copd

Group 7Ablay-Andrade-Batario-Berbano-

Bibera-Borja-Borres-Burns-Cabañero-Corsiga-Custodio-

Cuyegkeng

Case Presentation

BRONCHIAL ASTHMA IN ACUTE EXACERBATION

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

INTRODUCTION

INTRODUCTION

COPD, or chronic obstructive pulmonary disease, is a progressive disease that makes it hard to breathe. "Progressive" means the disease gets worse over time.

COPD can cause coughing that produces large amounts of mucus, wheezing, shortness of breath, chest tightness, and other symptoms.

Cigarette smoking is the leading cause of COPD. Most people who have COPD smoke or used to smoke. Most cases of COPD occur as a result of long-term exposure to lung irritants that damage the lungs and the airways.

Breathing in secondhand smoke, air pollution, and chemical fumes or dust from the environment or workplace also can contribute to COPD. (Secondhand smoke is smoke in the air from other people smoking.)

In rare cases, a genetic condition called alpha-1 antitrypsin deficiency may play a role in causing COPD. People who have this condition have low levels of alpha-1 antitrypsin (AAT)-a protein made in the liver.

Having a low level of the AAT protein can lead to lung damage and COPD if you're exposed to smoke or other lung irritants. If you have this condition and smoke, COPD can worsen very quickly.

COPD develops slowly. Symptoms often worsen over time and can limit your ability to do routine activities. Severe COPD may prevent you from doing even basic activities like walking, cooking, or taking care of yourself.

Most of the time, COPD is diagnosed in middle-aged or older people. The disease isn't passed from person to person—you can't catch it from someone else.

COPD has no cure yet, and doctors don't know how to reverse the damage to the airways and lungs. However, treatments and lifestyle changes can help you feel better, stay more active, and slow the progress of the disease.

CHRONIC BRONCHITIS

Lung damage and inflammation in the large airways results in chronic bronchitis. Chronic bronchitis is defined in clinical terms as a cough with sputum production on most days for 3 months of a year, for 2 consecutive years. In the airways of the lung, the hallmark of chronic bronchitis is an increased number (hyperplasia) and increased size (hypertrophy) of the goblet cells and mucous glands of the airway.

As a result, there is more mucus than usual in the airways, contributing to narrowing of the airways and causing a cough with sputum. Microscopically there is infiltration of the airway walls with inflammatory cells. Inflammation is followed by scarring and remodeling that thickens the walls and also results in narrowing of the airways. As chronic bronchitis progresses, there is squamous metaplasia (an abnormal change in the tissue lining the inside of the airway) and fibrosis (further thickening and scarring of the airway wall). The consequence of these changes is a limitation of airflow.

Patients with advanced COPD that have primarily chronic bronchitis rather than emphysema were commonly referred to as “blue bloaters” because of the bluish color of the skin and lips (cyanosis) seen in them. The hypoxia and fluid retention leads to them being called “Blue Bloaters.

EMPHYSEMAEmphysema is a chronic obstructive

pulmonary disease (COPD, as it is otherwise known, formerly termed a chronic obstructive lung disease). It is often caused by exposure to toxic chemicals, including long-term exposure to tobacco smoke. Emphysema is characterized by loss of elasticity (increased pulmonary compliance) of the lung tissue caused by destruction of structures feeding the alveoli, owing to the action of alpha 1 antitrypsin deficiency.

This causes the small airways to collapse during forced exhalation, as alveolar collapsibility has decreased. As a result, airflow is impeded and air becomes trapped in the lungs, in the same way as other obstructive lung diseases. Symptoms include shortness of breath on exertion, and an expanded chest. However, the constriction of air passages isn’t always immediately deadly, and treatment is available.

ASTHMA Asthma is a chronic lung disease that inflames and narrows the airways. Asthma causes recurring periods of wheezing, chest tightness, shortness of breath, and coughing. The coughing often occurs at night or early in the morning. Asthma affects people of all ages, but it most often starts in childhood.

The airways are tubes that carry air into and out of your lungs. People who have asthma have inflamed airways. This makes the airways swollen and very sensitive. They tend to react strongly to certain substances that are breathed in.When the airways react, the muscles around them tighten. This causes the airways to narrow, and less air flows to your lungs. The swelling also can worsen, making the airways even narrower. Cells in the airways may make more mucus than normal. Mucus is a sticky, thick liquid that can further narrow your airways.

When your asthma symptoms become worse than usual, it's called an asthma attack. In a severe asthma attack, the airways can close so much that your vital organs do not get enough oxygen. People can die from severe asthma attacks. Asthma is treated with two kinds of medicines: quick-relief medicines to stop asthma symptoms and long-term control medicines to prevent symptoms.

NURSING THEORIES

VIRGINIA HENDERSON

NURSING THEORIES

Virginia HendersonHenderson defined nursing in functional terms.

She stated, “The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery that he would perform unaided if he had the necessary strength, will or knowledge.

And to do this in such a way as to help him gain independence as rapidly as possible.

Person (Patient)Henderson viewed the patient as an individual

who requires assistance to achieve health and independence or peaceful death. The mind and body are inseparable. The patient and his or her family are viewed as a unit.

