ Measurable, attainable, realistic:
will walk with a cane at least to the
end of hall & back
▪ Time bounded: in 1 week
NURSING INTERVENTION
⎯ Nursing Action
⎯ Render actual nursing care
o Independent - on their own, without input or
assistance from others; Within scope of function
▪ Example: Auscultate apical purse,
assess heart rate, rhythm; Document
dysrhythmia if telemetry is available
o Interdependent/Collaborative - work alongside
multiple members of a care team to perform
these interventions.
▪ Example: Administer diuretics as
indicated. Administer IV solutions,
restricting total amount as indicated
o Dependent - require an order from a physician
▪ Example: Refer to dietitian for
counselling specific to individual
dietary customs
EVALUATION
⎯ Purpose: evaluate client’s progress towards attainment of
outcome of care
⎯ Steps:
o Assess: What happened to the health problem.
Did it improve? Still the same? Or has worsen?
o Compare findings with the goal/outcomes
o Draw conclusion about outcome (problem
status)
⎯ Conclusion on problem status
o Achieved
o Partially Achieved
o Not achieved
⎯ If partially achieved or not achieved, reassessment is done.
⎯ Modifications in interventions are made based on the
health status
THE ANATOMY AND PHYSIOLOGY OF THE
RESPIRATORY SYSTEM
• Responsible for respiration
• Composed of:
Structures Main Function
Upper Respiratory nose, pharynx, passage of gasses
Tract (URT) larynx, during
trachea inspiration and
expiration
Lower Respiratory bronchi and exchange of gasses
Tract (LRT) bronchioles and (oxygen
lungs (main and carbon
structure) dioxide)
STRUCTURES
NO UPPER RESPIRATORY TRACT (URT) KEY ROLES
NO 1. to assist with the movement of air into the lower airways,
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2. to protect the lower airway from foreign matter which • Requires energy
may be inhaled, and • Diaphragmatic and intercostal muscles contract.
3. to warm, filter and humidify inspired air • The diaphragm goes downwards, while the
intercostal muscles pull the chest wall outwards.
LOWER RESPIRATORY TRACT (LRT) This results in filling with air into
• lower airways are branching tubes that become 2. Expiratory Phase
progressively smaller until they terminate in the alveoli, a • normally passive and requires very little energy
series of balloon-like structures. • The diaphragm and intercostal muscles relax and
• The alveoli are the main respiratory units, where gas the air is expelled from the lungs
exchange occurs Remember:
• LUNGS - are surrounded by tissue called pleura, which is 1. Breathing in = muscles contract = lungs are inflated = air
lubricated with pleural fluid. The pleural fluid prevents gets in
friction during inspiration and expiration 2. Breathing out = muscles relax = lungs are deflated = air
gets out
3. Alveoli - main respiratory units, where gas exchange occurs
DEFENSES
• The upper respiratory tubes have specific defenses that
protect the respiratory tract. MECHANICS OF PULMONARY VENTILATION
• If the upper respiratory structures are unable to defend (PHYSICAL FACTORS THAT GOVERN AIRFLOW)
the respiratory system, the lower respiratory tract is 1. Air pressure variances
affected. • Variance means the
o For example, an upper respiratory tract infection difference between
(common cold) may progress to an infection of the pressures in the
the lower respiratory tract like pneumonia atmosphere
• The lungs (type 2 epithelial cells in the alveoli) secrete (external) and the
surfactant which is a complex material composed of lipids lungs (internal).
and proteins. o A
• Surfactant functions in three ways: difference in the pressures between
o prevents alveolar collapse at low lung volume; the external and internal areas causes
o preserves bronchiolar patency and; the movement of air/gas in and out of
o protects the lungs from injuries and infections the respiratory system.
caused by inhaled particles and micro-organisms o No variance/difference in the pressure
between the external and internal
STAGES OF RESPIRATION areas → no movement of gasses will
happen.
