INTRODUCTION:

Breathing is a basic human function that tend to be unconscious. Breathing

is a physiologic function that is almost synonymous with being alive. Difficulty in

breathing as a threat to life itself. People with respiratory disorders are often very

anxious and fearful that they may die, perhaps agonizingly. Whether death is a real

possibility often has nothing to do with the fear.

Respiratory problems are widespread. They may be acute (short term) or

chronic( long term). Acute disorders range from minor inconveniences, such as

colds or flu, to more life-threatening problems, such as asthma some types of

pneumonia, and chest trauma Chronic respiratory problems are also widespread,

and are the cause of significant disability.

People who experience them often have to make radical life-style changes,

often retiring from work earlier than they wish. Such disabling conditions include

chronic obstructive pulmonary disease (COPD), now called chronic airflow

limitation, and certain restrictive lung diseases.

Respiratory problems have many causes: allergies, occupational factors,

genetic factors, smoking and tobacco use, infection, neuromuscular disorders, chest

abnormalities, trauma, pleural conditions, and pulmonary vascular abnormalities.

The most significant factor in chronic respiratory illness and lung cancer is

cigarette smoking.

Gas exchange is the primary function of the respiratory system. The

respiratory system takes oxygen from the atmosphere, transports it to the lungs,

exchanges the oxygen for carbon dioxide in the alveoli, and returns carbon dioxide

to the air.

OBJECTIVES:

To collect baseline information from the client.

To establish a good rapport with the client and his family.

To provide a cost effective nursing care to the client.

To promote positive attitude towards the treatment in the client.

To identify the clinical significance and related nursing implications of the

various tests and procedures used in the diagnostic evaluation.

To assess the parameters appropriate for determining the status of

COPD(chronic obstructive pulmonary disease)

To use nursing process as a framework of care for clients with COPD.

To study disease condition in practical.

To reduce the complications.

To educate the client and her relatives regarding the need for follow-up care

after discharge and life style after the discharge.

CLIENT PROFILE:

Name of client : Mrs. Lakshmi

Age : 62 years

Sex : Female

I P No. : 3922

Ward : 11

Unit : III Mu

Marital Status : Married

Educational Qualification : 10th st

Religion : Hindu

Occupation : Cooly

Income : Rs.900/-

Address :

Admitted on : 26-5-11 at 11:05 a.m

Source of data : Patient

Diagnosis : COPD.

HISTORY COLLECTION

CHIEF COMPLAINTS:

Patient had a history of fever for 3 days, cough with scanty mucoid

sputum expectoration, breathlessness, wheezing for 5 years. No history of

vomiting, diarrhea, head ache, chest pain, abdominal pain.

PRESENT HEALTH HISTORY:

History of fever for 3 days, cough and scanty mucoid sputum expectoration,

breathlessness, wheezing for 5 years.

PAST HEALTH HISTORY:

No child hood disease. Patient had wheezing for the past 5 years and took

treatment in private hospital but not getting well. No history of any previous

history of surgeries.

FAMILY HISTORY:

Mrs.Lakshmi husband died due to aging process. She had one son and two

daughters and son was married and had two children

No history of -> DM/IHD/ Allergies / no communicable disease.

FAMILY TREE:

70 yrs 62 yrs

40 yrs 35 yrs 32 yrs

30 yrs

10 yrs 8 yrs

MALE

FEMALE

DIED

FAMILY HEALTH HISTORY:

ALLERGIES : NIL

Chronic illness:

Asthma : Absent

Bronchiectasis : Present

Cancer : Absent

Cystic Fibrosis : Absent

Emphysema : Absent

Sarcoidosis : Absent

TB : Absent

PERSONAL HISTORY:

Alcohol drug abuse : NIL

PSYCOSOCIAL HISTOPRY:

Occupation exposure : to dust

Hobbies : Dust

Geographic location : Environment

Exercise : Not doing

SOCIO ECONOMIC CONDITION:

Patient`s son is the only bread winner for the family. No other source of

support .Her family income of Rs 900/ month . Her son is a cooly. Her family is

comes under low socio economic group. She is living in a hut rented house, having

one window and one door. Her house is electrified. She is getting water from

public pipe connection.

SPIRITUAL HISTORY:

Mrs.Lakshmi is Hindu. She visits temples once in a week. She celebrated

Diwali and pongal festival.

REVIEW OF SYSTEM

PHYSICAL ASSESSMENT

GENERAL HEALTH

Nourishment : Well nourished

Body built : Normally built

Health : Healthy

Activity : Dull

Skin condition:

Color : Pale

Texture : Warm

Temperature : 1oo F

Head and Face:

Scalp : Hair black and white

Face : Pale

Eyes:

Eye brow : Normal

Eye lash : Normal in color

Eye lid : No swelling

Eye ball : Normal

Conjunctiva and sclera : Not jaundice

Pupil : Normal

Lens :Opaque

Vision : Dim blurred vision

Ears:

External ear : No discharge

Tympanic membrane : Normal

Hearing : Normal

Nose : No bleeding/ No obstruction

Mouth:

Pharynx : No redness/ swelling/ No gum

Bleeding/ No gingivitis.

Teeth : Stained teeth/ No dental carries.

Tongue : No ulcer / normal

Neck :No lymph node enlargement/ Normal

Chest : Symmetry/wheezing present

Tachyapnea/ cough present

No hemoptysis

Heart : S1/S2 heard

Breast/axilla : Symmetry

Abdomen:

Inspection :No lesion /No swelling

Palpation :No tenderness

Percussion :No mass/ No distended bladder

Auscultation : Normal bowel sound

Genitals : No ulcer/ pain / itching/discharge

:No pain during urination/defecation

Rectum No hemorrhoids/No Melina

Upper extremities : Normal ROM

Lower extremities :Knee pain

SYSTEMIC ASSESSMENT

RESPIRATORY SYSTEM:

Chest movement : Symmetrical

Shape : Normal

INSPECTION

Chest wall Configuration : Normal

Symmetry of Chest Wall : Symmetrical

Presence of superficial veins : Absent

Angle of the Ribs : 45 Degree

Intercostals Space - Retraction : Absent

Muscles of Respiration : Use of accessory muscles: No

Respiration : 22/mt

Rate : Tachypnoea

Rhythm : Normal

Pattern : Tachypnoeal

Depth : Hyperphoea

Symmetry : Symmetrical

Audiblity : Audible

Patient position : Upright

Mode of breathing : Nasal

Sputum Color : Light yellow

PALPATION:

General Palpation

Pulsation : Present

Masses : Absent

Thoracic tenderness : Absent

Crepitus : Absent

Thoracic excursion : Bilateral increased

Tactile Fremitus : Absent

Tracheal Position : Midline

Percussion

Lung : Resonant

Diaphragm : Dull

Rib : Flat

Diaphagmatic Excursion : 3-5cm

CARDIO VASCULAR SYSTEM

Heart rate : 78/min

Palpation : Present

Murmur : No murmur

Peripheral pulse : Palpable

GASTRO INTESTINAL SYSTEM

Abdomen No distention

Liver : Not palpable

Spleen : Not palpable

CENTRAL NERVOUS SYSTEM

Pupil reaction : Equally reacting

Response to stimuli : Present

MUSCULO SKELETAL SYSTEM

Movements : ROM normal

Joints : Knee pain present

INTEGUMENTARY SYSTEM

Skin color : pale

Nail : No clubbing

Temperature : 100 F

HEIGHT : 150 cm

WEIGHT : 50 kg

VITAL SIGNS:

TEMPERATURE : 100’F

PULSE : 78/min

RESPIRATION : 22/min

BP : 120/80 Hg

PAIN SCALE:

0 1 2 3 4 5 6 7 8 9 10

No Moderate Pain Worst Pain Possible Pain

LABORATORY DATA : NORMAL VALUE PATIENT

VALUE

Hematocrit :Female :35 – 45 % 35%

Hemoglobin : Female : 12 – 15 gm /dl 10 gm /dl

Cholesterol : < 200 Desirable; > 240 High 180 mg/dl

HDL : <40 low / > 60 high < 50

LDL : < 100 – optimal < 80

Triglyceride : < 150 normal < 160

Total Lymphocyte count : 1500 - 1800 cells/mm3 1600 cells/mm3

Albumin : 3.5 – 5.0 gm/dl 4 gm/dl

Glucose : 85 – 125 mg/dl 80 mg/dl

Creatinine : 0.6 – 1.2 mg % 0.9mg%

TREATMENT

Inj. Cefatoximine 5oomg bd,

Tab Ranitidine 150 mg tds

DRUG CHARTNAME OF

THE DRUG

DOSAGE

ROUTE

ACTION

SIDE EFFECTS

NURSES RESPONSIBIL

ITYInj cefatoxamie

Inj metromidazole

1 gm bd

500mg Iv

IV

Bd

Broad spect rum antibiotic inhibits bacterial cell wall synthesis rendering cell wall osmotically austable leading to cell death

Anti infective direct acting

Head ache dizziness. Seizures heart failure syncope. Nausea vomiting GI bleeding protein uria, nephrotoxicity renal failure leukcopenia anaphylusis

Headache dizziness fatigue blurred vision sore throat nausea vomiting,

Nephro toxicity watch for increased BUN, urine output.Asses the signs of anaphylaxisis rash uticaria, purities, chills watch for over growth of infection perineal itching , fever, malaise redness pain

Assess for infection WBC corent, wound symptoms fever assess vision by ophthalmic exam during cyter therapy maintain I/o chart

amibicide tricho monocide binds distrupts DNA structure inhibiting bacterial metucic acid synthesis

darkened urine, albunimuria neuro toxicity

Methylxanthine compound- relaxes muscle by

increasing cyclic adenosine mono-phosphate

Mild bronchodilator, maintenance Therapy for bronchospasm

CNS-irritability, restlessness,

insomnia, seizures in toxic ranges

CV- palpitation, tachycardia, hypotension

GI- nausea, vomiting, diarrhea

Teach patients to take at equal intervals throughout the day.

To decrease GI irritation, take with milk or crackers.

