Case presentation-1 copd

Case presentation
on
Copd

Submitted to : submitted by :

Ms. Sucheta yangad ms. Sonali vaidhya

(asso.professor) msc 2nd yr student

Submission date
History-taking
& physical-
Examination
 Demographic data:

Name :-mr. Guluf dadubhai shinde

Age :-72 year

Sex :-male

Address : - annsaheb nagar,chinchwad, pune ip

number :-48967

Education : - illiterate

occupation : - shopkeeper

income :-10000/month

marital status: - married religion

:-hindu mother

tongue:-marathi ward :

- medicine icu. Date of admission: -

28/02/2020

Diagnosis :- copd

History-taking
Chief compliants:-

➢ Cough with copious expectoration : since 5 days

➢ Breathlessness : since 1 day.

Present history of illness: -

Patient was apparently alright 15 days back then developed mild, which was remain untreated and
progressivly changed in sever cough with expectoration, breathlessness which is more in supine position.
The expectorant is white colour and mucoid in nature. He has shown to one local doctor. From there he is
referred here for further treatment.
 Past history of illness:-

Medical history: -patient is a known case of bronchial asthema since 5 years, not on regalar treatment
with tab asthalin 50 mg.

Surgical history:-no significant history of any major or minor surgical intervention given by patient.

Menstrual history [female]- not applicable

Family history:-

Name Age/ sex Education/occupation Relationship Health status

Mr. Guluf dadubhai 72 y/ m 4th std/ shopkeeper Himself Copd
Shinde
Mrs. Marembi g. 68 y/ f Illiterate/ housewife Wife Healthy
Shinde
Mr. Gururaj g shinde 42 y/ m 12th std / salesman Son Healthy

Mrs. Rupa g.shinde 33y/ m 10th std/ housewife Daughter in Healthy

Law
Master jijesh g.shinde 5y/m Nursery Grandson Healthy

Personal history:-

Habits : non-alcoholic, ciggrete smoker but stoped since 5 years.

Diet : non- vegetarian, appatite decreased, 4 meal/day.sleeping habits :

patient sleeps 3 hrs at day time and 6 hrs at night time, currently
S sleep patern distrubed due to cough.

Allergy : no history of allergy to any food/medications given by patient. Bowel and

bladder habits: bowel and bladder movement are normal.

Socio- economic status:-

Condition of the house:pakka house& adequate ventilation 2room&1 window, kitchen water supply:

corporation water

Drainage system: closed drainage

Surrounding environment:the environment is clean around the house.

Physical examination

General appearance:

Constitution : my bye built state

of nutrition : good

Personal appearance:good and maintained posture

: normal

Skin and hair : fair complex, bluish discoloration and no pediculi in the hair. Emotional

state : anxious

Co-cooperativeness : patient is co-operative

Height and weight:

Height : 5.8 feets

weight : 65kgs.

Vital signs:

Temperature : 99.4f

Pulse : 122 b/ minute

respiration : 26/minute blood

pressure : 140/90 mm hg head and

face:

Skull: round in shape

Scalp: clean, no dandruff, scar present

Hair: black and white color, and equally distributed face:

symmetrical

Node: not palpable

Eyes:

Eyebrows: symmetrical

Eyelashes: equally distributed and there is no infection, lesion present.

Eyelid : intact, no discharge, discoloration, and lids close symmetrically eyeballs:

both eyes coordinated; move in unison with parallel alignment. Conjunctiva:no infections

Sclera:white

Pupil: reactive to light lens:

dilated

Vision:patient has good visual capacity; he can read and saw easily.

Ears:

External structure: no any tenderness

Canal : no any discharge from ears.

Tympanic membrane : intact

Hearing: weber test- patient hear equal in both

Rinnie test- sound conducted by air is heard is more sound conducted by bone.air conduction is more
than bone conduction.

Nose:-

External structure – symmetric and straight septum - no

deviated nasal septum

Mucous membrane -moist, inflamed, irritation present

olfactory sense -present

Patency –patent
Mouth and pharynx:

Lips-pale in colour and dry

Teeth- no dental caries,shiny tooth enamel present. Gums

-healthy (no bleeding)

Palates – smooth and soft palate

Voice – hoarsness and agrevating cough to speech. Breathe

– no any bad smell present.

Taste –good

Neck:

Lymph nodes - not palpable

Muscles –muscles are in equal in both size and head in centered. Trachea

-centrally situated and space are equal in both side.

Thyroid gland- lobes are smooth, small, centrally located and painless rise freely with swallowing

Range of motion- present

breast and area nodes: -

inspection:-not applicable

palpation:-not applicable

chest:

Chest shape: -barrel shape

Type of respiration: - trachycardia, irregular, breathlesness. Expansions : -chest is

not fully expanding during inspiration.

Inspection:-no any tender scar, mass, node present, use of assessory muscls for breathing.

Palpation :-bilateral symmetrical and vocal fermitus. Percussion:-

no any dull sound present and no any fluid collection.

 Auscultation -during auscultation crepitation soundspresent .

Cardiovascular system:-

Rate and rhythm: - regular

Apical and radial:-122/m and regular

Carotid pulse: - full pulsation present and no bruit sound. Jugular

venous distension: -no distended jugular vein description of peripheral

pulses:-

Brachial Radial Femoral Popliteal Dorsal Post tibial

Pedial
Rate 124/m 123/m 123/m 123/m 122/m 122/m
Rhytham Regular Regular Regular Regular Regular Regular

Abdomen and inguinal areas:-

Contour and tone : - convex , soft, notenderness, pain while breathing. Scar : - no

any scar present

Liver: - not palpable and no hepatomegaly spleen: - not

palpable and no spleenomegaly kidney: - not palpable

Bladder: - no distention masses: -no

mass palpable.