• respiratory system works in concert with the
cardiovascular system; • During Inspiration: respiratory muscles contract,
o the respiratory system is responsible for the thoracic cavity enlarges (lungs expand),
ventilation and diffusion, thereby lowers pressure inside to a level below
o the cardiovascular system is responsible for the atmospheric pressure
perfusion o The negative pressure inside the lungs
causes the movement of oxygen from
Stages Description Processes
the atmosphere into the respiratory
Pulmonary Exchange of gasses Ventilation
tubes and to the alveoli
Ventilation between lungs & (inspiration and
• During Expiration: respiratory muscles relax
atmosphere. During expiration)
causing a decrease in the size of the thoracic
inspiration, O2
cavity (lungs get smaller), thereby the alveolar
enters the
pressure is higher than atmospheric pressure.
respiratory tract and
This caused air to flow from the lungs into the
during expiration
atmosphere
CO2 carbon dioxide
is excreted 2. Airway Resistance
External Exchange of gases Diffusion • Resistance refers to force between the size of
Respiration between lungs & the airway (diameter)
blood in the versus the rate of airflow.
pulmonary o A change in
capillaries diameter of
Gas Transport Refers to the Perfusion airways affects
transport of O2 & airway
CO2 resistance and
the rate of
Internal Exchange of O2 &
airflow during respiration.
Respiration CO2 between the
o Increase airway resistance = increase
blood and tissues
in the respiratory effort to achieve
normal levels of ventilation.
*RESPIRATION- whole process from the gas exchange between the
• Respiratory effort means that accessory muscles
atmospheric air and the lungs, the diffusion (entry) of O2 into the
are used in addition to the diaphragmatic and
blood and perfusion of gasses from the
intercostal muscles, resulting to dyspnea.
blood into the tissues up to the utilization of oxygen and excretion
o When the airway is narrow the client
of CO2
exerts effort, in an attempt to achieve
PULMONARY VENTILATION
normal ventilation.
Pulmonary ventilation is made possible Contraction of these • Signs of difficulty in breathing (dyspnea) are
muscles makes flaring of alai nasi, a rise of sternocleidomastoid
1. diaphragm (muscles at the base of the lungs) and muscles.
2. intercostal (muscles around the ribs) 3. Compliance
PHASES OF RESPIRATION • ability of the lungs and pleural cavity to expand
1. Inspiratory Phase and contract based on changes in pressure

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• normal lungs and thorax easily stretch & distend 2. Pneumotaxic center in the upper pons controls the
when there are changes in pressure. rhythm of respiration
o High lung Example
compliance 1. The apneustic center operates when you
occurs when are under stress and you involuntarily sigh.
the lungs are 2. Pneumotaxic center operates when a client
too pliable in the delivery room is in contraction, and
and have a you coach her to perform slow relaxed
lower-than-normal level of elastic breathing or pant-blow breathing
recoil (maygrant.com).
▪ Exhalation of air becomes
more difficult because the CHEMICAL REGULATION
loss of elastic recoil reduces
• Chemoreceptors sense the changes in the chemical
the passive ability of the
content and stimulate neural regulators to adjust. The rate
lungs to deflate during
and depth of respiration are based on changes in the
exhalation.
blood concentrations of the following chemicals.
▪ Commonly seen in
• Carbon dioxide (CO2)
obstructive diseases, such as
• Oxygen (O2)
emphysema
• Hydrogen ion concentration (pH). pH is the
o In low lung compliance, the lungs are
degree of acidity or alkalinity of the blood
“stiff” and have a higher-than-normal
level of elastic recoil. • Examples
▪ stiff lung • An increase in CO2 concentration leads to a
would decrease in the pH of blood due to the
need a production of H+ ions from carbonic acid
greater- o In response to a decrease in blood pH,
than- the respiratory center (in the medulla)
average sends impulses to the external
change in intercostal muscles and the
pleural diaphragm, to increase the breathing
pressure to change the rate and the volume of the lungs
volume of the lungs, and during inhalation
breathing becomes more o Obstructive respiratory problems like
difficult. Chronic Obstructive Pulmonary
▪ commonly seen in restrictive Disease, there is a narrowing of
lung diseases, like pulmonary airways/bronchoconstriction. Carbon
fibrosis. The presence of scar dioxide accumulates because it cannot
tissues in the lung. These easily exit causing an increase in CO2
scar tissues are hard which and a decrease in pH.
makes the lungs inelastic. • Hyperventilation causes alkalosis, which causes a
Inelasticity causes difficulty feedback response of decreased ventilation (to
in lungs expansion and increase carbon dioxide), while hypoventilation
deflation.\ causes acidosis, which causes a feedback
response of increased ventilation (to remove
Remember: carbon dioxide).