3 levels comprising the nurse patient relationship

• 1. nurse as a substitute for the patient• 2. nurse as a helper to the patient• 3. nurse as a partner with the patient

Henderson identified 14 basic needs of the patient, which comprise the components of nursing care. These include the following needs:

1. Breathe normally2. Eat and drink adequately3. Eliminate body wastes4. Move and maintain desirable postures

5. Sleep and rest6. Select suitable clothes—dress and

undress7. Maintain body temperature within normal

range by adjusting clothing and modifying the environment

8. Keep the body clean and well groomed and protect the integument9. Avoid dangers in the environment and

avoid injuring others

11. Worship according to one’s faith12. Work in such a way that there is a sense

of accomplishment13. Play or participate in various forms of

recreation14. Learn, discover, or satisfy the curiosity

that leads to normal development and health and use the available health facilities

PERSONAL DATA

PERSONAL DATA

Mr. R.B, a 50-year-old Filipino, male. He was born Roman Catholic on August 13, 1959 and resides in Mamatid, Cabuyao Laguna. His wife died four years ago and now, he’s living with his 3 children. He earned his income being a tricycle driver. Mr. R.B was admitted to the hospital last June 29, 2010 because he experienced difficulty of breathing and was diagnosed of having COPD under the management of Dr. Cuadra

HISTORY

NURSING HISTORY

Sources of History- Mr. R.B. - daughter of Mr. R.B. (unfortunately she only

knows a few about her father’s illness and medications).

Reasons for Seeking Care A few hours prior to admission, the patient

experienced dyspnea accompanied with a productive cough.

Present Health or History of Present illnessThree days prior to admission (June 25, 2010),

Mr. R.B has been having an on and off productive cough. Then a few hours before he was admitted (June 28, 2010), he suffered from difficulty of breathing that is why his relatives rushed him at the ER of Calamba Doctors’ Hospital and admitted to our institution. Patient manifested productive cough greenish in color, with nasal canula connected to oxygen tank at 2-3 liter per minute as ordered.

His initial vital signs were:

BP = 160/100 mmHgRR = 36 cpmPR = 138 bpmTemp = 36.5 C

Diagnostic exams included Chest X-ray, CBC, BUN, NA, K, Urinalysis, ABG.

Past Health HistoryPatient was known to be asthmatic since

childhood. His usual attacks are precipitated by dust or smoke inhalation. He has maintenance medication of Ventolin.

During his teenage years, He worked as a farmer and was exposed to fertilizers and other different chemicals used for the crops. According to him, he often sweats himself in the field and doesn’t bother to change his clothes which he concluded as the source of his Pneumonia. No accidents or injuries are noted.

At 20 years old, he worked as a Construction worker. He also worked in a Textile factory and worked as a tricycle driver. During those days, he was diagnosed with PTB. He had suffered dyspnea and had hemoptysis. According to him, he had his shots of Streptomycin in their health center.

Nebulization was done for about 3 times but offered no relief of the said condition

Last year, he suffered from difficulty of breathing and he was admitted in Calamba Medical Center with a diagnosis of COPD

At year 2010 of January, patient seeks consultation and was then admitted in Calamba Doctors Hospital and diagnosed him COPD. Complaining of DOB accompanied by greenish phlegm. Patient also started to complain of easy fatigability. Patient was also unable to sleep at night associated with wheezes, chest pain.

Patient History at the ICUPatient sensorium is unpredictable and the

GCS is only 9 then the next day is 15. After several minutes the patient was intubated, size of ET tube is 7.5 lip level is 21, and continuous ambubagging was done prior the patient was connected to mechanical ventilator with the setting of FIO2 100%, TV -450 RR is 22, he has Nasogastric tube

and after several minutes Foley Catheter is inserted connected to urine bag with a minimal Urine Output, on Physical Restrains. Patient is full pulses 94 beats per minute, pulse oximeter O2 Saturation 98%. After 9 days, patient was extubated and placed O2 face mask at 10LPM as ordered and the next day he was transferred to medical ward with same medications and with nasal canula connected to oxygen tank at 5-6LPM and with Indwelling Foley Catheter.

Family HistoryHe is not Hypertensive and Diabetic but his brother is only

known for this disease.

Psychosocial HistoryThe patient is a widow and has 3 children. His neighbors are

friendly and helpful. He is a high school graduate and work as a Tricycle driver. He is a not an alcohol drinker and only an occasional smoker.

Whenever the patient has problems, he is usually supported by his children and relatives. Everytime he gets hospitalized when he is having an asthma attack, his family is worried about what might happen to him and also with the expenses that they will have. Work and money was considered as primary stressor and his ways of coping are laughing and spending time with peers.

PHYSICAL ASSESSMENT

PHYSICAL ASSESSMENT

IntegumentaryMr. RB’s skin is cold when touched, cyanotic,

has no edema, no signs of dehydration, scar on the left foot. Nail convex curvature, smooth in texture, capillary refill is not normal. Hair is dark brown with some gray in color, shiny and equally distributed.

Head and NeckSkull is rounded, smooth contour, absence of nodules or masses. Facial gestures are symmetric. Has sunken eyeballs. Eyebrows are symmetrically aligned.