Palpation : - there is no tenderness, relax abdomen with consistent tension. Percussion

: - tympany sound present, no sign of ascitis or fluid collection. Auscultation

: - audible bowel sound present.

Genitals area:

Rectal examination: - it’s smooth and not tender.

Musculoskeletal system:

Upper extremities : no any deformity normal rom present lower

extremities:no any deformity normal rom present deformities : no any

deformity

Joint evaluation : no any tenderness, crepitation, nodules etc

Muscle strength:- according to grading system- grade-5 , 100% normal strength – normal movement
against gravity&resistence-present

Muscle mass : no any mass present

node: not present

Range of motion : present

Nervous system:-

Mental status:- patient is oriented to time , place and person.

He can calculate the normal value like 12+17=29 he has

good judgment quality.

Patient has good immediate, recent and recall memory. Cranial nerves:-

present the sensory and motor response of the nerves.

Deep tendon reflex: - deep tendon reflex present, bicep’s, triceps, patellar, brachio- radialis etc.

Superficial sensory reflex:-the reflexs are reactive to light, pain, vibration, and touch.
 Investigation:-
Type Patient report Normal values Impression
Hemogram
Hb 7.2 mg/dl 13-18 mg/dl Decresed

Tlc 15500/ cumm 4000-11000/cumm Increased

Platelet 2.63 lakh/cumm 1.5-4.5 lakh/cumm Normal

Count

Rbc. Microcytic hypochromic Normocytic Indicating sever anamiae

Rbc seen,few pencil cell ,normochromic
Seens

Bsl random 90 mg% 70-100 mg% Normal

Lft
Sr.bilurubine
Total 0.8 0.2-1.0 gm%
Dierect 0.2 0-0.3gm% Normal
Sr.protien 6.6 6-8 gm%
Albumin 3.8 3.5-4.5 gm%
Globulin 2.8 2-3.5 gm%

Sgpt 18 0-40

Sgot 53 18-112
Serum
Electrolyte

Serum sodium 138meq/l 135-145meq/l Normal

Serum 3.7meq/l 3.5-5.5 meq/l Normal

Potassium

Rft
Blood urea 30 mg% 15-50mg% Normal

Serum 1.2 mg% 0.6-1.4 mg% Normal

Creatinine

Uric acid 4.6 2.5-6.5mg/dl Normal

Chest x -ray: there are bilateral lower lobe infiltrate

 Disease
condition
Introduction:
Chronic obstructive pulmonary disease (copd) is a preventable and treatable disease state
characterised by airflow limitation that is not fully reversible. The airflow limitation is usually
progressive and associated with an abnormal inflammatory response of the lungs to noxious
particles or gases, primarily caused by cigarette smoking.some clinicians consider asthma as part
of copd, but due to its reversibility, it is considered by most to be a separate entity.

Copd may include diseases that cause airflow obstruction (eg, emphysema, chronic bronchitis) or
a combination of these disorders. Other diseases such as cystic fibrosis, bronchiectasis, and
asthma were previously classified as types of chronic obstructive lung disease. However, asthma
is now considered a separate disorder and is classified as an abnormal airway condition
characterized primarily by reversible inflammation. Copd can coexist with asthma. Both of these
diseases have the same major symptoms; however, symptoms are generally more variable in
asthma than in copd.

Chronic bronchitis is a chronic inflammation of the lower respiratory tract characterized by

excessive mucous secretion, cough, and dyspnea associated with recurring infections of the
lower respiratory tract.

Pulmonary emphysema is a complex lung disease characterized by destruction of the alveoli,

enlargement of distal airspaces, and a breakdown of alveolar walls. There is a slowly progressive
deterioration of lung function for many years before the development of illness.
Related anatomy and physiology:

Lungs lie on each side of the midline in the thoracic cavity. They are cone shaped &
have an apex, a base, costal surface & medial surface.

The right lung is divided into three distinct lobes & the left lung has two lobes. Pleural space is
the space between the inner & outer layer of pleura which normally contains a small volume of
lubricating fluid to allow the lungs to expand without friction.

The interior of the lungs are composed of the bronchi & smaller air passage, alveoli, connective
tissue, blood vessels, lymph vessels & nerves, all embedded in an elastic connective tissue
matrix.

Each lobe is made up of a large number of lobules. Each lobule is supplied with air by a terminal
bronchiole, which further subdivides into respiratory bronchioles, alveolar ducts, & large
numbers of alveoli (air sacs) there are about 150 million alveoli in the adult lung, in this
structures that the process of gas exchange occurs.
As airways progressively divide & become smaller and smaller, their walls become gradually
thinner until muscle & connective tissue disappear, leaving a single layer of squamous epithelial
cells in the alveolar duct & alveoli.

The alveoli are surrounded by a dense network of capillaries. Exchange of gases in the lung
(external respiration) takes place across a membrane made up of the alveolar wall & the capillary
wall fused firmly together.

This is called the respiratory membrane. Surfactant, a phospholipids fluid secreted by septal cells
prevents the alveoli from drying out, it also prevents alveolar walls collapsing during expiration.

Definition:
Copd is a disease state characterised by airflow limitation which is not fully reversible. Includes
chronic bronchitis, emphysema and small airway disease.