Monitor Theophylline blood level periodically as directed to ensure

Sympathomimetic (beta2-adrenergic against) with highly selective beta2 activity

Oral Maintenance therapy for bronchospasm, works within 30min MDI, nebulized liquid rapid relief of bron- chospasm, dyspnea-works within

3-5min

Nervousness, tachycardia head ache, nausea, tremors.

Continuous nebulization may cause hypokalemia.

Therapeutic range and prevent toxicity.

Observe inhalation by patient to be certain that correct technique is

Used.

Caution patient not to exceed prescribed dose. Adverse-effects often associated with excessive use. Does not reduce inflammation.

DRUGS/

ADMINISTRATION

PHARMACOLOGIC EFFECTS

INDICATIONS

ADVERSE

EFFECTS

NURSING

CONSIDERATIONS

Corticosteroids

Hydrocortisone/

Patent anti-inflammatory-

Acute exacerbation of asthma or

CNS: Depresion; euphoria, mood

Long term use Do not stop abruptly due to adrenal

prednisone (DeItasone) (intravenous

Injection, oral preparation).

CIPROFLOXACIN

(250 bd)

Paracetamol

(500mg tds)

activity

It inhibiting bacterial DNA and cause bacterial lysis

It acts on CNS to produce analgesia and antipyretic effect

bronchitis

(l.V preparation)

Acute exacerbation or maintenance theraphy

(oral preparation)

Respiratory tract, Urinary track, ENT, Bone and joint infection

Pain and fever

changes

GI : gastric irritation peptic ulcer

Metabolic hypernatremia, hypokalemia, hyperglycemia,

water retension, and weight gain

Nausea, head ache, vomiting, Diarrhoea, restlessness, abdominal pain, skin rash

Nausea, Epi gastric distress, skin rash

suppression

Take oral form with food.

• Usually given as taper from higher dose to lowest possible dose that achieves desired effect.

Observe complication

Avoid lon-term use,

Observe complication

ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM

Upper Airway

Structure

Nasal Cavity

The nose is formed from both bone and cartilage. A very small portion of the nose is bone; the nasal hone only forms the bridge of the nose. The remainder of the nose composed of cartilage and connective tissue. The nasal cartilages form the shape of the nose.

The openings of the nose on the face are called nostrils or nares. Each nostril leads to a cavity, called a vestibule. The vestibule is lined anteriorly with skin and hair (called vibrissae). The vibrissae filter foreign objects and prevent them from being inhaled. The posterior vestibule is lined with mucous membrane. This membrane is composed of columnar epithelial cells, which secrete mucus. The portion of mucous membrane that is located at the top of the nasal cavity, just beneath the cribriform plate of the ethmoid bone, is specialized epithelium, called olfactory epithelium, which provides the sense of smell.The region is supplied by the &factory nerve (cranial nerve I) which passes through holes in the cribriform plate. The olfactory epithelium does not lie along the usual path of air movement, so smell is enhanced by sniffing.

Along the sides of the vestibUle are turbinates. The turbinates are mucous membrane-covered projections. They contain a very rich blood supply (from the internal and external carotid arteries), and they warm and humidify inspired air. Paranasal sinuses are open areas within the skull. They are named for the bones in which they lie—frontal, ethmoid, sphenoid, and maxillary. Passageways from the paranasal sinuses drain into the nasal cavities. The nasolacrimal ducts, which drain tears from the surface of the eyes, also drain into the nasal cavity.

The mouth is considered part of the upper airway, but only because the mouth can be used to deliver air to the lungs. The mouth may be used for breathing when the nose is obstructed or when high volumes of air are needed, such as during exercise. The mouth does not perform the functions of the nose efficiently, especially warming, humidifying, and filtering air.

PHARYNX:

The pharynx is a funnel-shaped tube that extends from the nose to the larynx. It is used for digestion as well as for respiration. The pharynx is divided into three sections:

(1) The nasopharynx, located above the margin of the soft palate;

(2) The oropharynx, the part of. the pharynx that is visible when the tongue is depressed with a tongue depressor;

(3) The laryngopharynx, located below the base of the tongue.

The nasopharynx is the upper Section and receives air from the nasal cavity. The nasopharynx is lined with ciliated columnar epithelium. From the ear, the eustachian tubes open into the nasopharynx. The pharyngeal tonsils are located on the posterior wall of the nasopharynx. The tonsils are masses of lymphoid tissue; they serve as an additional defense mechanism against bacterial infection. When the pharyngeal tonsils become enlarged following repeated infections or are at their point of maximum growth during adolescence, they are called adenoids.

The oropharynx serves both respiration and digestion. It receives air from the nasopharynx and food from the oral cavity. Palatine (facial) tonsils are located along the sides of the posterior mouth, and the lingual tonsil are located at the base of the tongue.

The laryngopharynx (hypopharynx) is the most inferior portion of the pharynx. It connects to the larynx and serves both respiration and digestion.

Larynx:

The larynx is commonly called the voce box. It connects the upper (pharynx) and lower (trachea) airways. It is located anterior to the fourth and sixth cervical vertebrae. The upper esophagus is just posterior to the larynx.

The larnyx is formed by nine cartilages: three paired and three single cartilages. The three large unpaired cartilages are the epiglottis, thyroid, and cricoid; the three paired cartilage , which are smaller, are the arytenoid, corniculate, and cuneiform. The cartilages are held together and attached to the hyoid hone above the trachea and below the trachea by muscles aids ligaments. The larynx consists of the endolarynx and a surrounding triangle-shaped bone and

cartilage. The endolarynx is formed by two pairs of folds of tissue, which forms the false vocal cords and the true vocal coids.

The slit between the vocal cords forms the glottis. The epiglottis, a leaf-shaped structure immediately posterior to the base of the tongue, lies above the larynx. When food or liquids are swallowed, the epiglottis closes over the larynx, protecting the lower airways from aspiration. The thyroid cartilage protrudes in front of the larynx, forming the Adam’s apple. The cricoid cartilage lies just below the thyroid cartilage and is the anatomic site for an artificial opening into the trachea (tracheostomy). These cartilages are all connected by ligaments that prevent the larynx from collapse during inspiration and swallowing the internal portion of the larynx is composed of muscles that assist with swallowing, speaking, and respiration, and contribute to the pitch of the voice. The, blood supply to the larynx is through the branches of the thyroid arteries. The nerve supply is through the recurrent laryngeal and superior laryngeal nerves.

Function:

Major functions of the upper airway are,

(1) Air conduction to the lower airway for gas exchange;

(2) Protection of the lower airway from foreign matter;

(3) Warming, filtration, and humidification of inspired air. It is important for the nurse to appreciate the function of the upper airway.

In various disorders and in the treatment of some disorders, this function is lost or altered. For example, when a client has a cold, it is difficult to breathe through the swollen nose, and mouth breathing is common. When the client breathes through the mouth, the normal functions of the nose (smell, taste, humidification, and filtering) are lost.

The upper airway is lined with mucous membranes to assist in warming and humidifying inspired air. Regardless of the temperature of air inspired, by the time the air reaches the lung (in about 0.25 seconds) the air has been warmed to 36° to 37° C (96.8° to 98° F) and humidified to 70% to 80%. The mucus also helps trap foreign particles. The cilia of the membrane assist in moving the particles down

into the pharynx. The posterior part of the nasal cavity opens into the internal nares and the nasopharynx. The two nasal vestibules are divided by the septum.

The nose also provides for the sense of smell and is an adjunct to taste. The part of the mucous membrane covering the cribriform plate is modified for olfaction. The nose provides a sneeze reflex, which is similar to the cough reflex. Irritation of the nasal passages causes receptors in the trigeminal nerve (cranial nerve V) to stimulate the respiratory centre in the medulla. The medulla stimulates a blast f air through the nose that carries foreign matter out the nose and mouth. Sinuses lighten the weight of the skull and modify sound by acting as resonating chambers.

Lower Airway:

Structure:

The lower airway (trachea-bronchial tree) is composed of the,

(1) trachea,

(2) right and left mainstem bronchi,

(3) segmental bronchi,

(4) subsegmental bronchi,

(5) terminal bronchioles.

Smooth muscle, wound in overlapping clockwise and counterclockwise helical bands, is found in all of these structures. This muscle is subject to spasm in many airway disorders.

Trachea:

The trachea (windpipe) extends from the larynx to the level of the seventh thoracic vertebrae where it divides into two main bronchi (also called primary bronchi). The point at which the trachea divides is called the carina. The trachea rests anterior to the surface of the esophagus. The trachea is a flexible, muscular, long air passage with C-shaped cartilaginous rings. It is Iined with pseudostratified ciliated columnar epithelium that contains numerous goblet (mucus-secreting)

cells. Because the cilia beat upward, they tend to carry foreign particles and excessive mucus away from the lungs to the pharynx. No cilia are present in the alveoli.

Bronchi and Broncholes:

The right main-stem bronchus is shorter and wider, and extends more vertically downward, than the left. Thus, foreign bodies are more likely to lodge in the right main- stem bronchus than in the left main-stem bronchus.

The segmental and sub-segmental bronchi are subdivisions of the main bronchi and are spread in an inverted, treelike formation through each lung.

Cartilage surrounds the airway in the bronchi. This structure contrasts with the bronchioles, the final pathway to the alveoli, which contain no cartilage and thus can collapse and trap air. The terminal bronchioles are the last airways of the conducting system. This area does not have gas exchange and is called the anatomical dead space. Inspired air that remains in the dead space is what allows artificial respiration (mouth-to-mouth resuscitation).

Function:

The lower airways continue to warm, humidify, and filter inspired air that is en route to the lungs. In addition, they provide several defense mechanisms.

The respiratory gas-exchanging membrane has a surface area that is almost the size of a tennis court. The size of the membrane of the lungs and the daily exposure of the lungs to atmospheric pollutants requires efficient protective mechanisms. The elaborate defense mechanisms of the lungs fall into three categories:

(1) Clearance mechanisms,

(2) Immunologic responses in the lung, and

(3) Pulmonary reaction to injury. An intact respiratory epithelium and mucociliary system are necessary for the efficient functioning of the lung defense mechanisms.