• Air pressure variances or difference in pressure between o Hyperventilation can occur when you
lungs & atmosphere result to exchange in gasses are anxious and when you breathe
(diffusion) fast, causing an increase in excretion of
• Increase in Airway resistance results increased effort to carbon dioxide during expiration. The
promote gas exchange opposite occurs in hypoventilation
• Normal Compliance or elasticity promotes the exchange of • Any situation with hypoxia (too low oxygen
gasses levels) will cause a feedback response that
increases ventilation to increase oxygen intake.
• High compliance (absence of elasticity) results to
o This happens when you go mountain
overdistention of the lungs (remains inflated)
climbing, the higher the altitude the
thinner the air, meaning there is less
CONTROLS OF RESPIRATION
oxygen to breathe
• Respiration is an involuntary reflex. It is a result of the
cyclical excitation of the respiratory muscles by the
phrenic nerve.
2 TYPES OF CHEMORECEPTORS
1. Central chemoreceptor –
• located in the medulla and respond to changes
NEURAL REGULATION
in the pH and –
• Comes from the term neuron • send message to the lungs to change the depth
• refers to the two respiratory centers in the brainstem, that and rate of ventilation to correct the imbalance
control respiration of pH
o Medulla Oblongata 2. Peripheral chemoreceptor
o Pons • located in the aortic arch and carotid arteries
and
2 Respiratory Center • responds first to changes in PaO2 then
• control the rate and depth of ventilation to meet the
metabolic demands of the body. LUNG VOLUMES AND LUNG CAPACITIES
1. Apneustic center in the lower pons stimulates the Lung volumes measure the amount of gas for a specific function,
inspiratory medullary center to produce deep, while lung capacities are the sum of two or more volumes. Lung
prolonged respiration. volumes refer to four units:

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1. Tidal volume (TV) measures the amount of air that is
inspired and expired during a normal breath. On average,
this volume is around one-half liter, which is a little less
than the capacity of a 20-ounce drink bottle.
2. Expiratory reserve volume (ERV) is the additional amount
of air that can be exhaled after a normal exhalation
3. Inspiratory reserve volume (IRV) is the additional amount
of air that can be inhaled after a normal inhalation.
4. Residual volume (RV) is the amount of air that is left after
expiratory reserve volume is exhaled. RV cannot be
measured directly because it is impossible to completely
empty the lung of air. RV can only be calculated
• lungs are not completely emptied; there is
always some air left in the lungs after a maximal
exhalation. If this residual volume did not exist
and the lungs emptied completely, the lung
tissues would stick together
SPIROMETRY MEASURES LUNG VOLUMES
• Measurements taken during spirometry
a) Forced expiratory volume (FEV) - measures how much air
can be forced out of the lung over a specific period, usually
one second (FEV1).
b) Forced vital capacity (FVC), which is the total amount of
air that can be forcibly exhaled
• The ratio of these values (FEV1/FVC ratio) is used to diagnose
lung diseases including asthma, emphysema, and fibrosis.
• If the FEV1/FVC ratio is high, the lungs are not compliant
(meaning they are stiff and unable to bend properly);
o Example: Lung fibrosis.
• Conversely, when the FEV1/FVC ratio is low, there is resistance
in the lung that is making it is difficult for the patient to get the
air out of his or her lungs.
o Example: Bronchial Asthma
LUNG CAPACITIES
Lung capacities are measurements of two or more volumes. The
vital capacity (VC) measures the maximum amount of air that can
be inhaled or exhaled during a respiratory cycle. It is the sum of the
expiratory reserve volume, tidal volume, and inspiratory reserve
volume.
a) Inspiratory capacity (IC) is the amount of air that can be
inhaled after the end of a normal expiration. It is,
therefore, the sum of the tidal volume and inspiratory
reserve volume.
b) Functional residual capacity (FRC) includes the expiratory
reserve volume and the residual volume. The FRC
measures the amount of additional air that can be exhaled
after a normal exhalation.
c) Total lung capacity (TLC) is a measurement of the total
amount of air that the lung can hold. It is the sum of the
residual volume, expiratory reserve volume, tidal volume,
and inspiratory reserve volume
ASSESSMENT OF RESPIRATORY FUNCTION
HISTORY TAKING
• This is the ASK portion. From the term history you are
going to get a detailed story.
• Ask the the chief complaint (cc). Have a FOCUS- follow the
guide COLD SPA.