Significant obstruction is always present:

• It is chronic

• It is progressive

• Mostly fixed airway obstruction

• Non reversible by bronchodilators

• Exposure to noxious agent is a must two

entities in copd are:

1. Chronic bronchitis:

Chronic bronchitis is defined clinically as persistent cough with sputum production for at least 3
months in at least 2 consecutive years, in the absence of any other identifiable cause

➢ Small airway disease: condition in which small bronchioles are narrowed

2. Emphysema.

It is acondition characterised by permanent and abnormal dilation of airspaces owing to

destruction of lung panacinar: in this type, the acini are uniformly
Enlarged from the level of the respiratory bronchiole to the terminal blind alveoli. Seen in alpha
1 at deficiency. Common in lower lobes

1. Centriacinar: the central or proximal parts of the acini, formed by respiratory bronchioles, are
affected, whereas distal alveoli are spared. More common in upper lobes.most common in
smokers.
2. Paraseptal (distal): the proximal portion of the acinus is normal, and the distal part is
predominantly involved.
3. Irregular: irregular emphysema, so named because the acinus is irregularly involved, is
almost invariably associated with scarring

Incidence:
It is more common in men than women. It is more frequent in clients living in urban
environment and among the socieo-economically disadvantages. 30% of smokers develop copd
20% of adult males have copd 15% of copd patients are severely symptomatic 4th leading cause
of death (usa). Mortality rate still rising.increase prevalence in low birth weight and low socio
economic status.
 Etiology and risks factors:

Book picture Patient

picture
• Cigarette smoking: when cigarette is inhaled, which contains
Approximately 4000 chemiclas. Over 60 carcinogens have been isolated from cigarette
smoke, including cyanide, formaldehyde, and ammonia.it also has direct effect on Present
respiratory tract. The irritating effect of the smoke causes hyperplasia of cells, including
goblet cells which subsequently results in increased production of mucus, coughing,
destruction of ciliary function and inflammation and damage of bronchiolar and alveolar
walls.

• Passive smokers: also known as environmental tobacco smoke (ets). In

Adults involuntary smoke exposure is associated with decreased pulmonary function.
Increased respiratory symptoms,and severe lower respiratory tract infection resulting in Present
pneumonia.
• Occupational chemicals and dusts: prolonged exposure to various dusts, Absent
Vapours, irritants or fumes in the work place.
• Air pollution Absent

• Chronic respiratory infection such as sinusitis. Common causative Absent

Organism are h. Influenza, streptococcus pneumonia etc.

Absent

• Allergy, autoimmunity.
• Heredity: alpha1-antitrypsin (aat) deficiency is a genetically determined
Cause of emphysema and occasionally liver disease. Alpha1-antitrypsin serves primarily
as an inhibitor of neutrophil elastase, an elastin- degrading protease released by
neutrophils. When alveolar structures are left unprotected from exposure to elastase, Absent
progressive destruction of elastin tissues results in the development of emphysema.
Emphysema occurs because of aat deficiency.

• Aging: it results in changing of the lung structure, the thoracic cage and
Respiratory muscle. As people age there is gradual loss of respiratory recoil of the lung. Patient is 65
The lungs become more rounded and smaller. The number of functional alveoli years old
decreases as a result of alveolar supporting structure and loss of intra alveolar septum,
these changes are similar to those seen in the patient with emphysema.
• Chronic uncontrolled asthma Present

• Low socioeconomic status Her family

income is rs
10,000/
month.

• Bio mass fuel smoke, open fires Absent

• Low birth weight Absent

Pathophysiology:-

In copd, the airflow limitation is both progressive and associated with an abnormal inflammatory
response of the lungs to noxious particles or gases. The inflammatory response occurs
throughout the airways, parenchyma, and pulmonary vasculature. Because of the chronic
inflammation and the body’s attempts to repair it, narrowing occurs in the small peripheral
airways. Over time, this injury-and-repair process causes scar tissue formation and narrowing of
the airway lumen. Airflow obstruction may also be due to parenchymal destruction as seen with
emphysema, a disease of the alveoli or gas exchange units.
 Noxious particle & gases
(e.g. tobacco smoke, air
pollution)

Inflammation of Peripheral airway Parenchymal destruction Pulmonary vascular

central airways: changes
• Remodeling • Imbalance between
• Inflammatory proteinase
• Thick vessels
cells &antiproteinase.
• Inflammatory
(lymphocytes, cells infiltrate.
macrophages, • Collagen
neutrophils) deposit.
• Inflammatory • Destruction of
mediators. capillary bed.

COPD

• Mucus hypersecretion
• Cilia dysfunction
• Airflow limitation
• Hyperinflexion of lungs
• Gas exchange abnormalities
• Pulmonary hypertension
• Corpulmonale

Clinical manifestation:-
 Chronic bronchitis
Usually insidious, developing over a period of years

• Presence of a productive cough lasting at least 3 months a year for 2 successive

years.
• Production of thick, gelatinous sputum; greater amounts produced
During superimposed infections.
• Wheezing and dyspnea as disease progresses

Emphysema
Gradual in onset and steadily progressive

• Dyspnea, decreased exercise tolerance.

• Cough may be minimal, except with respiratory infection.
• Sputum expectoration—mild.
• Increased anteroposterior diameter of chest (barrel chest) due to air trapping with
diaphragmatic flattening.

Book picture Patient picture

Cough with expectoration, sputum is white in

• Intermittent cough which is the earliest symptom, usually colour. It is more in night.
occurs in the morning with the expectoration of small
amount of sticky mucous resulting from bouts of coughing.

• Dyspnea , usually occurs with exertion. Present, more in supine position.

• Wheezing and chest tightness may be present, but may vary Present.
by time of the day or from day to day, especially in patient
with more severe diasease. The wheeze may arise from
laryngeal area, or may not be present on auscultation.

• Prolonged expiratory phase of respiration(>6 sec) Present.

• Barrel chest: the anterior-posterior diameter of Present.

The chest is increased from the chronic air tapping.

• Decreased movement of chest Present.

• Poor diaphragm excurtion Present. Absent
• Decreased breath sound Absent
• Obliteration of cardiac and liver dullness
ronchi- in early disease present on forced expiration, later Present.
present in inspiration and
Expiration
• Hemoptysis Absent
• Hypoxaemia (pao₂<60mmhg or o₂ saturation <88%) Saturation is 94% with oxygen
• Hypercapnia (pao₂>45mmhg) Absent
• Hyperinflation: ¯ cardiac dullness, liver dullnes, A-p chest diameter, ¯ heart and breath
A-p chest diameter, ¯ heart and breath sounds Sounds are present.
• Cyanosis Absent
• Weight loss and anorexia Present

• Cachexia Absent

• Fatigue Present.