Defense by the Respiratory:

Epithelium:

The predominant cell of the upper respiratory tract (trachea and bronchi) is a one-cell--layer thick squamous ciliated cell. The cilia are microscopic, hair-like projections that protect the airways with a rapid, coordinated, unidirectional sweeping motion toward the mouth. The movement of the cilia propels a mucus blanket toward the mouth. This blanket is produced by goblet cells located on the mucosal surface. The mucociliary system propels debris (pollutants and infectious agents) to the mouth within 30 minutes for the large bronchi, 2.5 hours for most of the bronchial tree, and 5.6 hours for the peripheral airways. At the mouth, the debris is removed from the airways by swallowing or coughing. Sputum is mucus expelled by coughing.

The alveolar lining is made up of flat, membranous pneumocytes (type I cells). Rounded granular cells (type II) are also found there. These type II cells are resistant to injury and cover most of the alveolar surface after exposure to infectious agents. Alveolar macrophages, derived from blood monocytes that migrate into the lungs, are also found over the surface o the alveoli. Alveolar macrophages are active phagocytes that remove deal cells and protein. Macrophages are also metabolically active cells that synthesize and secrete substances that regulate the immune system. They leave the lung by either the mucociliary system or the lymphatic system.

Thorax, Diaphragm, and Pleura:

Structure:

Thorax and Diaphragm:

The bony thorax provides protection for the lungs, heart, and great vessels. The outer shell of the thorax is made up of 12 pair of ribs. The ribs connect posteriorly to the transverse processes of the thoracic vertebrae of the spine. Anteriorly, the first seven pairs of ribs are attached to the sternum by cartilage. The 8th , 9th, and 10th ribs (false ribs) are attached to each other by costal cartilage. The 11th and 12th ribs (floating ribs) allow full chest expansion because they are not attached iii any way to the sternum.

At the top of the thorax in the neck area are two accessory muscles of inspiration—the scalene and sternocleidomastoid muscles. The scalene muscles elevate the first and second ribs during inspiration to enlarge the upper thorax and stabilize the chest wall. The sternocleidomastoid muscle elevates the sternum. The parasternal, trapezius, and pectoralis muscles are also accessory inspiratory muscles and are used during increased work of breathing.

Between the ribs are the inter-costal muscles. The external intercostal muscles pull the ribs upward and forward, thus increasing the transverse and anteroposterior diameter. The internal inter-costal muscles decrease the anteroposterior diameter of the chest wall. The diaphragm serves as the lower boundary of the thorax.

The diaphragm is dome shaped in the relax position, with central muscular attachments to the xiphoid process of the sternum and the lower ribs. The diaphragm’s nerve supply (phrenic nerve) comes through the spinal cord at the level of the third cervical vertebra. Thus, C3 spinal injuries impair ventilation.

Pleura:

The pleura are serous membranes that enclose the lung in a double-walled sac. The visceral pleura covers the lung and the fissures between the lobes of the lung. Toe parietal pleura covers the inside of each hemithorax, the mediastinum, and the top of the diaphragm. The parietal pleura joins the visceral pleura at the hilus (a notch in the. medial surface of the lung, where the main-stem bronchi, pulmonary blood vessels, and nerves enter the lung).

The pleural space is a potential space between the two layers of pleura. Normally, no space exists between the pleurae. A thin film (only a few milliliters) of serous fluid acts as a lubricant in the potential space. The fluid also causes the moist pleural membranes to adhere, creating a pulling force that helps to hold the lungs in an expanded position. The action of pleura is analogous to coupling two sheets of glass by a thin film of water. It is extremely difficult to separate the sheets of glass at right angles to their surfaces, even though they readily slide past each other. Because of the nature of this coupling, the movement of the kings

closely follows the movement of the thorax. If air or increased amounts of serous fluid, blood, or pus accumulates in the space, the lungs are compressed and respiratory difficulties follow. These conditions are called pneumorhorax (air in the pleural space) or hemothorax (blood in the pleural space).

Function:

The function of the thorax and diaphragm is to alter pressures in the thorax to move fresh air in and out. The movement of air depends on pressure differences between the atmosphere and the air in the lungs. Air flows from regions of higher pressure lo regions of lower pressure.

On inspiration, the dome of the diaphragm flattens and the rib cage lifts. This action increases the transverse diameter of the thorax, which increases the volume of the thorax and the lungs. As volume increases, pressure decreases and air moves into the lungs.

Airway resistance also affects air movement. Airway resistance it affected. by the viscosity of air length of the airways, and diameter of the airways. Doubling the length of the airway doubles the resistance. You can experiment with this change by trying to breathe through a straw and noting the increased effort that is required to move air. Decreasing the diameter by half creates a 16-fold increase in resistance. Thus, a decreased diameter of the airways due to bronchial muscle contraction or to secretions in the airways increases resistance and decreases the rate of air flow. This is a common finding in obstructive airway diseases such as asthma.

During quiet breathing, expiration is usually passive, that is, expiration does not require the use of muscles. The chest wall, in contrast to the lungs, has a tendency to recoil outward. The opposing forces of lung and chest wall create a sub-atmospheric (negative) force of about -5 cm H20 in the intrapleural space at the end of quiet exhalation. Exhalation is also due to the elastic recoil of the lungs, which is discussed later in the chapter.

Forced expiration and coughing bring the internal intercostal muscles and the abdominal muscles into play. The abdominal muscles force the diaphragm upward

to its dome-shaped position. The intercostals muscles contract, pulling the ribs inward.

The Lungs and Alveoli:

Structure:

Lungs:

The lungs lie within the thoracic cavity on either side of the heart. The lungs are cone shaped, with the apex above the first rib and the base resting on the diaphragm. Each lung is divided into superior and inferior lobes by an oblique fissure. The right lung is further divided by a horizontal fissure, which bounds a middle lobe. The right lung, therefore, has three lobes, whereas the left lobe has only two. In addition to these five lobes, which are visible externally, each lung can be subdivided into about 10 smaller units called bronchopulmonary segments. Each bronchopulmonary segment represents the portion of the lung that is supplied by a specific tertiary bronchus. These segments are important surgically, because a diseased segment can be resected without having to remove the entire lobe or lung.

The two lungs are separated by a space called the mediastinum. The heart, aorta, vena cava, pulmonary vessels, esophagus, part of the trachea and bronchi, and the thymus gland are located in the mediastinum.

Alveoli:

The lung parenchyma is the working area of the lung tissue. The parenchyma consisting of millions of alveolar units. It is estimated that 24 million alveoli are present in humans at birth. By age 8 years, the number of alveoli has increased to the adult number of 300 million. The total working alveolar surface area is approximately 750 to 860 ft2. The large number of alveoli and the large surface area are necessary to meet both resting and exercise oxygen requirements. Each alveolar unit is supplied with 9 to 11 pre-pulmonary and pulmonary capillaries. The blood supply for these capillaries comes from the right ventricle of the heart. The major function of the alveolar unit is the exchange of oxygen and carbon dioxide between pulmonary capillaries and alveoli. Because of the extensiveness of the capillary system, the flow of blood in the alveolar wall has been described as a “sheet” of flowing blood.

The entire alveolar unit (respiratory zone) is made up of respiratory bronchioles, alveolar ducts, and alveolar sacs, This is the region where gas exchange takes place. The respiratory zone consists of the respiratory bronchioles, the alveolar ducts, and alveolar sacs. Alveoli, small air sacs at the end of the respiratory bronchioles, permit exchange of the oxygen and carbon dioxide. The alveolar walls are extremely thin, and within them is an almost solid network of interconnecting capillaries.

Oxygen and carbon dioxide are exchanged through a respiratory membrane that is about 0.2 m thick.The average diameter of the pulmonary capillary is only about 5x10-6m, which means that a red blood cell must squeeze through it. Therefore the red blood, cell actually touches the capillary wall, so that oxygen and carbon dioxide need not pass through significant amounts of plasma as they diffuse. The thickness of the respiratory membrane occasionally increases (e.g., with pulmonary edema or fibrosis), Increases in thickness of the membrane interfere with normal exchange of gases.

The alveolus is comprised of two cell types: type I and II pneumocytes. Type I pneumocytes are thin and incapable of reproduction. They line the alveolus. Type II pneumocytes are cuboidal and do not exchange oxygen and carbon dioxide well. These cells produce surfactant and differentiate into type I cells. These cells are important in lung injury and repair. When lung tissue has been damaged, type II cells are produced, which eventually: differentiate into type 1 cells. During the transition, oxygenation is impaired due to the thickness of the cells.

Function:

The function of the lungs is to deliver oxygen to the mitochondria to liberate energy stored in molecular bonds of adenosine triphosphate (ATP) and remove carbon dioxide. Cellular processes for life require ATP. Ventilation, gas exchange, the relationship of ventilation and perfusion, and oxygen transport are discussed in the following text.

Gas Exchange:

Oxygen Transport

After oxygen diffuses into the pulmonary capillaries, it is transported throughout the body by the circulatory system. The oxygen is dissolved in the plasma (3%) or bound with hemoglobin (97%) in ferrous ion. The combination of ferrous iron and oxygen forms oxy-hemoglobin, which releases oxygen to tissues that have a low partial pressure of oxygen. Tissues take up oxygen at varying rates. The most metabolically active tissues receive it first. Methemoglobin, carbon monoxide, and other chemicals impair the uptake of oxygen by tissues.

The oxy-hemoglobin dissociation curve represents the relationship between Pa02 and the saturation of hemoglobin. This saturation reflects the amount of oxygen available to the tissues. In plotting the normal curve, it is assumed that the client’s temperature’ is 37° C, p1-I is 7.40, and Pa02 is 40 mm Hg. This relationship is represen2ed in Figure 38—13 as an S-shaped curve. Changes in the Pao2 at the flattened top portion of the curve result in small changes in oxygen saturation. The opposite is true as the slope of the curve steepens. At the steepest portion the curve, with the Pao2 below 60 mm Hg, small changes in the Pao2 result in large drops in ‘oxygen saw- ration.

The oxy-hemoglobin curve is affected by a number of factors, including temperature, pH, Pco2, enzymes in the red blood cell (2, 3-diphosphoglycerate [2,3,-DPGJ), presence of carbon monoxide, and abnormal hemoglobin. Changes in affinity of oxygen for hemoglobin cause the oxy-hemoglobin to move from its normal contour, or shift.