Eyelashes are equally distributed and curled slightly outward. Eyelids has no discharge, discoloration, closes symmetrically. There is no visible sclera above corneas, sclera appears white, the conjunctiva is pink in color, and both eyes are coordinated. Ears color are same with the facial skin, the auricle is aligned with other canthus of the eye, they are firm and not tender. His hearing is tested by asking questions and he response to his normal voice. The external nose are symmetric and straight there are no discharge, and has flaring, uniform in color, not tender and there are no lesions.

Air movement is restricted in both nares and he has nasal canula. His lips are dry, slightly pink in color. Teeth are incomplete, tongue is pink in color, slightly rough, there is no lesions, no tenderness and it moves freely. Muscles neck are equal in size, head centered with smooth movements with no discomfort.

Thorax/ Lungs/ Heart- thorax is barrel, it is decreased in vibratory sensation, asymmetric thoracic expansion and he has abnormal breathing pattern, his respiratory rate is 32 breaths per minute and his lips are pursed.

His left lung has dubbing sounds when it is auscultated and palpated. He has persistent cough which is productive; green in color. Heart rate is 105 beats per minute and irregular.

Abdomen- abdomen is soft, free of tenderness, no pain on light palpation.

Peripheral Vascular- pulses equal in both arms, pulses equal in both legs. No edema present.

Musculoskeletal- normal spinal curves. No joint deformities, tenderness, full active range of motion in all joints. Muscle strength equal bilaterally, there are no contractures, tremors.

Neurologic- facial expressions appropriate. Speech is not clear, he has husky voice. He has muscle strength to hold and grasp things. He is non alcoholic, feels pain on his head part.

NURSING ASSESSMENT

14 Fundamental Needs

Nursing Assessment (14 fundamental needs)

Breathe normallyDuring admission, his RR=20 and his chief complain is DOB.ICU Days, he is intubation

because of DOB and the result of pulse oximetry is 38- 40%.

Post ICU, he is negative in DOB but there is still oxygen

• Eat and Drink adequatelyhis usual eating pattern is 5 meals aday with meriendas.“magana naman akong kumain” as stated• Eliminate body waste Before hospitalization, his usual BM is every

morning.now, when he is in the hospital he did not bowel for 3 days.

• “hndi pa ako dumudumi ilang araw na” as stated.

On July 2,there is an insertion of foley cathether because of uncontrolled urination.he had bladder training on July 8 and because there’s an urge of urination it was removed on July 9 early AM.his urinary frequency in now normal.

Move and Maintain desirable postureHe works as a tricycle driver and did not usually

participate in activities like exercise because he has asthma.

“ madali ako hapuin”- as stated.Sleep and Rest

ICU days, he has difficulty of sleeping and resting because of severe productive cough. But after intubation, he slept and rest well.

Select suitable clothes- dress and undressbefore hospitalization, he wears his usual comfy clothes. Now, he is wearing a standard gown for patient.

Maintain body temperaturebefore he did not change clothes even if it is wet. Now, he’s been hospitalized he wears socks and uses blanket whenever he feels cold.

Keep the body clean and well groomed and protect the integument.before he takes a bath regularly. Now, he needs assistance on going to CR. He had sponge bath every morning with the assistance of the nurse and relatives.

Avoid dangers in the environment and avoid injuring othershe doesn’t know where he got TB. And he is

aware that might infect his family.Communicate with others in expressing emotions,

needs, fears/ opinionshe is the bread winner of his family and his children’s family.ICU days, he can’t talk because of intubation. after extubation, he can talk and express feelings even though his voice is husky

Worship according to one’s faithhe is Roman Catholic and believes in God but he doesn’t always pray and goes to church.

Play or Participate in various forms of recreationhe doesn’t have vices and recreational activities. Now, he is in the hospital he watches TV, sleeps, and sometimes makes joke with his family to eliminate his boredom.

Learn, Discover or Satisfy the curiosity that leads to normal development and Health and use the available Health Facilities.

he is aware and understands his illness. He gave information about the history of his illness and he complies on therapeutic regimen but due financial problem, his family sometimes

DRUG STUDIES

DRUG NAME CLASSIFICATION & ACTION

INDICATION ADVERSE REACTION / SIDE

EFFECTS

CONTRAINDICATION

NURSING CONSIDERATION

ACETYLCYSTEINE

(fluimucil)Dosages:Inhalation solution: 10%, 20%I.V. injection: 20% solution (200mg/ml)

Miscellaneous respiratory tract drugsMucolytic that reduces the viscosity of pulmonary secretions by splitting disulfide linkages between mucoprotein molecular complexes.

- for abnormal viscid thickened mucous secretions

CNS: fever, drowsiness, gait disturbancesCV: tachycardia, hypotension, hypertension, flushing, chest tightnessGI: stomatitis, nausea, vomitingRESPI: bronchospasm, dyspnea, coughSKIN: rash, diaphoresisOTHER: chills

Contraindicated to patients with hypersensitive to drug.Use cautiously in elderly patients with severe respiratory insufficiency. Use I.V. formulation in patients with asthma or history of bronchospasm.

- drug smells strongly of sulfur. Mixing oral form with juice or cola improves its taste- drug delivered to nasogastric tube maybe diluted with water.- monitor cough type and frequency- monitor patient for bronchospasm, specially if he has asthma- facial erythema may occur within 30-60 mins. Of start of IV infusion and usually resolves without stopping infusion.