• Ankle edema in right sided heart involvement Absent

 Classification of severity of copd:-

Stage Symptoms Pulmonary function tests

Fev1/fvc Fev1% predicted

0: at risk Chronic symptoms Normal

(cough,sputum spyrometry
Production)
1: mild With or without <70% Less than or equal
Symptoms To 80%
2: moderate With or without <70% 50%-80%
Symptoms
3: severe With or without <70% 30%- 80%
Symptoms
4: very severe With or without symptoms <70% <30% or <50% and
Chronic espiratory
failure.
Diagnostic evaluation:-

Book picture Patient picture

• History of smoking, occupational history, personal Done

History, respiratory disease.
•
• Physical examination may reveal: Done
➢ Wheezing sound and rhonchi in auscultation.
➢ Barrel shaped chest.
➢ Edema and cyanosis
• Chest x-ray: Done
➢ Hyperinflation
➢ Increased translucency of lungs
➢ Bulla may be seen

• Pulmonary function test:

Pfts demonstrate airflow obstruction reduced forced vital Not done
capacity (fvc), fev1, fev1 to fvc ratio; increased residual
volume to total lung capacity
(tlc) ratio, possibly increased tlc
 Done
• Abg levels decreased pao2, ph, and increased co2.

• Alpha1-antitrypsin assay useful in identifying Not done

genetically determined deficiency in emphysema
• Body mass index Normal body index

• Sputum culture and sensitivity Not done

• Complete blood count Done

• Ecg Not done

• Pulse oxemetry 94%

Management:
The treatment goals for copd are as follows:

1) The prevention of disease progression;

2) The relief of symptoms

3) Improvement in exercise tolerance;

4) The prevention and treatment of exacerbations;

5) The prevention and treatment of complications;

Treatment options for copd exacerbation include smoking cessation, oxygenation,

bronchodilators, anticholingerics, antibiotics& corticosteroids.

1. Risk reduction:

Smoking cessation is the single most effective intervention to prevent copd or slow its
progression. Referral to a smoking cessation program may be helpful. Smoking cessation can
begin in a variety of health care settings— outpatient clinic, pulmonary rehabilitation,
community, hospital, and the patient’s home.
Regardless of the setting, the nurse has the opportunity to teach the patient about the risks of
smoking and the benefits of smoking cessation.

2. Oxygenenation:
Initial therapy should focus on maintaining oxygen saturation at 90 percent or higher.
Oxygen supplementation by nasal cannula or face mask is frequently required. Administering
supplemental oxygen raises the risk of partial pressure of oxygen.
With more severe exacerbations, intubation or a positive-pressure mask ventilation method
(e.g., continuous positive airway pressure [cpap] is often necessary to provide adequate
oxygenation).
3. Bronchodilators:
Bronchodilators relieve bronchospasm and reduce airway obstruction by allowing increased
oxygen distribution throughout the lungs and improving alveolar ventilation. These medications,
which are central in the management of copd are delivered through a metered-dose inhaler, by
nebulization, or via the oral route in pill or liquid form. Bronchodilators are often administered
regularly throughout the day as well as on an as-needed basis. They may also be used
prophylactically to prevent breathlessness by having the patient use them before an activity, such
as eating or walking. Bronchodilators used are:

a) Beta-adrenergic agonist agents:

a. Albuterol (proventil, ventolin, volmax), bitolerol (tornate), levalbuterol
(xopenax), metaproterenol (alupent), pirbuterol (maxair), salbutamol (asmavent),
salmeterol (serevent),
b. Terbutaline (brethaire)
b) Anticholinergic agents:
a. Ipratropium bromide (atrovent), oxitropium bromide (oxivent) etc.
c) Methylxanthines:
a. Aminophylline (phyllocontin), theophylline (slo-bid, theo-dur)

4. Corticosteroids:
A short trial course of oral corticosteroids may be prescribed for patients with stage ii or iii copd
to see if pulmonary function improves and symptoms decrease. Inhaled corticosteroids via mdi
may also be used. Examples of corticosteroids in the inhaled form are beclomethasone
(beclovent, vanceril), budesonide (pulmicort), flunisolide (aerobid), fluticasone (flovent), and
triamcinolone (azmacort).

5. Antibiotic choices for copd:

1. Mild to moderate exacerbations

First-line antibiotics:

Doxycycline (vibramycin), 100 mg twice daily

Trimethoprim-sulfamethoxazole (bactrim ds, septra ds), one tablet twice daily

Amoxicillin-clavulanate potassium (augmentin), one 500 mg/125 mg tablet three times daily or
one 875 mg/125 mg tablet twice daily

Alternative antibiotics

Clarithromycin (biaxin), 500 mg twice daily

Azithromycin (zithromax), 500 mg initially, then 250 mg daily

Fluoroquinolones, levofloxacin (levaquin), 500 mg daily, gatifloxacin (tequin), 400 mg daily,

moxifloxacin (avelox), 400 mg daily

2. Moderate to severe exacerbations: recommend iv antibiotics:

Ceftriaxone (rocephin), 1 to 2 g iv daily cefotaxime

(claforan), 1 g iv every 8 to 12 hours ceftazidime (fortaz),

1 to 2 g iv every 8 to 12 hours antipseudomonal

penicillins

Piperacillin-tazobactam (zosyn), 3.375 g iv every 6 hours

Ticarcillin-clavulanate potassium (timentin), 3.1 g iv every 4 to 6 hours

Fluoroquinolones

Levofloxacin, 500 mg iv daily gatifloxacin,

400 mg iv daily humidifications nad

nebulisation:

O2 obtained from cylinders or wall is dry. Dry o2 has an irritating effect on mucus membrabes and dyr
secretions. Therefore it is important to humidify o2 when
Administered either by humidifications or nebulisation. A common humidification when patient
hsa a catheter, cannula or low flow mask is bubble through humidifier. It is small plastic jar
filled with sterile distilled water that is attached to the o2 source by means of a flow meter. O2
passes into the jar, bubbles through the water and then goes through the patient’s catheter,
cannula or mask. The purpose of humidifier is to restore humidity conditions of room air.the
flow rate should between 1 and 4l/min is dependent on patient preference.