A shift to the left of the oxy-hemoglobin dissociation curve increases the affinity of the hemoglobin molecule for oxygen. It is easier for oxygen to bind to hemoglobin, but it is not easily released at the tissues. Thus, at any P02 level, oxygen saturation is greater than normal, but tissue hypoxia is present. Clinical situations that cause decreased affinity include alkalosis, hypocapnia, hypothermia, decreased 2, 3-DPG, and carbon monoxide poisoning.

A shift of the curve to the right indicates an easier release of oxygen at the tissue level. It is more difficult for oxygen to bind in the lungs, but it releases easily at the cells. This shift protects the body by allowing oxygen attached to hemoglobin to be released in the tissues in an attempt to maintain adequate tissue oxygenation. Clinical situations that cause decreased affinity include acidosis,

hypercapnia, hyperthermia, hyperthyroidism (which increases 2, 3-DPG), anemia and chronic hypoxia.

Carbon Dioxide Transport

Carbon dioxide is the waste product of tissue metabolism. It is carried by the blood in the three following ways:

(1) In plasma:

(2) Coupled with hemoglobin;

(3) Combined with water as carbonic acid. Most carbon dioxide is carried by red blood cells as carbonic acid. It rapidly breaks down into hydrogen ions and bicarbonate ions. As venous blood enters the lungs for gas exchange, these chemicals form carbon dioxide, which is exhaled from the lungs.

Regulation of Acid-Base Balance:

The lungs, through gas exchange, have a key role in regulating the acid-base balance of the body. Pulmonary disorders that change the carbon dioxide level in the blood cause either respiratory acidemia or respiratory alkalemia. Hypercapnia (retention of excessive amounts of carbon dioxide) causes respiratory acidemia, and hypocapnia (low amounts of carbon dioxide in the blood) results in respiratory alkalemia.

The effectiveness of ventilation is best measured by the partial pressure of carbon dioxide in the arterial blood (Paco2). Because the respiratory system is normally set to maintain a PaC02 between 35 and 45 mm Hg at sea level, a PaC02 above this range represents hypoventilation. Anesthetic agents, sedatives, and narcotics all tend to increase the resting Paco2.

Chronic Obstructive Pulmonary Disease

DEFINITION:

Chronic obstructive pulmonary disease (COPD), also called chronic obstructive lung disease (COLD), refers to several disorders that affect movement of air in and out of the lungs.

The most important of these disorders are obstructive bronchitis, emphysema, and asthma. Although bronchitis, emphysema, and asthma may occur in a “pure form,” they most commonly coexist, and clinical manifestations overlap the term COPD is commonly used

COPD may occur as a result of increased airway resistance secondary to bronchial mucosal edema or smooth muscle contraction. It may also be a result of decreased elastic recoil, as seen in emphysema. Elastic recoil, like the recoil of a stretched rubber band, is the force used to passively deflate the lung. Decreased elastic recoil results in a decreased driving force to empty the lung.

COPD is a widespread disorder, affecting I in every 10 Americans, Most COPD clients are men over the age of 45. With the increase in smoking among females, however, the incidence of COPD among women is steadily rising.

Etiology and Risk Factors:

The specific causes of COPD are not clearly understood. However, the effects of numerous irritants found in cigarette smoke (i.e., stimulation of excess mucus production and coughing. destruction of ciliary function and inflammation and damage of bronchiolar and alveolar walls) make smoking the leading risk factor for the development of the disorder. Chronic respiratory infections, including sinusitis, contribute to the development of COPD, as does the aging process. In addition, heredity and genietic predisposition appear to have a role.

Pathophysiology:

COPD is a combination of chronic obstructive bronchitis, emophysema, and asthma. The pathophysiology of bronchitis and emphysema is :

• Chronic Obstructive Bronchitis

Chronic obstructive bronchitis is inflammation of the bronchi. This causes increased mucus production and chronic cough. In contrast to acute bronchitis, the clinical manifestations of chronic bronchitis continue for at least 3 months of the year for 2 consecutive years. Additionally, if the client has a decreased FEV, /FVC ratio of less than 75% and chronic bronchitis, then the client is said to have chronic obstructive bronchitis. This term implies that the client has obstructive lung disease combined with chronic cough. Clients with chronic bronchitis have

(1) an increase in the size and number of sub mucous glands in the large bronchi, which increases mucus production

(2) An increased number of goblet cells, which also Secrete mucus;

(3) Impaired ciliary function, which reduces mucus clearance.

Therefore, the lung’s mucociliary defenses are impaired, and there is increased susceptibility to infection. When infection occurs, mucus production is even greater, and the bronchial walls become inflamed and thickened.

Chronic bronchitis initially affects only the larger bronchi, but eventually all airways are involved.

The thick mucus and inflamed bronchi obstruct airways, especially during expiration. The airways collapse and air is trapped in the distal portion of the lung. This obstruction leads to reduced alveolar ventilation. An abnormal V/Q (ventilation-perfusion) ratio develops, with a corresponding fall in Pa02, Impaired ventilation may also result in increased levels of Paco2.

As compensation for the hypoxemia, polycythemia overproduction of erythrocytes) occurs.

Emphysema

Emphysema is a disorder in which the alveolar walls are destroyed. This leads to permanent over distention. Air passages are obstructed as a result of these changes, rather than from mucus production, as in chronic bronchitis. Although the precise cause of emphysema is unknown. Research has shown that the enzymes protease elastase can attack and destroy the connective tissue of the lungs . Emphysema may_resuIt from a breakdown in the lung’s normal defense mechanisms(alpha antitrypsin or AAT), against these enzymes. Difficult expiration emphysema is the result of destruction of the walls (septa) between the alveoli, partial airway collapse, and loss of elastic recoil. As the alveoli and septa collapse, pockets of air form between the alveolar spaces (blebs) and within the lung parenchyma (bullae). This process leads to increased ventilatory dead space, areas that do not participate in gas or blood exchange. The work of breathing is increased because there is less functional lung tissue to exchange oxygen and carbon dioxide. Emphysema also causes destruction of the pulmonary capillaries, further decreasing oxygen perfusion arid ventilation.

There are three types of emphysema).Centrilobular emphysema, the most common type, produces destruction in the bronchioles, usually in the upper lung region. Inflammation develops in the bronchioles, but usually the alveolar sac remains intact. Panlobular emphysema affects both the bronchioles and alveoli and most comnonly involves the lower lung. These form of emphysema occur most often in smokers. Paraseptal (or panacinar) emphysema destroys the alveoli in the lower lobes of the lungs resulting in isolated blebs along the lung

periphery. Paraseptal emphysema is believed to be the likely cause spontaneous pneumothorax, Paraseptal emphysema occurs in the elderly and in clients with an inherited deficiency of AAT.

CLINICAL MANIFESTATION

BOOK PICTURE PATIENT PICTURE

• Cough Cough

• Dyspnea Dyspnea

• Sputum production Sputum production

• Weight loss Weight loss

• Barrel chest (emphysema) _____________

• Hemoptysis _____________

• Exertional dyspnea ______________

• Clubbing of fingers ______________

• Malaise ______________

• Wheezes Wheezes

• Crackles ______________

• Anemia ______________

• Anxiety ______________

• Diaphoresis ______________

• Use of accessory muscles ______________

• Orthopnea _____________

Diagnostic test findings:

• Chest X-ray: congestion, hyperinflation

• ABG analysis: respiratory acidosis, hypoxemia

• Sputum studies: positive identification of organism

• PFTs: increased residual volume, increased functional residual capacity decreased vital capacity

LABORATORY DATA : NORMAL VALUE PATIENT

VALUE

Hematocrit :Female :35 – 45 % 35%

Hemoglobin : Female : 12 – 15 gm /dl 10 gm /dl

Cholesterol : < 200 Desirable; > 240 High 180 mg/dl

HDL : <40 low / > 60 high < 50

LDL : < 100 – optimal < 80

Triglyceride : < 150 normal < 160

Total Lymphocyte count : 1500 - 1800 cells/mm3 1600 cells/mm3

Albumin : 3.5 – 5.0 gm/dl 4 gm/dl

Glucose : 85 – 125 mg/dl 80 mg/dl

Creatinine : 0.6 – 1.2 mg % 0.9mg%

DATE TIME WORK PLAN

16-05-2011

7.30 am to9.30 am

10.30 a.m to 7.00 p.m

Selected the patient for my careEstablished a good rapport between thepatient and her relatives..Bed making doneVital signs checkedCollected baseline Informations

TIME PLAN

17-05-2011

18-05-2011

19-05-2011

20-05-2011

21-05-2011

7.30 am to9.30 am

4.00 pm to7.00 pm

7.00 am to10.00 am

5.00 pm to7.00 pm

7.00 am to9.00 am

4.00 pm to 7.00 pm

7.00 am to9.00 am11.00 am to12.00 noon

7.00 am to10.30 am

4 pm to 7 pm

Bed making doneVital signs checkedBlood samples taken for routine investigationsCollected and sent to laboratoryPhysical examination doneHer doubt regarding the disease, clarified.Medicines given (Tab Ciprofloxcin 5oo mg bdTab Derriphylline 1 tds)

Bed making doneVital signs checkedMorning dose medicine givenAccompanied him to X-ray departmentHealth education given regardingnutritious diet.Bed making doneVital parameters checkedAccompanied the client’s relatives to collect the result of the investigationsClarified the client’s doubts regarding the results

Bed making doneVital parameters checkedMedicine givenAdministered nebulization to the patientAdvised regarding personal hygieneBed making done Vital parameters checkedCollected all the investigations reportsNebulization given.Administered medication.