DRUG STUDIES



EFFECTS

CONTRAINDICATION


AMBROXOL (Mucosolvan)Dosage:Tablet: 75mg, 30 mg, 50mg Mucosolvan Liquid 30 mg, 60ml

MucolyticIt enhances pulmonary surfactant production and stimulates ciliary activity. These actions result in improved mucus flow and transport (mucociliary clearance). Enhancement of fluid secretion and mucociliary clearance facilitates expectoration and eases cough.

acute and chronic bronchopulmonary diseases associated with abnormal mucus secretion and impaired mucus transport.

Mild upper gastro-intestinal side effects (primarily pyrosis, dyspepsia, and occasionally nausea, vomiting) have been reported, principally following parenteral administration. Allergic reactions have occurred rarely, primarily skin rashes. There have been extremely rare case reports of severe acute anaphylactic-type reactions but their relationship to ambroxol is uncertain. Some of these patients have also shown allergic reactions to other substances.

should not be used in patients known to be hypersensitive to ambroxol or other components of the formulation.

-should be taken with food- monitor S/SX of aspiration of excess secretions and bronchospasms, if occurred notify physician- have suction apparatus immediately available.- tell the patient or family to report any difficulty clearing the airway or any other repi distress.

http://www.pharmaoffshore.com/?cPath=131

http://www.pharmaoffshore.com/?cPath=131

http://www.en.wikipedia.org/wiki/Mucociliary_Clearance

http://www.en.wikipedia.org/wiki/Mucociliary_Clearance



EFFECTS

CONTRAINDICATION


DOXOFYLLINE(ansimar) Dosage: Tab Adult 1 tab bid-tid. Syr Childn >12 yr 10 mL once-tid, <12 yr 6-9 mg/kg bid.

Antiasthmatic Bronchodilator its mechanism of action is related to the inhibition of phosphodiesterase activities, resulting in bronchodilating effects.

Bronchial asthma & pulmonary disease w/ spastic bronchial component

After xanthine administration, nausea, vomiting, epigastric pain, cephalalgia, irritability, insomnia, tachycardia, extrasystole, tachypnea and occasionally, hyperglycemia and albuminuria, may occur. If a potential oral overdose is established, the patient may present with severe arrhythmias and seizure; these symptoms could be the 1st sign of an intoxication.

Individuals who have shown hypersensitivity to Ansimar and its components. Patients with acute myocardial infarction and hypotension.Use in lactation: Doxofylline is contraindicated in nursing mothers.

-maybe taken with or without food- assess lung sounds, BP before administration and during peak of medication. Note amount, character, and color sputum produced.- monitor pulmonary function test before initiating therapy and during therapy to determine effectiveness of medication.- observe for paradoxial bronchospasm ( wheezing ). If occurred, withhold medication and notify physician.

http://www.mims.com/Page.aspx?menuid=mimssearch&searchcategory=THERAPEUTIC&searchstring=Antiasthmatic+&+COPD+Preparations&CTRY=PH

http://www.mims.com/Page.aspx?menuid=companionhome&ID=2716




INDICATION ADVERSE REACTION / SIDE EFFECTS

CONTRAINDICATION NURSING CONSIDERATION

COMBIVENT(albuterol) Dosage: Each Combivent inhaler is good for 200 "sprays" (pumps).

Antiasthmatic Bronchodilator expected to maximize the response to treatment in patients with chronic obstructive pulmonary disease (COPD) by reducing bronchospasm through two distinctly different mechanisms, anticholinergic (parasympatholytic) and sympathomimetic.

chronic obstructive pulmonary disease (COPD) on a regular aerosol bronchodilator who continue to have evidence of bronchospasm and who require a second bronchodilator.

edema, fatigue, hypertension, dizziness, nervousness, paresthesia, tremor, dysphonia, insomnia, diarrhea, dry mouth, dyspepsia, vomiting, arrhythmia, palpitation, tachycardia, arthralgia, angina, increased sputum, taste perversion, and urinary tract infection/dysuria.

COMBIVENT Inhalation Aerosol is also contraindicated in patients hypersensitive to any other components of the drug product or to atropine or its derivatives.

-do not use more than 12 inhalations in a 24-hour period. Doing so may increase the risk of serious side effects.- Extreme heat can cause the medicine canister to burst. Do not store your inhaler in your car on hot days. Do not throw an empty canister into open flame.- Exhale deeply through your mouth, then close your lips around the mouthpiece. Keep your eyes closed to protect them against an accidental spray. Inhale slowly through the mouth, and at the same time press down once on the canister's base. Hold your breath for 10 seconds, then remove the mouthpiece from your lips and exhale slowly. Wait 2 minutes, shake the canister again, and repeat.

http://www.rxlist.com/script/main/art.asp?articlekey=3192








EFFECTS

CONTRAINDICATION


HYDROCORTISONE SODIUM SUCCINATE(solu-cortef)Dosage:Injection: 100mg vial, 250mg vial, 500mg vial, 1,000mg vial

Corticosteroids Not clearly defined. Suppresses immune response, stimulates bone marrow and influences protein, fat and carbohydrate metabolism

- severe inflammation- shock- treatment for ulcerative colitis

CNS: insomnia, psychotic behavior, vertigo, headache, seizuresCV: heart failure, hypertension, arrythmias, thrombophlebitis, thromboembolismGI: peptic ulceration, GI irritation, increased appetite, nausea, vomitingHEMATOLOGIC: easy bruisingSKIN: delayed wound healingMUCOSKELETAL: muscle weakness, osteoporosisMETABOLIC: hypokalemia, hyperglycemia, carbo intolerance, hypocalcemia

Contraindicated to patients hypersensitive to drugs and in those with systematic fungal infections.