Nebulisation delivers particulate water mist (aerosols) with nearly 100% humidity. When
nebulisation is used large size tubing should be used to connect the device to a face mask or t
bar.

Surgical management:

Bullectomy:a bullectomy is a surgical option for select patients with bullous emphysema. Bullae
are enlarged airspaces that do not contribute to ventilation but occupy space in the thorax; these
areas may be surgically excised. Many times these bullae compress areas of the lung that do have
adequate gas exchange. Bullectomy may help reduce dyspnea and improve lung function. It can
be done thoracoscopically (with a video-assisted thoracoscope).
Or via a limited thoracotomy incision.
Lung volume reduction surgery: treatment options for patients with end-stage copd (stage iii)
with a primary emphysematous component are limited, although lung volume reduction surgery
is an option for a specific subset of patients. This subset includes patients with homogenous
disease or disease that is focused in one area and not widespread throughout the lungs. Lung
volume reduction surgery involves the removal of a portion of the diseased lung parenchyma.
This allows the functional tissue to expand, resulting in improved elastic recoil of the lung and
improved chest wall and diaphragmatic mechanics. This type of surgery does not cure the
disease, but it may decrease dyspnea, improve lung function, and improve the patient’s overall
quality of life
Lung transplantation:
Patients who are less than 65 years old with end-stage copd in the absence of other significant
disease should be considered for lung transplant evaluation and referral.lung transplantation is a
viable alternativefor definitive surgical treatment of end-stage emphysema. Ithas been shown to
improve quality of life and functional capacity.

Respiratory and physical therapy:

Respiratory and physical therapy should be given repiaratory and physical therapist depending
on the institutions. Respiratory and physical therapy include breathing retraining,effective cogh
techniques, respiratory and chest physiotherapy.

1. Breathing retraining:
➢ Pursed lip breathing : the patient is taught to inhale slowly through the
Nose and then to exhale slowly, through pursed lip, almost as if
whistling. Exhalation should atleast 3 times as long as inhalation.
➢ Diaphragmatic breathing.
➢
2. Effective coughing:
➢ The main goal is to conserve energy, reduce fatigue and removal of secretion.
➢ Huff coughing

3. Chest physiotherapy:
Indicated to the patient with excessive bronchial secretion with expectorated sputum
production greater than 25ml/day.evidence of retained secretion in the presence of artificial
airway, lobar atelectasis caused by mucous plugging. Chest physiotherapy consists of
percussion, vibration and postural drainage. Percussion and vibration are manual or
mechanical techniques used to augment postural drainage. Percussion and vibration are used
after postural drainage to assist in loosening the mobilized secretion.

4. Nutritional therapy:
➢ Should rest at least for 30 minutes before eating.
➢ Use bronchodilators before meal and select food that cen be prepared in advanced.
➢ Should eat five to six small, frequent meal to avoid feeling of bloating
And early satiety when eating.
➢ Food that require great deal of chewing should be avoided. Cold food may give
less of sense of a fullness than hot food.
➢ They may need 25 – 45 kcal/kg and1.2 -1.9g of protein kilogram to
Maintain their weight.
➢ High calorie and high protein diet is recommended.
➢ Megestrol has been used to stimulate and increase appetite.
➢ Fluid intake should be at least 3l/day unless contra-indicated.
Drug
study
 Medication:-
Name of Dosage/ Mode of action Side effect Nsg responsibility
Drug Route
Inj. 1gm Ceftriaxone is a third- Central nervous system- Take history of cephalosporin allergy.
Ctriaxone /iv/bd generation cephalosporin dizziness,
antibiotic; it has broad Headache.
spectrum activity against Take history of lactating women
gram positive and gram Gastrointestinal- diarrhea, because it can enter into breast milk.
negative bacteria. In most Nausea and vomiting.
cases, it is considered to be Assess patient of fever for
equivalent to cefotaxime in Blood- diarrhoea because it causes
terms of safety and efficacy. High concentration of eosinophils, platelet colities.
counts in the blood, decrease in white blood
cells, Assess for patachy, echimosis nose
Low prothrombin levels, bleeding and any unusual bleeding
bleeding. without specific regions.

Lab tests-
Increase in liver enzyme,
Elevated bun (blood urea, nitrogen). Local-
indurations/tightness/warmth.

Genitourinary- vaginal
inflammation.

Miscellaneous- fatal ceftriaxone-calcium

precipitates in lung and kidneys of neonates.
Name of Dosage/ Mode of action Side effect Nsg responsibility
Drug Route
Inj. 50mg Block histamine h2 Interfere with absorption, - drug is given by following
Rantac Orally Receptor in stomach and Headache, Five r’s.
Bd Prevent histamine- Dizziness, - it should not be given with
Mediated gastric acid Hypersensitivity, Food or immediately after
Secretion. Acid secrtion And confusion. Taking food as it interferes
In response to With absorption.
Pentagastrin and food - before giving first dose,
Is also inhibited. Check for hypersensitivity
Reaction.
- note for any side effects like
Headache, dizziness, confusion
Etc
Name of Dosage/ Mode of action Side effect Nsg responsibility
Drug Route
Nebulisatio n 100µgm/6 It stimulates bet adrenergic Tremors, hyokinesa, Should reduce the dose in cardiac
salbuta- mol Th
hourly receptors to produce nausea vomiting, patient.
sympathomimeticnactio ns in headache,
smooth muscles. tachycardia,
arrhythmias, muscle
cramps
And palpitation.