DATE TIME WORK PLAN

23-05-2011

24-05-2011

25-05-2011

26-05-2011

27-05-2011

11.00 am to1.00 pm

4.00 pm to7.00 pm

7.00 am to10 am

11 00 pm to1.00 pm

7.30 am to 9.30 am

4.00 pm to7.00 pm

7.30 am to 9.00am

4.00 pm to7.00 pm

10.00 am to11.00 am

Bed making doneNebulization givenMedicine given Physical assessment doneEducated about deep breathing and coughing exercizeVital parameters checked

Bed making doneProvided contusive environmentVital parameters checked Nebulization givenMedicine givenDrug chart maintained

Bed making doneVital parameters checkedPersonal hygeine care givenPhysical assessment doneTab ciprofloxacin 500mg is given.Nebulization givenEducated about the importance of drug and nutricious diet.

Bed making done -Vital parameters checkedTab ciprofloxacin 500 mg given orallyAdvised to do breathing exercizeNebulization given

Bed making doneProvided a comfortable bedEncouraged the patient to do deep breathing and coughing exercize

4.00 pm to7.00 pm

Vital parameters checkedPhysical assessment done

DATE TIME WORK PLAN

28-05-2011

30-05-2011

31-05-2011

24-08-2010

8.00 am to10.00 am

1.00 pm to 2.30 pm

5.00 pm to8.00 pm

7:30 am to9.00 am

4.00 pm to7.00 pm

7.30 am to9.30 am

2.00 pm to4.00 pm

Bed making doneMorning dose of medicine givenVital parameters checkedNebulization givenPhysical assessment done

Evening dose of medicine givenVital parameters checkedHealth education given regarding dietaryHabit

Bedmaking doneVital parameters checkedNebulization givenHealth education given regarding follow up care.

Prepared the client for discharge Explained them about the discharge summaryHealth education given regarding exercise, activities and restAccompanied him up to bus stop and sent him to home

Medical management:

• Oxygen therapy: 2 to 3 L/minute

• Intubation and mechanical ventilation if necessary

• Monitoring: vital signs, I/O, pulse oximetry, and respiratory status

• Position: high Fowler’s

• Treatments: chest physiotherapy, postural drainage, intermittent positive pressure breathing, high-flow nebulizer treatments, and incentive spirometry

• Diet: high-calorie diet

• Dietary recommendations: fluids o 3 qt (L)/day if not contraindicated

• I.V. therapy: saline lock

• Activity: as tolerated

• Laboratory studies: ABG values, WBCs, and sputum studies

• Bronchodilator: Terbutaline (Brethine), aminophylline (Truphylline), isoproterenol (Isuprel), theophylline (Theo-Dur); via nebulizer: albuterol (Proventil), ipratropium (Atrovent), metaproterenol (Alupent)

• Corticosteroids: hydrocortisone (Solu-CorteO, methylprednisolone (SoluMedrol)

• Expectorant: guaifenesin (Robitussin)

• Antibiotics: ampicillin (Omnipen), tetracycline (Achromycin), cefixime (Suprax)

• Antacid: aluminum hydroxide gel (AlternaGEL)

• Beta-adrenergic medication: epinephrine (Adrenalin)

• Mast cell stabilizer: cromolyn (Intal)

Nursing interventions:

a Assess respiratoty status

• Administer low-flow oxygen

• Monitor and record vital signs, I/O, pulse oximetry and laboratory studies

• Provide chest physiotherapy, intermittent positive pressure breathing, turning, postural drainage, and suction; encourage coughing, deep breathing, and use of incentive spirometry

• Keep the patient in high Fowler’s position

• Administer medications as prescribed

• Reinforce pursed-lip breathing to prolong exhalation and to increase airway pressure

• Maintain the patient’s diet

• Administer small, frequent feedings

• Encourage fluids

• Encourage the patient to express his feelings about difficulty breathing

• Allow activity as tolerated -

• Monitor and record the color, amount, and consistency of sputum

• Provide emotional support to allay the patient’s anxiety

• Weigh the patient daily

• Provide information about the American Lung Association

• Individualize horn” care instructions

— know about the disorder and its implications

Follow instructions for medication use and be aware of possible adverse effects

Stop smoking and avoid second-hand smoke

Control weight and folic w dietary recommendations

Identify ways to reduce stress

Recognize the signs and symptoms of respiratory infection and respiratory distress

Adhere to activity limitations

Know proper use of home oxygen

Demonstrate pursed-lip and diaphragmatic breathing

Avoid exposure to chemical irritants and pollutants

Demonstrate deep-breathing and coughing exercises

Complications:

Carbon dioxide narcosis

Acute respiratory failure

Pneumonia

From emphysema

Pulmonary hypertension

Right-sided heart failure

Spontaneous pneumothorax

Possible surgical intervention: None

EVIDENCE BASED PRACTICE FOR NURSING:

Women with COPD need social support and specific guideline for management of dyspnea and fatigue to cope well with the disease.(0’ Neil ,(2002), illness representation and coping of women with chronic obstructive pulmonary disease . A Pilot study. Heart and Lung, 31 (4), 295-302. The purpose of this qualitative study was to determine how women with chronic obstructive pulmonary disease (COPD) recognize and respond to symptoms. A total of 21 participants reviewed and kept symptom diaries.The most difficult physical problems for the subjects were fatigue and dyspnea. Other important findings included the high level of depression and stigma felt by the subjects. They also perceived a loss of social support and intimacy.

Level of Evidence : 6—Uncontrolled descriptive qualitative study.Critique. The study designed followed acceptable procedures for qualitative research. Data were collected until redundancy was apparent. Information was obtained by audio taping direct interviews using an open guide with questions and probes to allow for flexibility of response. The interviewer also took notes. A professional transcriptionist transcribe tapes. Feedback from participants was used to verify the data. An independent researcher analyzed selective portions of transcripts for reliability. A drawback of the study was that all participants were also participating in a pulmonary rehabilitation program. Thus the sample may have different motivations and perceptions compared to women with COPD who do not choose or are unable to participate in a pulmonary rehabilitation program.Implications for Nursing. Nurses must provide more practical information on ways to manage dyspnea and fatigue. These physical problems have a large impact on the client’s (quality of life and degree of continued socialization. Nurses must individualize energy conservation plans to meet each client’s

needs rather than just provide a general listing of energy conservation measures.

Iam applying this theory to my nursing process:

Abdellab’s Typology of 21 ProblemsEvolution of Theory:

Abdellah realized that for nursing to gain full professional status and autonomy, a strong knowledge base was imperative. Nursing also needed to move away from the control on medicine and toward a philosophy of comprehensive patient-centered care. Abdellah and her colleagues conceptualized 21 nursing problems to teach and evaluate students. The typology of 21 nursing problems first appeared in the 1960 edition of Patient-centered Approach to Nursing and had a far-reaching impact on the profession and on the development of nursing theories

The patient or family presents with nursing problems that the nurse helps them address through her professional function. The nurse addresses 21 problem categories:

(I) Hygiene and physical comfort,

(ii) Activity and rest,

(iii) Safety,

(iv) Body mechanics,

(v) Oxygenation.

(vi) Nutrition,

(vii) Elimination,

(viii) Electrolytes,

(ix) Responses to disease,

(x) Regulatory mechanisms,

(XI) Sensory function,

(xii) Feelings and reactions,

(xiii) Emotions and illness interrelationships,

(xiv) Communication,

(xv) Interpersonal relationships,

(xvi) Spirituality,

(xvii) Therapeutic environment,

(xviii) Awareness of self,

(xix) Limitation acceptance,

(xx) Resources to resolve problems,

(xxi) Role of social problems in illness.

Nursing problems are both overt or obvious and covert. Nurses must be aware covert problems to meet care requirements.

Overt and covert problems must be identified to make a nursing diagnosis. Identification of problems precedes solution. The nursing process is the method nurses-use to establish and focus on a nursing diagnosis. The overall goal is a client’s fullest possible functioning.

Individualized patient care is important for nursing. Both patients and nurses should be aware of the wholeness of clients and the need for continuity of care from before hospitalization to afterward. Individualized care will require changes in the organization and administration of nursing services and education.

Abdellah was influenced by the desire promote client centered comprehensive nursing care and described nursing “service to individuals and families and therefore, to Society.” Nursing is based an art and science that mould the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people, sick or well, cope with their health needs. Nursing may be carried out under general or specific medical direction.

Abdellah’s theory was derived from following premises of comprehensive nursing care. As a comprehensive service, nursing includes the following:

• Recognizing the nursing problem of patient (client).

• Deciding the appropriate courses of action to talk in terms of relevant nursing principles.

• Providing continuous care to relieve pain and discomfort and provide immediate security for the in difficult.

• Adjusting the total nursing care plan meet the patients (clients) individual needs.

• Helping the individual to become more- self-directing in attaining or maintaining a healthy state of mind and body.

• Instructing nursing personnel and family to help the individual do for himself that which he can within his limitations.

• Helping the individual to his limitations and emotional problems.

• Working with allied health professional in planning for optimum health on local, state, national and international level.

• Carrying out continuous evaluation and research to improve nursing techniques and to develop new techniques to meet the health needs of people.

These original premises have undergone evolutionary process. For example, “providing continuous cares of the individual’s total needs, was eliminated without any reason, but may be than it is impossible to provide continuous and total care.

CONCEPTS USED BY ABDELLAH:

Nursing:

Abdellah defined nursing as “Service to individuals. It is based upon an art and science which mould the attitudes, intellectual competences, and technical skills of the individual nurse into the desire and ability help people sick or well cope with their health needs and may be carried out under general or specific medical direction.

Abdellah was clearly promoting the image the nurse who was not only kind and caring, but also intelligent, competent and technically well prepared to provide service the patient.

Health:

Abdellah never defined health per se, her concept of health may be defined as the dynamic pattern of functioning, whereby there is a continued interaction with internal and external forcer, that result in the optimal use of necessary resources that serve to minimize vulnerabilities. Emphasis should be placed upon prevention and rehabilitation with wellness as a lifetime goal. By performing nursing services through a holistic approach to the client, the nurse helps the client achieve a state of health. However, effectively performs these service the nurse must accurately identify the lacks or deficits are the client’s health needs.