-give oral dose with food when possible. Patient may need another drug for GI irritation- monitor patient’s weight, BP and electrolyte level- watch for depression or psychotic episodes especially during high dose therapy- warn patient about easy bruising- unless contraindicated, give a low sodium diet that is high in potassium and protein. Give potassium suplements


INDICATION ADVERSE REACTION /

SIDE EFFECTS

CONTRAINDICATION

NURSING CONSIDERATIO

NRANITIDINE HCL(zantac)Dosage:Injection: 25mg/mlSyrup: 15mg/mlTablets: 75mg, 150mg, 300mg

Antiulcer drugsCompetitively inhibits action of histamine on the H2 receptor sites of parietal cells decreasing gastric acid secretion.

- active duodenal and gastric ulcer- GERD- heartburn

CNS: headache, vertigo, malaiseHEPATIC: jaundiceOTHER: burning and itching at the injection site

Contraindicated to patients hypersensitive to drugs.

- assess patient for abdominal pain. Note presence of blood in emesis, stool or gastric aspirate.- drug maybe added to TPN- instruct patient to take without regard to meals because absorption isn’t affected by food- urge patient to avoid smoking because this may increase gastric acid secretion and worsen disease.



EFFECTS

CONTRAINDICATION


CEFUROXIME for injection USPDosage:I.V. administration:250mg,500mg,750mg,1 gm

Antibacterialinhibits synthesis of bacterial cell wall, causing cell death.

Lower Respiratory Tract InfectionsUrinary Tract InfectionsSkin and Skin-Structure InfectionsBone and Joint InfectionsMeningitis

Diarrhea; headache; loose stools; nausea; vomiting. Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); bloody stools; change in the amount of urine; dark urine; easy bruising or bleeding; fatigue; fever; seizures; severe diarrhea; stomach cramps/pain; vaginal irritation or discharge

Cefuroxime for Injection USP and Dextrose Injection USP is contraindicated in patients with known allergy to the cephalosporin group of antibiotics.

- Determine history of hypersensitivity reactions to cephalosporins, penicillins, and history of allergies, particularly to drugs, before therapy is initiated- Inspect IM and IV injection sites frequently for signs of phlebitis.- Monitor for manifestations of hypersensitivity Discontinue drug and report their appearance promptly.-Monitor I&O rates and pattern: Especially important in severely ill patients receiving high doses. Report any significant changes.- Report onset of loose stools or diarrhea.



SIDE EFFECTS

CONTRAINDICATION

NURSING CONSIDERATIO

NCEFTAZIDIME(Zeptrigen)Dosage:Powder for injection:

500 mg

1 gram

2 grams

6 grams

Antibiotic,Cephalosphorin(3rd Generation)inhibits mucopeptide synthesis in the bacterial cell wall, making it defective and osmotically unstable. The drug is usually bactericidal. It is more effective against rapidly growing organisms forming cell walls.

Lower Respiratory Tract Infections, Skin and Skin-Structure Infections , Urinary Tract Infections , Intra-abdominal Infections, Central Nervous System Infections

CNS: Headache, dizziness,lethargies,paresthesias,malaise, fatigue, vertigo, confusion, precipitation of seizures, (especially inclients withimpaired renalfunction)GI: nausea, vomiting,diarrhea, glossitis,abdominalcramps or pain,dyspepsia,anorexia,flatulence,cholestasis,pseudomembranous colitisLocal: Pain, abscess at injection site, phlebitis, inflammation at IV site

Patients withallergies topenicillins,cepahlosporins.

-Monitorprothrombintime in patientsw/ renal orhepaticimpairment, in apoor nutritionalstate or are onprolongedtherapy.- Have Vit. Kavailable in casehypoprothrombinemia occurs.- Do not mix with aminoglycosidesolutions,administer thesedrugs separately.



EFFECTS

CONTRAINDICATION


DILTIAZEM HCL(dilzem)Dosage:Tablet: 30mg, 60mg, 90mg, 120mgInjections: 5mg/ml (25mg & 50mg)

AntianginalsA calcium channel blocker that inhibits calcium ion across cardiac and smooth muscle cells, decreasing myocardial contractility and oxygen demand. Also dilates coronary arteries and arterioles.

- angina pectoris- HPN

CNS: headache, dizziness, somnolenceCV: edema, arrythmias, flushing, bradycardia, hypotension, heart failure, AV blockGI: nausea, constipation, abnormal discomfortSKIN: rash

Contraindicated to patients with hypersensitive to drug and in those with systolic blood pressure below 90mm Hg.Use cautiously in elderly patients and in those with heart failure or impaired hepatic or renal function.