Name of Dosage/ Mode of action Side effect Nsg responsibility

Drug Route
Syrup 2 tsp Potent mucolytic and Rhinorrhoea, Use cautiously in renal and
mucolite mucokinetic agent, capable lacrimation, gastric hepatic patient.
of bringing out bronchial irritation
secreation And hypersensitivity.
Especially mucous plugs.
Name of Dosage/ Mode of action Side effect Nsg responsibility
Drug Route
Inj. 500mg/so s It blocks prostaglandin Nausea, vomiting, Use cautiously in renal and hepatic
Paracetamo l. synthesis by cycloxygenase leukopenia, , patient. Use in under 3 months with
pathway. Inhibits Liver dmage following overdose. extreme caution. Reduced dose
thromboxane a2 formation in necessary upto 12 years.
platelets reducing platelet
Aggregation.
 Nursing care -
plan

Nursing diagnosis:
1. Ineffective airway clearance related to broncho constriction, increased mucus production, ineffective cough as evidenced
by cough with sputum, presence of abnormal breath sounds, spo2 90% with oxygen, increased respiratory rate.

2. Ineffective breathing pattern related to chronic airflow limitation, alveolar hypoventilation as evidenced by dyspnoea, increased
respiratory rate, decreased oxygen saturation.

3. Impaired gas exchange related to chronic pulmonary obstruction, abnormalities due to destruction of alveolar capillary
membrane as evidenced paco2 ≥45mmhg, pao2<60mmhg, spo2 90%.

4. Imbalanced nutrition: less than body requirements related to increased work of breathing, air swallowing, depression as
evidenced by hb-7.2gm%, pallor of skin, weight 65kg.

5. Activity intolerance related to compromised pulmonary function, resulting in shortness of breath and fatigue.
6. Disturbed sleep pattern related to hypoxemia, dypsneoa, cough, anxiety and hypercapnia as evidenced by frequent
awakening, prolonged onset of sleep, lethargy.

7. Hyperthemia related to increased wbc counts secondary to respiratory infection

8. Ineffective coping related to the stress of living with chronic disease, loss of independence.

Application of roys adaptation model:-

 Stimli effectors

INEFFECTIVE AIRWAY CLEARANCE.

FOCAL
INEFFECTIVE BREATHING
BRONCHO CONSTRUCTION
PRESENT. PHYSIOLOGICAL PATTERN. IMPAIRED GAS
BRONCHIALINFLAMATORY FUNCTION EXCHANGE,
PROCESS.
IMBALANCED NUTRITION: LESS THAN BODY
HYPERMUCOSAL SERETION.
ACTIVITY INTOLERANCE
DESTRUCTION OF ALVEOLAR SELF-CONCEPT INTERVENTIONS
CAPILLARY MEMBRANE DISTURBED SLEEP PATTERN
WBC COUNT-15500/CUMM.
ROLE-FUNCTION
LOW HB LEVEL-7.6 GM %.

CONTEXTUAL: INEFFECTIVE FAMILY COPING

INTERDEPENDENCE
CHRONIC SMOKER

ADVANCED AGE-72

Y MALE
 Nursing care plan-1
Assessment of Assessment of Nursing Goal Intervention Evaluation
behaviour stimuli diagnosis
Subjective:- Focal: broncho Ineffective The patient will Assessed the genral condition of the The goal was
Patient says he can’t construction airway have clear patient.
partially met as
inspire air into lungs. present. clearance airway as Dyspoea present,rr-22/m.
related to evidence by Oxygenation-82% on o2 4 l/m. evidence by absence
Bronchial prsence of absence of Peripheral cynosis-present.
of secretion
inflamatory secretion, secrition, spo2- Auscultation-wheezing present.
process. broncho- 95-100%, and Excess secrition –present. ,reduction of
construction absence of
wheezing and spo2-
Excess mucosl secondary to wheezing. Semi-fowler position given to the
secretion. c.o.p.d. patient. 100% on 4l/minute
Objective data:-
✓ Dysponea- Administered oxygen to the patient, 4
oxygen.
Contextual:
present. respi. Infection l/m.
✓ Use assessory wbc count-
Muscle for 15500/cumm. Nebulisation given to the patient (with
breath. duolin & budocort).
✓ Hypoxia-spo2-
82%. Provided chest physiotherapy to the
✓ Cynosis- patient.
present.
✓ Look Taught patient about effective
Reatlessness& coughing mechanisum.
weak.
✓ Ineffective
Cough Monitore vital signs of the
response. patient.
 Nursing care plan-2
Assessment of Assessment of Nursing Goal Intervention Evaluation
behaviour stimuli diagnosis
Subjective:- Focal: broncho The patient will Assessed the genral condition of the The goal was partially
Patient says that he construction Ineffective have normal patient.
met as evidence by
can’t breath properly. present. breathing pattern breathing Dyspoea present,rr-22/m.
related to chronic pattern as Oxygenation-82% on o2 4 l/m. Rr-25/m
Bronchial airflow limitation, evedence by Peripheral cynosis-present.
alveolar normal Auscultation-wheezing present. And spo2-100% on
inflamatory process.
Objective data:- Hypermucosal hypoventilation as Rr-16-20. Excess secrition –present. 4l/minute oxygen.
Dysponea-present. seretion, evidenced by Oxygenation-
dyspnoea increased spo2-95-100%. And reduction of
Semi-fowler position given to the
Use assessory muscle Alveolar damage respiratory rate, And absence of patient. assossory muscle
for breath. decreased oxygen assossory
saturation. muscle use. use.
Administered oxygen to the patient, 4
Cynosis-present. Contextual: l/m.
respi. Infection
Ineffectivecough response.
wbc count-
Rr-35/m. 15500/cumm. Provided chest physiotherapy to the
patient.
Irregular respiration Low hb level-
7.6 gm %. Provided deep breathing
Not expanding full lung exercise&spirometery to patient.
during inspiration.
Monitored vital signs of the
patient every 1 hourly.
 Nursing care plan-3