Nursing Problem:

The client’s health needs can be viewed as problems. The nursing problem presented by the patients is condition faced by the patient or family which the nurse can assist him or them to meet through the performance of her professional functions. The problem can be either an overt or covert nursing problem. An overt nursing problem is an apparent conditions faced by the patient or family which the nurse can assist him or them to meet through the performance of her professional functions. The covert nursing problem is a concealed or hidden condition faced by the patient or family which the nurse can assist him or them to meet through the performance of her professional functions. Covert problems can be emotional, sociological and interpersonal in nature. They are often missed or perceived incorrectly. Yet many instances solving covert problems may solve the overt problem as well. Use of the term ‘nursing problem’ is more consistent with “nursing functions” or “nursing

goals” than with client- control problems. Although Abdellah spoke of the patient-centered approaches she wrote nurses identifying and solving specific problems. This identification and classification of problems was called the “typology of 21 nursing problems as listed below:

1. To maintain good hygiene and physical comfort.

2. To promote optimal activity, exercise, rest, sleep.

3. To promote safety through prevention of accident, injury or other trauma and through the prevention of the spread of infection.

4. To maintain good body mechanics and prevent and correct deformities.

5. To facilitate the maintenance of a supply of oxygen to all body cells.

6. To facilitate the maintenance of nutrition to all body cells.

7. To facilitate the maintenance of elimination.

8. To facilitate the maintenance of fluid and electrolytes balance.

9. To recognize the physiological responses of the body to disease conditions—pathological, physiological and compensatory.

10. To facilitate the maintenance of regulatory mechanisms and functions.

11. To facilitate the maintenance of sensory function.

12. To identify and accept positive and negative expressions, feelings and sanctions.

13. To identify and accept interrelatedness of emotions and organic illness.

14. To facilitate the maintenance of effective verbal and non-verbal communication.

15. To promote the development of productive interpersonal relationship.

16. To facilitate progress towards achievement of personal spiritual goals.

17. To create and/or maintain a therapeutic environment.

18. To facilitate awareness of self as an individual with varying physical, emotional and developmental needs.

19. To accept the optimum possible goals in the light of limitations, physical, emotional.

20. To use community resources as an aid in resolving problems arising from illness.

21. To understand the role of social problems as influencing factors in the cause of illness.

Abdellah, typology was divided into three

areas:

1. The physical, sociological and emotional needs of the patients (clients).

2. The types of interpersonal relationships between of the nurse and the patients (clients).

3. The common elements of patient (client)

Care:

In the process of identifying overt and covert nursing problems and interpreting, analyzing and selecting appropriate course

action to solve these problems. “Quality professional nursing care requires that nurses be able to identify and solve overt and covert nursing problems. These requirements can be met by the problem-solving pertinent data, formulating hypotheses, testing hypotheses, through the collections of data, and revising hypothesis when necessary on the basis conclusion obtained from the data.

Many of these steps parallel to the steps of the nursing process. The problem-solving approach was selected because of the assumption that the correct identificationnursing problems influences the nurse’s judgment in selecting the next steps in solving the client’s nursing problems. The problem- solving approaches is also consistent with such basic elements of nursing practice espoused by Abdellah as observing, reporting and interpreting the signs and

symptoms that comprise the deviations from health and constitute nursing problems and with analyzing the nursing problems and selecting the necessary course of action.

An examination of the 21 problems yields similarity to other viz., Virginia Henderson (1991), Abraham Marsow theory of hierarchy of needs (1954).

PARADIGM OF ABDELLAH’S TYPOLOGY:

Abdellah does not clearly specify each of the four major concepts: human being, health, environment/society and nursing.

Human Being

She does describe the recipient of nursing as individuals (and families) although she does not delineate her beliefs or assumption about the nature of human beings. She describes people as having physical, emotional and sociological needs. These needs may be overt, consisting largely physical needs, or covert, such as emotional and social needs. The typology and nursing problem is said to evolve from the recognition of a need for patient-centred approach to nursing. The patient is described as the only justification for the existence of nursing. People are helped by the identification and alleviation of problems they are experiencing.

Health

As Abdellah discusses in “patient-centred” approaches to nursing in a state mutually exclusive of illness. Health is defined implicitly as a state when the individual has no unmet needs and no anticipated or actual impairments. Achieving of health is the purpose of Nursing Services. Although Abdellah does not give a definition of health, she speaks of ‘total health needs” and ‘a healthy state of mind and body’ in her description of nursing as a comprehensive nursing service.

Environment

The environment is the least-discussed concept in her model. Nursing problem number 17 from the typology is ‘ito create and/or maintain a therapeutic environment and she also states that if the nurses reaction to the patient is

hostile or negative, the atmosphere in the room may be hostile, or negative. This suggests that patient interest and respond to their environment. Society is included in the premises of comprehensive nursing care, i.e. planning for optimum health on local, state, national and international.

Nursing

Nursing is a helping profession. Nursing care is doing something to or for the person or providing information to the person with goal meeting needs, increasing or restoring self- help-ability, or alleviating an impairment.

Nursing is broadly grouped into the 21 problems areas to guide care and promote the use of nursing judgment. Abdellah considers nursing to be a comprehensive service that is based on an art and science and aims to help people sick or well, cope with these health needs.

NURSING PROCESS AND ABDELLAH

Abdellah’s typology of 21 nursing problems helps nurses practice in an organized systematic way. The use of this scientific base enables the nurse to understand the reason for her actions. Their use in the nursing process is primarily to direct the nurse indirectly to the client’s benefits.

In assessment phase, each of the identified 21 nursing problems relevant data are collected. The overt or covert nature of the problems necessitates a direct or indirect approach, respectively For Example the overt problem of nutritional status can be assessed by direct measures of weight, food intake and

body size, whereas the covert problem of maintaining a therapeutic environment requires more indirect approach to data collected. The nursing problems can be divided into those that are basic to all clients and those that reflect sustainable, remedial or restorative care needs.

Nursing diagnosis: is the result of data collection would determine the client’s specific overt and/or covert problems. These specific problems would be grouped under one or more of the broader nursing problems.

In planning phase of nursing process, her statements of nursing problems most closely resemble goal statements. Therefore, once the problem has been

diagnosed, the goals have been established. Many of the nursing problems statements can be considered goals for either the nurse or the client.

In implementation, nurse using the goals as the framework, a plan is developed and appropriate nursing intervention are determined. Again holism tends to be negated in implementation because of the isolated particular nature of the nursing problems.

Evaluation: The plan is evaluated in terms of client’s progress or lack of progress toward the achievement of the goals.

Abdellah’s Work and Characteristics of Theory

Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomena.

1. Abdellah, theory has interrelated concepts of health, nursing problems and problem solving as she attempts to create a different way of viewing nursing phenomena. The results the statement that nursing is the use of the problem-solving approach with key nursing problems related to the health needs of the people.

2. Theoretical statement places heavy emphasis on problem-solving an

activity that is inherently logical in nature.

3. Theory is appearing to be limited to use which seems to focus quite heavily on nursing practice with individuals. Theory does not provide the framework on human and society in general. This somewhat limits the ability to generalize, although the problem solving approach readily generalizable to clients with specific health needs and specific nursing problem.

4. One of the most important questions that arises when considering her work is the role of the client within the framework, a question that could generate hypotheses for testing. The results of testing such hypothesis would contribute to the general body of nursing knowledge.

5. Abdella’s problem-solving approach can easily be used by practitioners to guide various activities within their nursing practice. This is especially true when

considering nursing practice that deals with clients who have specific needs and specific problem.

6. Abdellah theory consistent with other validated theories, such as those of Maslows and Henderson. Although the consistency exists, many questions remain unanswered.

Evaluation of Theory

The typology is very simple and is descriptive of nursing problems thought to be common among patients. The concepts of nursing, nursing problems, and the problem-solving process, which are central to this work, are defined explicitly. The concepts of person, health, and environment, which are associated with the nursing paradigm today, are implied. There are no stated relationships between Abdellah’s major concepts or those of the nursing paradigm in her writing. This model has a limited number of concepts, and its only structure is a list.

A somewhat mixed approach to concept definition is present in this work. Nursing and nursing problems are connotatively defined, while the problem-solving process is defined denotatively. These approaches to definitions do not seem to detract from the clarity of definitions. The typology does not yet constitute a theory because it lacks sufficient relationship statements. The 21 nursing problems are general and linked to neither time nor environment. “She acknowledges that her list is neither exhaustive nor listed according to priorities.” Assuming that persons experience similar needs, the nursing goals stated in the list of 21 problems could be used by nurses in any time frame to meet patients’ needs. However, according to this model, some persons do not need nursing.

Other service professions could use the typology of 21 nursing problems to focus on the psychosocial and emotional needs presented by patients. The goals of this model vary in generality. The broadest goal is to positively affect nursing education, while sub goals are to provide a scientific basis on which to practice and to provide a method of qualitative evaluation of educational experiences for students. The goals are appropriate for nursing.

• The concepts are very specific with empirical references that are easily identifiable. The concepts are within the domain of nursing. Ready linkage of

the concepts and the typology to reality is secondary to an inductive approach to theory development. Validation of the typology was done by the faculty of 40 collegiate schools of nursing.

The typology provided a general framework in which to act, but continued neither specific nursing actions nor patient-centered outcomes, despite the title of the book. However, two subsequent publications did address outcome measures (effect variables) and suggested models for organizing curricula to emphasize patient-centered outcomes. Except for stating the importance of nursing the whole patient, today’s idea of holism is not apparent in this work. The skills list includes skills thought necessary for nurses to meet patients’ needs but is not prescriptive. Abdellah suggests nursing research as a method for validating treatments toward resolution of patients’ needs.

The emphasis on problem-solving is not limited by time or space and therefore provides a means for continued growth and change in the provision of nursing care. The problem-solving process and the typology of nursing problems can be respectively considered precursors of the nursing care process and classification of nursing diagnoses in evidence today.

In Patient-centrered Approaches to Nursing Care, Abdellah addressed nursing education problems linked to the use of the medical model. Her typology provided a new way to qualitatively evaluate experiences and emphasized a practice based on sound rationales rather than note.

“She proposes that nurses could take a leadership role in making the public aware that quality nursing health care is available. Quality is defined as the care that the patient needs. Need is determined by a classification system that identifies the medical treatment and nursing care essential for that individual.”