• At the end of the history taking, analyze the data. It these
normal or abnormal data. Record your findings and cluster
related data.
• By clustering, we mean group the data which are
connected to each other, then determine which system of
the body is involved.
• Your analysis will guide you in which area of the body are
you going to perform the 2 nd activity- PHYSICAL
EXAMINATION.
PHYSICAL EXAM
• performed in a sequential manner.
• Perform a PE of the thorax- Top- down and Left to Right.
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• Document findings and determine whether your findings
are normal or abnormal data.
• Correlate them with the data in the history.
DIAGNOSTIC EXAM
• When the history + PE are completed, the need of the
DIAGNOSTIC EXAM is determined by the physician.
• The diagnostic exam is a confirmation of the findings in the
History & P.E.
UPPER RESPIRATORY DISORDER- VIRAL RHINITIS
(COMMON COLD)
VIRAL RHINITIS
• “cold” – most frequent viral infection in the general
population
• infectious, acute inflammation of the mucous
membranes of the nasal cavity
• “rhinitis” -> “rhino”=nose
• “common cold” – referring to an upper respiratory
infection that is self-limited and caused by a virus
• Self-limited- viral infections runt heir course
• Course of a disease refers to the
development of the sequence of
development of diseases, from appearance
of symptoms to recovery
• Average viral rhinitis course- approximately
7 days
• Does not respond to antibiotics
ASSESSMENT: VIRAL RHINITIS
Etiology :
• caused by as many as 200 different viruses.
• Rhinovirus – most common: 10-40% of
colds
• Other common cold viruses: coronavirus
and respiratory syncytial virus
• More than 200 viruses that cause common colds-
human body can never build up resistance to all 🡪
colds are common and often return
• Highly contagious - most individuals become
communicable about a day before cold symptom
develop and remain communicable for about 5-7
days
• Considering the etiology, and the characteristic of
being communicable, it is IMPORTANT to assess in
history taking, the client’s EXPOSURE to the virus
(example: contact with a person with viral rhinitis
and similar diseases of viral in origin).
• This is similar to COVID 19, where the exposure/
movement of a client is asked.
• Where have you been for the past weeks (
travel history, place of residence,
employment, any infected person at
home?)
CLINICAL MANIFESTATIONS
Symptom of Viral Rhinitis (last for 1-2 weeks))
a. Low grade fever
b. Nasal congestion
c. Rhinorrhea – excessive nasal drainage, runny nose
d. Halitosis- “bad breath”
e. Sneezing
f. Sore throat
g. Headache and muscle aches
h. General malaise
i. Cough- appears as illness progresses
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j.If severe systemic infection occurs, it is no longer Proximal airways Increased hypersecretion of
considered viral rhinitis but an acute upper (trachea and number of goblet mucus
respiratory infection (URI). bronchi > 2 mm cells and
a. It is because the disease is beyond the its in diameter) enlarged
submucosal
course of seven days, and recovery without
glands
antibiotics.
Peripheral thickening of the Airway narrowing
PLAN AND IMPLEMENTATION:
airways airway wall,
Medical and Nursing Interventions (bronchioles < 2 peribronchial
• Management is SYMPTOMATIC- purpose of mm diameter) fibrosis and
interventions given is to alleviate the symptoms and not exudates in the
treat the cause of the disease which is a virus. airway
Alveoli ducts and Alveoli are Enlargement of
INDEPENDENT NURSING INTERVENTION alveol damaged alveolar wall and
loss of elastic
• Adequate fluid intake recoil
• Adequate Rest Remember:
• Prevention of Chilling • Over time, this ongoing injury-and-repair process
• Warm salt-water gargles causes scar tissue formation and narrowing of the
airway lumen (GOLD, 2008).