Assessment of Assessment of Nursing Goal Intervention Evaluation

behaviour stimuli diagnosis
Subjective:- Focal: broncho The patient will Assessed the genral condition of the The goal was partially
Patient says that he construction Impaired gas have normal gas patient.
met as evidence by
feels restlessness , present. exchange related to exchange as Dyspoea present,rr-22/m.
fatigue. chronic pulmonary evidence by Oxygenation-82% on o2 4 l/m. Rr-25/m
And gidiness. Bronchial obstruction, spo2 100% and Peripheral cynosis-present.
abnormalities due absence of Auscultation-wheezing present. And spo2-100% on
inflamatory
process. to destruction of peripheral Excess secrition –present. 4l/minute oxygen. And
alveolar capillary cynosis and
membraneas normal-rr normal abg analysis
Objective data:- Hypermucosal Semi-fowler position given to the
seretion and evidenced paco2 (16-20). patient. value.
Peripheral cynosis- present. accumlation in ≥45mmhg,
alveoli. pao2<60mmhg, Administered oxygen to the patient, 4
Hypoxia:-spo2-82%. spo2 90%. l/m.
Destruction of
Rr-35/m. alveolar capillary Monitored abg analysis- paco2
membrane ≥45mmhg, pao2<60mmhg
Not expanding full lung
contextual: respi.
during inspiration.
Infection wbc Provided deep breathing
count- exercise&spirometery to patient.
X-ray: both side 15500/cumm.
infiltration of lung
tissue. Monitored vital signs of the
Low hb level-
Abg:paco2 ≥45mmhg, patient every 1 hourly.
7.6 gm %.

Administer antibiotics as
Pao2<60mmhg Bp- 100/70. Prescrbed to reduce lung
Crp- 2 sec. Damage

Patient name: - mr. Guluf dadubhai shindenurse’s note-1diagnosis:-co.p.d..

Age:- 72 year d.o.a:- 28/02/2020

Sex:- male surgery:-not done

Ward:- medicine i.c.u. Student name-sonali vaidhya

Date Diet Medication Time Nursing observation Nursing care Remark Sign.

29/02/20 9am Inj.c-trie 1 gm, iv, 9am My patient mr.gulufdadubhaishinde, Assessed the Patient was co- Sonali
Breakfast:- Bd 10, 10. 72 yr. Male admitted with complaints General condition of Operative
Of breathlessness cough with copious The patient
Poha 1 plate Inj. Rantac 50 mg expectoration and diagnosed as c.o.p.d.
Tea-50 ml ,iv,
Tds, 6,2,10.

Inj. Emset 4 mg iv Patient was not slept at last night

Tds.6, 2, 10. Because of breathlessness&cough.

Inj febrinil 500 mg iv Patient has activity intolerance due to

bd & sos.
dyspnea& low hb level.
Tab folvit 5 mg po,
od, 10 am. Patient’s personal hygiene is
Maintained
Cap. Autrin po, od,
2pm. Patient has loss of appetite due to
Reastlesness&fever.
Syp ascoryl 2 tsf, tds, Patient bowel and bladder movement
po, 9, 3,9. Is normal.
Intracath was present on left hand
Nebu with Bed making done Bed looks clean and Sonali
douline,qid 6, tidy.
12,6,12.
Patient bed looks unclean and untidy
Nebu with
budocort, qid 6, Vital signs checked Patient is febrile,
12,6,12. t -99.4f, bp-100/70 trachypoea present
p -88/m ,rr-35/m
Vital sign has to be check
Medication given to No local
the patient. complication
occurred.
Tepid sponge and Temp-98.6 f.
Medication has to be give inj. Febrinil 500
mg. Is given

Patient has fever (99.4 f) Nebulization with Patients secretion

douline& budocort removed & cough
is given. is relived

History taking Patient is coperative

&physical
Patient cough with expectorant lead to
examination is done
abdominal pain.

Patient is sited alone

Patient name: - mr. Guluf dadubhai shinde nurse’s note- 2diagnosis:-co.p.d..
Age:- 72 year d.o.a:- 28/02/2020

Sex:- male surgery:-not done

Ward:- medicine i.c.u. Student name-sonali vaidhya

Date Diet Medication Time Nursing observation Nursing care Remark Sign.

2/3/2020 9am Inj.c-trie 1 gm, iv, bd 9am Patient is oriented to time place, Assessed the Patient was co- Sonali
breakfast:- 10, 10. person. general condition of operative
Patient is restless and looks weak. the patient
Poha 1 plate Inj. Rantac 50 mg
Tea-50 ml ,iv, Patient was not slept at last night
Tds, 6,2,10. because of breathlessness & cough.

Inj. Emset 4 mg iv Patient has activity intolerance due to

tds.6, 2, 10. dyspnea& low hb level.