Abdellah has made significant contributions to patient care, education, and research nursing and health care in this country and throughout the world.

NURSING DIAGNOSIS Ineffective breathing pattern related to hypertrophy of cardiac muscle as evidenced

by use of accessory muscles

Ineffective airway clearance related to secretions in the bronchi as evidenced by auscultation

Hyperthermia related to inflammatory process as evidenced by temperature assessment

Intolerance level II as evidenced by increased heart rate after walking

Imbalanced nutritional status less than body requirement related to less intake of food as evidenced by Hb level

Disturbed sleep pattern related to breathlessness as evidenced by increasing irritability

Fatigue related to increase physical exertion as evidenced by breathlessness

Anxiety mild, related to unconscious conflict about values of life as evidenced by sympathetic stimulation like facial tension

Deficient knowledge therapeutic regimen related to inaccurate follow up as evidenced by non compliance of medications

Ineffective role performance related to changes in physical health as evidenced by change in usual patterns of responsibility

Subject Data : Patient Complaints, “ I am having difficulty in breathing”

Objective Data : patient looks dull, anxious, worried, and having increased

respiratory rate.

Nursing Diagnosis : Ineffective breathing pattern related to hypertrophy of cardiac

muscle as evidenced by use of accessory muscles

Expected outcome : Patient will establish effective respiratory pattern

Planning Implementation Rationale Evaluation

Assess clients respiratory rate using dysnoea scale

Monitor cardiac function studies

Administer Oxygen as prescribed by doctor

Administer medication as prescribed by doctor

Encourage self assessment & symptom management

Reassess breathing pattern

Client rates 2 in the modified Borg category scale

Monitored oxygen saturation level is 8o%

4liters of O2 administered as prescribed

Administered as prescribed Bronco dilator drugs

Client is encouraged to identify the situation and avoid stress producing situation

Reassessed the breathing level is normal , oxygen saturation level increased to 90%

To identify baseline data

To diagnose degree of respiratory compromise

To improve saturation level

To Reduce breathing difficulty

To reduce the workload of heart & thus prevents complication

To know the condition of the patient

Through all these measures patient’s breathing pattern is improved as evidenced by oxygen saturation level is 90%

Subject Data : Patient Complaints, “ I am having difficult in expectoration of

sputum”

Objective Data : patient is having difficult to expel the sputum, dull , sweating.

Nursing Diagnosis : Ineffective airway clearance related to secretions in the bronchi as

evidenced by auscultation.

Expected outcome : client will expectorate secretions & maintain patent airway

Planning Implementation Rationale Evaluation

Assess ability to protect own airway

Evaluate amount & type of secretions being produced

Provide proper position

Give expectorant as prescribed

Auscultate breath sounds after administering expectorant

Teach about breathing exercise, pursed lip breathing exercise.

Reassess breathing pattern

Client is able to protect airway but coughing effort is ineffective and unable to expel sputum.

Secretions is excessive & sticky

Semi fowler’s position provided using back rest.

Administered expectorant corex syrup 5ml oral as prescribed

On auscultation, crackles reduced

Taught deep breathing & coughing exercise, pursed lip breathing

Crackle reduced on auscultation

To know baseline data.

To assess the difficulty in maintaining airway

Upright position facilities respiratory function by use of gravity

Expectorants stimulate bronchial secretions

To assess the effectiveness of expectorants

To reduce risk of pneumonia

Through these entire measures

client maintained

clear airway as evidenced

by diminished crackles on auscultatio

n.

To identify improvement

Subject Data : Patient Complaints, “ I am having fever and headache, unable to take

food.

Objective Data : patient is having temperature 100’ F, lethargy, anxiety, dull.

Nursing Diagnosis : Hyperthermia related to inflammatory process as evidenced by

elevated temperature.

Expected outcome : Client will maintain core temperature within normal range

Planning Implementation Rationale Evaluation

Monitor temperature by oral route

Monitor blood pressure & and ECG, and oxygen saturation level

Administer antipyretic as ordered

Administer supplemental Oxygen as prescribed

Administer fluids as

Oral temperature is 100ºF

Monitored ECG & oxygen saturation level ,ECG shows sinus tachycardia & oxygen saturation level is 80%

Administered Inj . paracetamol 1 amp as prescribed by doctor.

To know baseline data

Pre existing cardiovascular symptoms can cause changes in hemodynamic status.

Antipyretic act on the hypothalamus to reduce fever.

Through all these measures patient temperature is reduced to 98.4ºF.

prescribed by physician

Provide dry cloth to the patient

Reassess the temperature

Administered 4ltrs of Oxygen by mask as prescribed by doctor

Administered 1000ml of oral fluids per day

Provided clean and dry cloth to the patient

Reassessed the temperature is 98.4’F

To reduce cardiac work load

To replace fluids lost through perspiration

To reduce shivering & thus reduce cardiac workload

To evaluate the effectiveness of care

Subject Data : Patient Complaints, “ I am having difficulty in breathing while

waking.

Objective Data : patient is having dyspnea, sweating, anxiety.

Nursing Diagnosis : Activity intolerance level II as evidenced by increased heart rate

after walking

Expected outcome : Client will breathe normally.

Planning Implementation Rationale Evaluation

Assess Cardiopulmonary response to physical activity

Provide rest in between activities

Assist with activities

Administer oxygen as per physician advice

Reassess activity level

Assessed heart rate after activities like walking .

Provided rest in between activities

Assisted with activities like bathing, feeding & walking

Administered oxygen 4/l as per physician advice

Client heart rate is 78/ min after walking

To know the base line data

To reduce fatigue

To maintain mobility

To maintain oxygen saturation level.

To identify improvement.

Through all these measures patient breathing level is improved.

Subject Data : Patient Complaints, “I am unable to take adequate food.

Objective Data : Client looks dull, lethargy, anxiety.

Nursing Diagnosis : Imbalanced nutritional status less than body requirement related to

less intake of food as evidenced by unable to

Do daily living activities.

Expected outcome : Client nutritional level will be improved.

Planning Implementation Rationale Evaluation

Obtain diet history

Advise to take small & frequent diet

Plan diet menu to the patient

Teach food sources rich in protein, iron, carbohydrate.

Reassess the knowledge about diet.

Patient takes less food due to breathing difficulty

Advised to take small quantity of food every 2 hourly

Provided planned diet menu to the patient.

Taught about protein iron carbohydrate rich foods like ragi, drumstick leaves, dates, dhal, pulses, bread.

Client list out certain food like drumstick, ragi.pulses, dhal , bread.

To know baseline data

Heavy meal aggravates breathing difficulty

To monitor nutritional status

To improve the nutritional level

To know the progress.

Through all these Measures the patient nutritional level is improved.

Subject Data : Patient Complaints, “Iam unable to sleep during night due to breathing

difficulty..

Objective Data : patient looks dull, lethargy, worried, anxiety. Pulse rate is increased.

Nursing Diagnosis : Disturbed sleep pattern related to breathlessness as evidenced by

increasing irritability

Expected outcome :patient sleeping pattern will be improved.

Planning Implementation Rationale Evaluation

Assess sleep pattern

disturbance associated with

breathlessness

Observe for physical signs

of sleeplessness & fatigue

Administer medication for

breathlessness as

prescribed by doctor.

Advise to avoid activities

that causes breathlessness

at night provide sedation

Reassess sleep pattern

Patient awoke 7

times at night due

to breathlessness

Patient looks

restless &

irritable

Inj. Deriphylline l

amp IV given as

prescribed by

doctor.

Advised to avoid

heavy meal,

caffeine content

at night

Provided Tab.

Diazepam 1 Hs as

per doctor advice

Patient sleeps for

To know baseline data

To assess the level of

fatigue

To induce sleep

adequately

Heavy meal & caffeine

impair breathing

pattern

To induce sleep

To identify progress.

Through all these

Measures patient

is able to sleep at

least for 5 hrs in

night as evidenced

by reduced awoke

during night.

5 hours without

Interruption.

Subject Data : Patient Complaints, “I am unable to do my routine activity.

Objective Data : patient looks dull, irritable, lethargy.

Nursing Diagnosis : Fatigue related to increase physical exertion as evidenced by

breathlessness

Expected outcome : patient activity level will be improved.

Planning Implementation RationaleEvaluati

on

Assess the activity level

Assess severity of fatigue using 0-10 scale

Measure physiological response to activity especially respiratory rate.

Provide fowler’s position

Patient is having breathlessness respiratory rate is 30 breaths / min

Patient rates 5 in the fatigue rating scale

Patients respiratory rate is 30 breaths / min

To know baseline data

To identify the intensity of fatigue

It indicate need for intervention

Through all these measures patient relieved from breathlessness as evidenced by respiratory rate is 22/min

Provide adequate rest

Provide small frequent diet

Reassess the activity level

Semi fowler’s position is provided using back rest.

Provided adequate rest

Provided small frequent diet like fluid, Idly, dhal.

Patient rates 4 in fatigue rating scale & respiratory rate is 22 breaths / min while doing self care activities

To improve the lung expansion

To reduce cardiac work lode

To provide energy, and reduce breathlessness.

To know the base line data

Subject Data : Patient Complaints, “ I am worried about my body condition.

Objective Data : patient is worried, pulse rate is increased, dull lethargy.

Nursing Diagnosis : Anxiety moderate, related to bronchial congestion as evidenced by

worried , and irritable and tensed facial expression.

Expected outcome : patient anxiety level will be reduced.

Planning Implementation Rationale Evaluation

Assess the level of anxiety

Develop interpersonal relationship

Observe and listen patient complaints

Provide assistance to self care activity

Explain about the disease condition in simple way

Reassess anxiety level.

Patient had moderate anxiety level

Improved interpersonal relationship, shows empathy to the patient

Observed and listened patient complaints of having anxiety about his future life.

Provide assistance to daily living activities by family members.

Explained about the disease condition, allergy and stress provoking situation in simple way.

Patient controlled his anxiety level

To know baseline data

To improve confidence.

To know the patient inner thought

To reduce activity level

To reduce anxiety

To know the anxiety level

Through all these measures patient is free from anxiety.

.

Subject Data : Patient asks, “ May I know about the disease condition and its

treatment. and home care .