- monitor blood pressure and heart rate before, when starting therapy and during dosage adjustments.- if systolic blood pressure is below 90 or heart rate is below 60 bpm, withhold dose and notify physician.- tell patient to swallow extended release capsules whole, and not to open, crush or shew them.



SIDE EFFECTS

CONTRAINDICATION

NURSING CONSIDERA

TION

NITROGLYCERIN PATCH(deponit)Dosage:Transdermal: 0.1mg/ hour, 0.2mg/hour, 0.3mg/hour, 0.4mg/hour, 0.6mg/hour, 0.8mg/hour

AntianginalsReduces cardiac oxygen demand by decreasing left ventricular end- diastolic pressure (preload) and to a lesser extent, systemic vascular resistance (afterload). Also increases blood flow through coronary vessels.

- to prevent chronic anginal attack- acute angina pectoris- HPN

CNS: headache, dizziness, weaknessCV: orthostatic hypotension, tachycardia, flushing, palpitation, faintingGI: nausea, vomitingSKIN: rash

Contraindicated to patients with early MI orthostatic hypotension, allergy to adhesives.Use cautiously to patients with hypotension.

- closely monitor VS particulary the BP- apply to a non hairy part of the skin except distal part of the arms and legs.- remove patch before defibrillation.



SIDE EFFECTS

CONTRAINDICATION

NURSING CONSIDERATI

ON

AZITHROMYCIN

(zithromax)DosagesPowder for oral suspension: 100mg/5ml, 200mg/5mlTablets: 250mg, 500mg, 600 mg

Anti – infectivesBinds to the 50S subunit of bacterial ribosomes, blocking protein synthesis; bacteriostatic or bactericidal, depending on concentration.

- acute bacterial worsening of COPD- community acquired pneumonia- patients with advanced HIV infections

CNS: dizziness, vertigo, headache, fatigue, somnolenceCV: chest pain, palpitationGI: nausea, vomiting, diarrhea, abdominal pain,, flatulenceSKIN: photosensitivity, rash

Contraindicated to patients with hypersensitivity to erythromycin. Use cautiously in patients with impaired hepatic function.

- give meds 1 hour before or 2 hours after meals- do not give with antacids- monitor patients with super infections. Drug may cause overgrowth of no susceptible bacteria or fungi.- advise patient to avoid excessive sunlight and to wear protective clothing and use sunscreen when outside.



EFFECTS

CONTRAINDICATION


DIAZEPAM(valium)Dosage:Capsules: 15mgInjection: 5mg/mlTablets: 2mg, 5mg, 10mgOral solution: 5mg/5ml, 5mg/ml

AnxiolyticsA benzodiazepine that depresses the CNS, and suppresses the spread of seizure activity.

- anxiety- acute alcohol withdrawal- muscle spasm- preop sedation- severe recurrent seizure

CNS: drowsiness, slurred speech, fatigue, headache, insomnia, hallucinationsCV: hypotension, bradycardiaGI: nausea, constipation, diarrheaURINARY: retention and incontinenceHEPATIC: jaundiceRESPIRATORY: respi depression, apneaSKIN: rashOTHERS: altered libido, physical or psychological dependence

Contraindicated to patients hypersensitive to drugs and patients experiencing shock, coma or acute alcohol intoxication .

- inject deeply into a large muscle. - if patient takes other CNS drugs observed for over sedation- warn patient to avoid hazardous activities that require alertness and good coordination until effects of drug are known. - advise patient to use sugarless hard candy or gum to relieve dry mouth.

PATHOPHYSIOLOGY

NURSING CARE PLAN

NURSING CARE PLANAssessment Diagnosis Planning Intervention Rationale EvaluationObjectives:-Positive wheezes sound in both lungs-Positive productive cough-Positive sputum, greenish in color-RR 39 -With et tube connected to ventilator

Ineffective airway clearance related to secretions in the bronchi

After a week, the client will maintain airway patency

•Give expectorant or bronchodilators as ordered.

• Administer oxygen as ordered

• Suction prn

• Position client to optimize respiration (head of bed elevated 45 degree)

• For immediate recovery, broncho airway resistance secondary to bronchoconstriction• Oxygen has been shown to correct hypoxemia, which can be caused by retained respiratory secretions• To clear airway when secretions are blocking airway

• Upright position allows for maximal air exchange and lung expansion. And also will be easy to expectorate the sputum

Client still have productive cough but he can already expectorate it

Assessment Diagnosis Planning Intervention Rationale Evaluation

•Performed back tapping

• Chest Physical Therapy help mobilizes bronchial secretions


Objective:

Loss of weightFrom 70 kgs – 55 kgs)Less of muscle massPoor muscle toneAltered taste sensationAversion to eating

Nutritional imbalanced less than body requirements

The patient will display progressive weight gain toward goal as appropriate at least half kilo per week.