Inj febrinil 500 mg iv Patient’s personal hygiene is

bd & sos. maintained

Tab folvit 5 mg po, Patient has loss of appetite due to

od, 10 am. restlessness &fever.
Cap. Autrin po, od, 2pm. Patient bowel and bladder movement
is normal.
Intracath was present on left hand

Syp ascoryl 2 tsf, tds,

po, 9, 3,9.
Patient bed looks unclean and untidy Bed making done Bed looks clean and
Nebu with douline, Tidy.
qid 6, 12,6,12.
Sonali
Nebu with
Budocort, qid 6, Vital sign has to be check Vital signs Patient is febrile,
12,6,12. checked t -100f, trachypoea present
bp-100/70 p -88/m
,rr-35/m

Medication has to be give Medication given to No local

the patient. complication
occurred.
patient has fever (100 f) Tepid sponge and Temp-98.6 f.
inj. Febrinil 500
mg. Is given

Patient cough with expectorant lead to Nebulization with Patients secretion

abdominal pain. douline& budocort removed & cough
is given. is relived

Patient is sited alone Health education Patient is positive

regarding his disese
condition and its
management is
Given
 Nurse’s note- 3
Patient name: - mr. Guluf dadubhai shinde diagnosis:-co.p.d..
Age:- 72 year d.o.a:- 28/02/2020

Sex:- male surgery:-not done

Ward:- medicine i.c.u. Student name-sonali vaidhya

Date Diet Medication Time Nursing observation Nursing care Remark Sign.

3/3/2020 9am Inj.c-trie 1 gm, iv, bd 9am Patient is oriented to time place, Assessed the Patient was co- Sonali
breakfast:- 10, 10. person. general condition of operative
the patient
Poha 1 plate Inj. Rantac 50 mg Patient was slept at last night because
Tea-50 ml ,iv, Of breathlessness & cough is reduced.
Tds, 6,2,10.
Patient has activity intolerance due to
Inj. Emset 4 mg iv Dyspnea& low hb level.
tds.6, 2, 10.
Patient’s personal hygiene is
Inj febrinil 500 mg iv Maintained
bd & sos.
Patient’s appetite is improved due to
Tab folvit 5 mg po, Reduction in fever.
od, 10 am.
 Patient bowel and bladder movement
Cap. Autrin po, od, 2pm. is normal.
Intracath was present on left hand

Syp ascoryl 2 tsf, tds,

po, 9, 3,9. Patient bed looks unclean and untidy
Bed making done Bed looks clean and
Nebu with douline, Tidy.
qid 6, 12,6,12.

Nebu with Vital sign has to be check

budocort, qid 6, Vital signs Patient is febrile,
12,6,12. checked t -100f, trachypoea present
bp-100/70 p -88/m
,rr-35/m
Medication has to be give
Medication given to No local
The patient. Complicatio
n occurred.

Patient cough with expectorant lead to

abdominal pain. Nebulization with Patients secretion
douline& budocort removed & cough
Is given. is
Relived
Patient’s abg analysis has to monitor.
Abg sample taken Patient is
From femoral artery. Cooperative
Prognosis note:-
first-day:-
➢ Patients vital signs checked its tachycardia (105),trachypnoea(35),bp(100/70),and febrile
(99.4 f.).
➢ Continuous cough with expectorant preset.
➢ Patient looks breathless on activity, fatigue &restlessness is there due to fever.
➢ Peripheral cyanosis is present,spo2-82%.
➢ Abg value shows respiratoy acidosis.

Second-day:-

➢ Patients vital signs checked its tachycardia (105),trachypnoea(35),bp(100/70),and febrile

(99.4 f.).
➢ Continuous cough with expectorant preset.
➢ Patient looks breathless on activity, fatigue & but restlessness& fever are reduced.
➢ Peripheral cyanosis is absent, spo2-90%.on 4 l/m oxygen.
➢ Abg value is normal.

Third day:-

➢ Patients vital signs checked its pulse (88),trachypnoea(30),bp(110/70),and afebrile

(98.6 f.).
➢ Cough with expectorant preset but reduced in intensity
➢ Patent’s breathlessness is reduced, appetite is improved.
➢ Patient is showing improvements as compare to first day of admission.
Health education:
1. To control cough and phlegm

➢ Drink plenty of water (8 to 10 glasses per day) to keep phlegm thin.

➢ Use inhalers on a regular basis as prescribed:

o Bronchodilators, such as proventil, to open up the airways.

o Atrovent to decrease cough and mucous production.
o Corticosteroids to reduced swelling.

➢ Avoid irritants to the lungs, such as cigarette smoke, dust, smog, perfume, cold air, and
very hot air.
➢ Report change in color, amount, or thickness of phlegm that could
Indicate an infection.

➢ Try to avoid respiratory infections by limiting contact with people during cold and flu
season. Get the influenza and pneumonia vaccines and wash hands frequently.

2. To control shortness of breath

➢ Practice pursed-lip breathing by breathing in through the nose and out through pursed
lips (like you are whistling), with a long, slow expiration.
➢ Position yourself for better breathing by leaning forward while sitting
With elbows on table or resting on knees.
➢ Use relaxation techniques, such as listening to soft music, imagining you are in a quiet
peaceful place, or having someone give you a massage.
➢ If prescribed, use oxygen as directed, especially while performing such
Activities as bathing, dressing, eating, and walking.
➢ 3. To control fatigue

➢ Do not stop doing physical activity; instead, learn how to manage by planning
activities to conserve energy.
➢ Start with an exercise program that is easy, and progress slowly to
Increase your activity.
➢ Talk to your health care provider about joining a pulmonary rehabilitation program.
➢ Eat a well-balanced diet.
➢ Sleep with head elevated using several pillows or in a reclining chair to reduce
shortness of breath and increase rest.
➢ If awakened by cough, sit up, sip fluid, and use inhaler to try to clear lungs
Of phlegm.
➢ Avoid overuse of inhalers, which may cause shakiness and insomnia
4. To compensate for poor appetite

➢ Eat six or more small meals and snacks per day rather than two or three large meals.
➢ Eat slowly; plan at least 30 minutes per meal. Sit forward with elbows
Propped on table.
➢ Unless otherwise directed, try a high-protein, moderate-fat, and lower- carbohydrate
diet of sufficient calories to cover the increased work of breathing.
➢ Consider a high-calorie, high-protein drink if you do not feel like eating.