DEPENDENT NURSING INTERVENTION • COPD is irreversible, the narrowing may improve with
• Expectorant: Guaifenesin (Mucinex) treatment, but the diameter will not be reverted to its
• Nonsteroidal anti-inflammatory drugs (NSAIDs): normal
aspirin or ibuprofen
Diseases that Cause Airflow Obstruction
• Antihistamines: Loratidine
1. Chronic bronchitis
• Nasal decongestant: phenylephrine nasal [Neo- • Chronic
Synephrine] inflammation of
• Topical nasal decongestants (eg, the bronchi with
phenylephrine nasal [Neo-Synephrine], a large
should be used with caution. Topical production of
therapy delivers medication directly to the mucus resulting
nasal mucosa, and its overuse can produce in obstruction and inflammation
rhinitis medicamentosa, or rebound 2. Emphysema
rhinitis. 1. Abnormal
• Rebound rhinitis is the enlargement of
inflammation of the nasal mucosa alveoli with the
caused by the overuse of topical destruction of
nasal decongestants. It is a subset alveolar walls
of drug-induced rhinitis
• Antiviral medications: Amantadine (Symmetrel) and • Asthma
rimantadine (Flumadine) : can reduce the severity of • characterized by an abnormal airway
symptoms and may reduce the duration of viral obstruction, and the signs and symptoms are
rhinitis similar, however it is a distinct separate
* Antimicrobial agents (antibiotics) should not be used, disorder from COPD because it is reversible.
because they do not affect the virus or reduce the incidence of • Note: Asthma is not under the category of
bacterial complications. COPD

LOWER RESPIRATORY DISORDER: CHRONIC ASSESSMENT

OBSTRUCTIVE PULMONARY DISEASE HISTORY TAKING
Chronic Obstructive Pulmonary Disorder
History Taking- to determine the etiology or the cause of
• obstruction of the airway
the health problem
• With exposure to the risk factor, narrowing develops
• Present History
slowly over a period of time.
▪ Chief Complaint
• The airflow obstruction is
▪ Criteria for Chronicity - occur for at least
associated with the abnormal
3 months in each of 2 consecutive years
inflammatory response of the lungs
▪ Signs and Symptoms
to gases
• Sputum is produced when the
• Once the narrowing of the airway,
goblet cells are irritated by smoke,
and the damaged alveoli occur, is
causing an increase in sputum
usually progressive and is
production. Since smoke paralyzes
irreversible.
the cilia, it the cilia cannot perform
oProgressive means that the
its role of filtering the gasses that
damage advances slowly, and that it cannot
enters the upper respiratory tract.
be reverted to the normal state, even with
Copious/increase amount of
medical management (irreversible)
sputum will cause obstruction. A
defense to expel the sputum is
Structure Changes Result
cough (the next symptom).
affected

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• Cough. The cough maybe bacteria to promote

intermittent and unproductive in healing).
some patients. Cough is a reflex o Deficiency in AAT
that protects the lungs from causes neutrophil
accumulation of secretions or elastase enzyme to
inhalati on of foreign bodies. The attack the healthy
client coughs in an attempt to clear lung tissue
the airways. Because of the o AATD testing is
copious amount of sputum, coupled recommended for all
with inflammation of the respiratory with a diagnosis of
tract, the narrowing is further COPD or adult-onset
aggravated. If it is not managed, it asthma (WHO))
will result to the next
• Dyspnea on exertion (DOE) is a PHYSICAL EXAMINATION
result of inadequate oxygen that
enters during inspiration and the • findings from P.E. are integrated with the findings
accumulation of carbon dioxide from the patient’s health history.
(CO2). CO2 accumulates because • The objective data should align and support the
it can not be released during subjective data - needed in the initial confirmation of
expiration. Dyspnea maybe severe the diagnosis.
and interferes with the patient’s
Subjective P.E Objective Data
activities and quality of life. It is Data Techniques
worse with exercise. As COPD Cough and Inspection Color and consistency
progresses, dyspnea may occur at Sputum of sputum and amount
rest. Production
• Weight loss: dyspnea interferes Dyspnea Inspection Rapid and shallow
with eating and the work of breathing Increase RR
breathing is energy depleting. Use of accessory
• Risk for respiratory insufficiency muscles
and respiratory infections, which  Flaring of alai nasi
in turn increases the risk of acute  a rise in
and chronic respiratory failure. sternocleidomastoid
• Emphysema, chronic muscles  intercostal
hyperinflation leads to Barrel chest” retraction Cyanosis-
thorax configuration. The chronic late sign of respiratory
problem
hyperinflation of the alveoli and loss
Auscultation
of lung elasticity leads to a more
Emphysema Faint and inaudible
fixed position of the ribs in the
breath sounds
inspiratory position.
Bronchitis Wheezes, Crackles
• Past History
⎯ Retrospective approach (retro=past) Remember:
⎯ As a student nurse, your role is to assist o Health History + P.E. = impression or an initial
the client to recall the past history diagnosis.
related to what had contributed to the o This means that the results show- “MAYBE ITS
⎯ Purpose: Determine the risks/etiology of COPD”. Maybe because there are other obstructive
COPD. diseases that the clinical manifestations are similar to
▪ Risk Factors COPD.