•Evaluated weight and body size •Provide good oral hygiene • Auscultated bowel sounds

•Provide frequent small feeding

•To have primary basis, because copd patient habitually eat poorly

•Enhance appetite

•Hypo active sounds may reflect decrease gastric motility and constipation

• Helps reduce fatigue during mealtime and provide opportunity to increase total caloric intake or decrease desire to vomit

Client has increased appetite


•Encourage patient to avoid drinking carbonated beverage

• Encourage patient to avoid very hot and very cold foods • Encourage to eat nutritious foods

•Can produce abdominal distention or increase dyspnea

• Extreme in temperature can precipitate or aggravate cough system

• To meet the total weight gain needs

Assessment Diagnosis Planning Intervention •Rationale Evaluation

Objective:(+) DOBRR= 36(+) productive cough with green in color sputum secretionContraction of abdominal muscles during inspirationRestlessnessWith pulse oximeterWith mechanical ventilatorABG’s result Ph= 7.285 (+) decreased Pco2= 93.4 (+) increasedPco2= 63 (+) decreasedHco3= 43.9 (+)increased

Impaired gas exchange related to alveolar capillary membrane changes (COPD)

Client will be able to demonstrate improved ventilation and adequate oxygenation of tissues by ABG’s within client’s normal limits and absence of symptom of respiratory distress after

• Elevate head of bed or position the client approximately (Moderate High back Rest) provide airway adjuncys and suction as indicated• Auscultate chest and check for breath sounds

• Performed back tapping after the nebulization

• Assesslevel of consciousness and mentation changes

• Evaluate pulse oximetry to determine oxygenation• Suction PRN as ordered

• Correct positioning will maintain airway patency and promote drainage secretions

• To identify the presence of secretions

• To easily remove the secretion

• To know if the patient can response to the motor, eye opening and verbal• To assess respiratory insufficiency

•To clear airway when secretions are blocking airway

Assessment Diagnosis Planning Intervention •Rationale Evaluation

Objective:• dyspneic•Restlessness•Increased use of accessory muscle• uncooperative• with ET tube connected to ventilator machine• unstable cardiac rate• pursed lip breathing• wheezes• lethargic• increased RR(39 bpms)•

Impaired Spontaneous Ventilation related to problem with secretion management

After the nursing intervention, the client will:

• maintain effective pattern via ventilator with absence of retractions or use of accessory muscles within acceptable range.

• Assessed spontaneous respiratory pattern, noting rate, depth, rhythm, symmetry of chest movement and use of accessory muscles

• Administered sedative drugs as required

• Verified clients respirations are in phase with the ventilator

• to measure the work of breathing

• to synchronize respirations and reduce work of breathing(to relax the patient prior to intubation as order)

• to decrease work of breathing maximizes Oxygen delivery

the client maintain effectiveness respiratory pattern via ventilator


• Checked cuff inflation at time whenever cuff is deflated or reinflated.

• Checked tubing for obstruction

• Suctioning provided

• Noted inspired humidity and temperature, maintain hydration

• to prevent risk associated with under or over inflation

• to prevent risk associated with under or over inflation

• to clear the secretion

• to liquefy secretions facilitating removal


• Noted changes in chest symmetry

• Elevated the head part of the bed in 45 degree

• may indicate improper placement of ET tube

• to facilitate oxygen


Subjective data: “Natatakot ako sa kung anu man ang pwedeng mangyari sa akin” as stated. Objective data: Poor eye contactTearfulnessElevated Blood pressure 150/100RestlessnessWith body weaknessSlightly irritablePale

Anxiety R/T changes in health status

Will appear relaxed and report anxiety is reduced to a manageable level

•Encourage client to acknowledge and to express feelings of sadness, fear or anger. •Be available to client for listening and talking. •Provide accurate information about the situation.

•To ease anxiety

•To establish therapeutic relationship/ communication

•Helps client to identify what is reality based


•Provide quiet and calm environment. •Encourage SO not to leave the patient alone. •Use comfort measures. ( Clean linen,siderails) •Encourage to use diversional activities.

•To be able the pt. to relax and relieve anxiety.

•In order for pt. to have someone if he needs a should to lean on

•In order for patient to relax and be comfortable.

•To divert anxiety.


Objective:•Weak in appearance.•Inability to ingest food safely.•Inability to chew or swallow food.•Inability to used bathroom.•With foley catheter.•With diaper•(+) pain•Uncooperative

Self Care Deficit related to weakness

After nursing intervention, the client will be able to:Perform self-care activities within level of own ability

•Plan time for listening to the client feelings and concern •Identify energy saving behavior •Implement bowel or bladder training as indicated •Assist with necessary adaptations to accomplish ADL’s, begin with familiar

•Help client into sitting position

•To discover barriers to participation in regimen and to work on problem solution

•To avoid fatigue • adaptive devices promote independence and safety •To encouraged client and build on

• Gravity assist with swallowing and spiration with decreased when sitting upright

Client now perform easy activity of daily living but still with supervision

Intervention rationale

• Advise S.O. to prepare small portion of favorite foods that acoording to clients diet

• advise S.O. to provide finger foods

•Functional feeding can be improved by altering physical context of the meal to appeal to the client

• finger foods can be nutritious as well as allowing independence and the choice of what and when to eat

LABORATORY

COMPLETE BLOOD COUNT and PLATELET COUNT

PARAMETER RESULTS UNITS NORMAL VALUESHemoglobin 16.30 g/L (13-17)Hematocrit 0.50 (0.4-0.5)

Red Cell Count 5.47 (4.5-5.5)White Cell Count 8.40 10^9/L (5-10)

Neuthophils 0.920 (0.55-0.65)Lymphocytes 0.80 (0.25-0.35)Eosinophils 0 (0.02-0.04)Basophils 0 (0-0.05)Platelet 266.00 10^9/L (140-340)

MCV 90.90 fL (86-100)MCH 29.80 Pg (26-31)

MCHC 32.80 g/dL (31-37)

JUNE 29, 2010

BLOOD CHEMISTRY

TEST NAME RESULT UNITS REFERENCE VALUES.