Objective Data : patient looks worried, and asking many question.

Nursing Diagnosis : Deficient knowledge therapeutic regimen related to inaccurate follow

up`as evidenced by non compliance of medications

Expected outcome : patient will able to know the disease condition, treatment, and home

care activities within a week.

Planning Implementation RationaleEvalua

tion

Assess the level of knowledge including educational status.

Explain about the disease condition and home care ,in a simple way.

Allow the patient to express their doubt

Answer all the question, that the patient asked

Assessed the knowledge the patient is not knowing the disease, and he studied up to 10th std

Explained about the disease condition and treatment, and home care activities in a simple way by using A.V.Aids

Allowed the patient to express their doubt, he is asking many questions.

Answered all the questions in simple way with explanation

To know baseline data.

Patient knowledge level is improved.

To-relieve anxiety

To improve the patient knowledge

Through all these measures the patient knowledge level is improved.

Provide written materials regarding diet & medication.

Reassess knowledge about home care

Provided discharge plan containing in formations regarding diet & medication.Patient verbalize about diet and ,drug regimen to be followed at home

To help for taking proper diet and medication

To know about progress.

Subject Data : Patient Complaints, “ I am unable to continue my job”

Objective Data : patient is having confusion, worried.

Nursing Diagnosis : Ineffective role performance related to changes in physical health as

evidenced by change

in usual patterns of responsibility

Expected outcome :Patient will able to continue his role and responsibility

Planning Implementation Rationale Evaluation

Identify type of role dysfunction observe stress providing situation

Discuss perceptions & significance of the situation as seen by client

Advise the family members

Patient shows role dysfunction

Observed stress providing situation and avoid the situation.

Discussed about the disease condition & its

To know baseline data

Helps client to accept reality

Provides opportunity to clarify any

Reassessment shows verbalization of realistic perception of role change .

to assisst the patient

Reassess about role dysfunction

management

Advised the family members to assist the patient in daily activities.

Patient verbalize about change of occupation

misperception

Provides ongoing supportTo know about progress.

HEALTH EDUCATION

Community and Home Care Considerations:

1. Encourage patient to live within the limitations that emphysema imposes.

2. Help to relax and work at a slower pace. Obtain occupational therapy consult to help employ work simplification techniques such as sitting for tasks, pacing activities, using dressing aids (grabber, sock aid, long-handled shoe horn), shower bench, and handheld shower head.

3. Encourage enrollment in a pulmonary rehabilitation program where available and Better Breathers club or other support group found through the American Lung Association or the American Association for Cardiovascular and Pulmonary Rehabilitation . Components include breathing retraining techniques, proper use of medications and inhalers, secretion clearance. techniques, prevention and

management of respiratory infection, panic control, controlling dyspnea with ADLs and stair climbing, control of pulmonary irritants, monitored and supervised exercise, proper use of oxygen systems, and group support.

4. Suggest vocational counseling to help patient maintain gainful employment within his physical limits for as long as possible: -

5. Warn patient to avoid excessive fatigue, which is a factor in producing respiratory distress.

6. Advise to adjust activities per individual fatigue patterns.

7. Advise to try to cope with emotional stress as positively as possible. Such stress triggers attacks of dyspnea. Teach coping strategies, such as relaxation techniques, meditation, guided imagery.

8. Stress that progression of worsening lung functions may be slowed through close medical follow-up for rest of life.

Patient Education and Health Maintenance:

General Education

1. Give the patient a clear explanation of the disease, what to expect, how to treat and live with it. Reinforce by frequent explanations, reading material, demonstrations, and question and answer sessions.

2. Review with the patient the objectives of treatment and nursing management.

3. Work with the patient to set goals (eg, stair climbing, return to work).

4. Encourage patient involvement in disease self management techniques, identification and prompt reporting of respiratory infection or respiratory deterioration. Encourage patient to have open communication and partnership with primary care provider.

Avoid Exposure to Respiratory Irritants

Advise patient to stop smoking and avoid exposure to second-hand smoke.avoid bronchospasm and dyspnea.

a. Keep a warm mask or scarf over nose and mouth, and drink a warm beverage to warm inspired air in cold weather.

b. Stay indoors with air condition in when air pollution level is high.

c. Try to avoid abrupt environmental changes.

d. Shower in warm water.

5. Instruct patient to humidify indoor air in winter to maintain 30% to 50% humidity for optimal mucociliary function.

6. Suggest the use of a HEPA air cleaner to remove dust, pollen, and other particulates; this is controversial as to the belief to the patient.

Prevent and Treat Respiratory Infections

1. Warn against exposure to people with respiratory infections; a respiratory infection makes symptoms worse and can produce further irreversible damage.

2. Advise patient to avoid crowds and areas with poor ventilation.

3. Stress the importance of obtaining influenza vaccine (annual) and pneumococcal vaccine to decrease likelihood of developing these infections.

4. Teach patient how to recognize and report evidence of respiratory infection promptly—changes in character of sputum (amount, color, or consistency—becoming purulent), increasing cough, wheezing, increasing shortness of breath, fever, chills, increasing difficulty in raising sputum, chest pain.

5. Instruct the patient to discuss with health care provider taking prescribed antimicrobial at first sign of infection and adding oral corticosteroids for exacerbation of COPD.

Reduce Bronchial Secretions

1. Advise patient to maintain an adequate fluid intake (8 to 10 glasses daily); mark down the amount of liquid consumed daily.

2. Encourage use of bronchodilators as directed.

3. Teach postural drainage exercises as prescribed.

a. Stay in each position 5 to 15 minutes as tolerated.

b. Use controlled cough after each position.

4. Use other secretion clearance techniques, such as PEP valve, flutter valve, huff cough and, possibly, chest percussion if needed for enhanced secretion clearance.

Improve Airflow

1. Teach the proper technique for inhalation of medication to maximize aerosol deposition in the bronchial tree.

a. Use spacer device, breathe out normally place MDI (attached to spacer device) in mouth, make tight seal around mouthpiece (if not using spacer device: place inhaler 1 inch [2.5 cm] in front of open mouth).

b. Actuate cartridge to release soray and inhale slowly over 5 seconds.

c. Pause, holding breathe for about 10 seconds; exhale slowly.

2. Encourage routine use of a spacer device or holding chamber to allow easier inhalation of bronchodilator medication and enhanced medication deposition. Follow manufacturer’s instructions for use of holding chambers.

3. If using a dried powder inhaler, instruct in proper use according to manufacturer’s instructions. Spacer devices are not necessary.

DRUG ALERT Instruct patient in proper sequence of medic lions, using bronchodilator first, followed by inhaled corticosteroid. Instruct patient to use a spacer device with inhaled corticosteroids, and rinse and spit after using inhaled corticosteroid to prevent oral candidacies.

Breathing Exercises

1. Explain that goal is to strengthen and coordinate muscles of breathing. to lessen work of breathing and help lung empty more completely.

2. Stress the importance of controlled breathing.

3. Teach diaphragmatic breathing and pursed-lip breathing for episodes of dyspnea and stress.

4. Encourage muscle toning by regular exercise.

General Health

1. Teach good habits of wel1-baanced, nutritious intake.

2. Encourage high-protein diet with adequate mineral, vitamin, and fluid intake.

3. Advise to avoid hard-to-chew foods (causes tiring) and gas-forming foods, which cause distention and restrict diaphragmatic movement.

4. Encourage five to six small meals daily to ease shortness of breath during and after meals.

5. Suggest rest periods before and after meals if eating produces shortness of breath.

6. Warn against potassium depletion. Patients with COPD tend to have low potassium levels; also, patient may be taking diuretics.

a. Watch for weakness, numbness, tingling of fingers, leg cramps.

b. Encourage foods high in potassium include bananas, dried fruits, dates, figs, orange juice, grape juice, milk, peaches, potatoes, tomatoes.

7. Advise patient on restricting sodium as directed.

8. Limit carbohydrates if CO2 is retained by patient, because they increase CO2.

9. Use community resources, such as Meals On Wheels or a home care aide if energy level is low.

CONCLUSION:

Through this care study presentation, I got an opportunities to enrich my knowledge, skill, about the COPD, and physical assessment, and its definition, causes, pathophysiology , medical and nursing management, and the way to apply theory in nursing process.

And I had a chance of referring current information from the Net reference and Journals.

I am very much thankful to our honorable madam for having given me a wonderful opportunity like this.

BIBLIOGRAPHY:

Arnold Bloom, 1979,’Toohey’s medicine for nurses,’ Twelth Edition, The English language Book society and Churchill living stone ,pp350

Anne Waugh Allison Giant, 2004,’Anatomy and physiology in health and illness , Ninth Edition, Churchill livingstone, pp 295-306.

B.T. Basavanthappa, 2007, ‘ Nursing Theories’, Jaypee Brothers, Medical publishers (p) Ltdspp 52-60.

Brunner &Suddarth B, 2009,’ Test book of Medical Surgical Nursing,’ Eleventh Edition, Joyce young johnson, Lippincott, Williams &wilkinspp 607.

Christopher R.W. Edwards, 1995,’ Principles and practice of medicine ,Seventeeth Edition, Churchill living stone, pp 426-434.

Datta T.K, 2005,’Fundamentals of operation theatre services,’ Second Edition, Jaypee Brothers, Medical publishers, (p) Ltds, pp 2.

Joyce M.Black,’Medical – Surgical Nursing,’ Fifth Edition ,W.B.Saunders Company, pp 1022-1050

Jenet Weber, R.N.EdD,2007,’ Health Assessment in Nursing,’ Third Edition, Lippincott, Williams & Wilkins, pp 450-456.

Lippincott,2006,’Manual Nursing Practice’, Eighth Edition, Jaypee Brothers, Medical publishers, (p) LTD, PP 203 -316.

Straight A’s, 2008,’Medical- Surgical Nursing,’ Second Edition, WoltersKlowerLippincott, Williams & Wilkins, pp 79-130

Swaminathan,M, 1997,’Hand Book of food and nutrition, The Bangalore printing & publishing co, Ltd,pp249.

Net Reference:

Respiratory system, Wikipedia, free encyclopedia.