• Environmental factors
(External) DIAGNOSTIC EXAMINATION
o Tobacco Smoke- o Its role is to confirm the impression or the initial diagnosis.
active and passive o Other disorders that can mimic COPD should be excluded
smoking (80-90% of based on clinical suspicion and differential diagnosis in
COPD cases) each patient.
o Occupational o The GOLD international COPD guidelines advise
exposure (dust, spirometry as the gold standard for accurate and
chemicals) repeatable measurement of lung function.
o Air pollution
o Alpha an antitrypsin 1. Bronchodilator reversibility test.
deficiency a. Spirometry is initially performed
• Genetic abnormalities - b. The patient is given an inhaled bronchodilator
deficiency of treatment
alpha1antitrypsin* c. Spirometry is repeated
o Alpha-1 produced d. Result FEV1/FVC ratio of < 70% means that
mostly in the liver there is the presence of airflow limitation after an
which protects the inhaled bronchodilator, showing a degree of
lungs from neutrophil irreversibility
elastase (enzyme that 2. Arterial blood gas (ABG)
digests damaged or
aging cells and
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 NCM 112 MEDICAL-SURGICAL NURSING OXYGENATION
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a. gas (ABG) is obtained to assess baseline Corticosteroids anti- Stage III or IV

oxygenation and gas exchange and are inflammatory (severe or very
especially important in advanced COPD severe) COPD,
b. Procedure one or more
i. Prepare heparinized syringe bronchodilators
ii. Locate an artery and cleanse site using & inhaled
cotton with 70% alcohol. Radial and corticosteroids
for repeated
brachial arteries preferred
exacerbations.
iii. Extract blood from an artery (.5-1 ml).
Arterial blood is bright red.
Pharmacologic Treatments
iv. Remove air from syringe.
• alpha1-antitrypsin augmentation therapy
v. Place syringe with blood in ice and bring
• antibiotic agents
to laboratory immediately for analysis
• mucolytic agents and antitussive agents
3. Chest x-ray
o Antitussives are cough
a. may be obtained to exclude alternative
suppressants. They relieve your
diagnoses.
cough by blocking the cough reflex.
b. Contraindicated for pregnant women.
Indicated for dry cough.
4. Screening for alpha1-antitrypsin deficiency may be
o Expectorants thin mucus. This may
performed for patients younger than 45 years of age and
help your cough clear the mucus
those with a strong family history of COPD
from your airway.
Remember: • vasodilators (pulmonary HPN)
• Health history + P.E. + Diagnostic Exam = Final • narcotics
Diagnosis This means that the confirmatory • vaccines- influenza and pneumococcal
diagnostic examination is a valid proof that the 3. Oxygen Therapy
medical diagnosis is COPD. 4. Nutritional Therapy

PLAN AND IMPLEMENTATION

NURSING AND MEDICAL MANAGEMENT
• First step in management: to make a correct
diagnosis
• In the planning it is important to review the risk factor
present in the client. Is it smoking/exposure to
environmental pollutants or a host risk (age, alpha
antitrypsin deficiency)
• The plan must be tailored fit to the client. However, for
the purpose of the general Management, we will
discuss all therapeutic strategies, these are:
o smoking cessation to prevent further
damage to the respiratory structures,
o prescribing medications to manage the
airway obstruction and
o oxygen therapy to assist the client in
correcting the lack of oxygen in the body.

1. Risk reduction:
• smoking cessation is the single most cost-
effective intervention to reduce the risk and
to stop progression
• Smoking cessation is difficult to achieve and
even more difficult to sustain in the long
term. It is because of the addiction to
nicotine.
• Nurses like you have a big role in assisting
the client to quit
2. Pharmacologic Therapy:
• Medication regimens used to manage COPD
are based on disease severity
Medication Action Indication
based
Bronchodilator relieve Stage I (mild)
s bronchospasm COPD, a short-
and reduce acting
airway bronchodilator
obstruction Stage II or III
COPD, a short-
acting + long-
acting
bronchodilator
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 NCM 112 MEDICAL-SURGICAL NURSING: CHAPTER 2: COMMUNITY-BASED NURSING PRACTICE
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