Blood Urea Nitrogen

12 mg/dL 9-20

Creatinine 0.8 mg/dL 0.66-1.25Sodium 133 mmol/L 137-145

Potassium 4.7 mmol/L 3.5-5.1

JUNE 28, 2010

URINALYSISMACROSCOPIC

Color YellowTransparency Clear

Reaction 5.5Specific Gravity 1.020

Albumin NegativeSugar Negative

MICROSCOPICWBC 2.5RBC None seen

Bacteria Moderate E.cells Rare

Amorphous Urates Mucuos Treads Few

CastCrystals

JUNE 29, 2010

X-RAY REPORT

EXAMINATION: CXR-PA6/28/10

FINDINGS:There are fibrotic and coarse reticular

densities in both upper lodes, consistent with fibroexudate and atelectatic PTB. Pleura- parenchymal adhensions seen in both lung bases. The heart and the rest of the visualized chest structures are unremarkable.

RESULT NORMAL VALUESPh 7.285 7.35-7.45

PC02 93.4 35-45 mmHgP02 63 80-100 mmHg

HC03 43.9 22-28 meq/lBE 17 (+-)2

02 sat 85 80-100%Temp. 37.8FI02 32%RR 28bpmsite RBA

ARTERIAL BLOOD GASES(JUNE 29, 2010)


PC02 96.7 35-45 mmHgP02 54 80-100 mmHg

HC03 51.3 22-28 meq/lBE 25 (+-)2

02 sat 83 80-100%Temp. 36.2FI02 44%RRsite RBA

ARTERIAL BLOOD GASES(JULY 1, 2010)


PC02 79.7 35-45 mmHgP02 57 80-100 mmHg

HC03 40.4 22-28 meq/lBE -14 (+-)2

02 sat 85% 80-100%Temp. 36.8FI02 70% MVRR 22site LBA

ARTERIAL BLOOD GASES(JULY 2, 2010)

JOURNAL

JOURNAL

According to a new study, published in the American Journal of Respiratory and Critical Care Medicine (American Thoracic Society), patients with severe Chronic Obstructive Pulmonary Disease (COPD) may benefit from a new treatment that includes the use of two drugs: salmeterol and fluticasone. This new treatment may be a better alternative than the standard treatment already in use (treatment with the drug tiotropium).

The new study used a multi-center approach to test the efficacy and safety of the new 2 drug treatment as compared to the traditional used. Dr. Jadwiga Wedzicha, from the Royal Free & University College Medical School in London, led the study.

Researchers were able to enrol more than 1300 patients with severe COPD and divided them in two groups (randomly).One of the group received the standard treatment with tiotropium and the other group received the new treatment. The treatment lasted for 2 years. During this time patients enrolled in both groups were closely followed as to evaluate the efficacy of the new treatment as compared to the old one.

They looked for exacerbation (number and type). They also used a standardized questionnaire which evaluates the overall respiratory condition of the patients (St. George's Respiratory Questionnaire (SGRQ), the lung function and how long people remained in the study.

A Healthy Diet as a Remedy for COPD:

A plant-based diet, like the one Dr. Joel Furhman recommends, is instrumental in helping COPD sufferers recover. The plant-based diet rids the body of foods that create mucus, like milk and cheese. The diet promotes the consumption of organic fruits and vegetables. Many natural hygienists also recommend avoiding animal products, including eggs. Many studies indicate that adding broccoli to the diet greatly improves the symptoms of COPD patients.

Omega-3 oils are also beneficial to COPD patients. Omega-3 oils are found in fish oil supplements and in foods like fish, flax seeds and walnuts. "Fatty" fish like mackerel, lake trout, herring, sardines, albacore tuna and salmon are high in omega-3 fatty acids. Natural remedies and a strict diet can improve COPD symptoms.

7 Tips to Avoiding Shortness of Breath When EatingWhile shortness of breath may be your constant

companion if you have COPD, experiencing it while eating can be very frustrating. It can also lead to malnutrition, a common complication of COPD.

If you are finding it difficult to complete a meal, try these 7 tips to help you manage shortness of breath during mealtimes:

1. Clear Your Airways before EatingBefore you eat, make sure you attempt to clear your airways of mucus. This will help you breathe better while eating.

2. Eat and Chew Your Food SlowlyTake small bites and chew your food slowly. Be sure to breathe while you are eating. Put your utensils down between bites to ensure that you eat slower. This will help you retain energy, making it easier to breathe.

3. Eat Foods That Are Easy To ChewEating foods that are easy to chew will help you conserve energy so you have more for breathing.

4. Eat Smaller, More Frequent MealsInstead of eating 3 larger meals, try eating 6 smaller meals. This will keep your stomach from feeling too full and make it easier to breathe.

5. Save Beverages Until After Your EatWhen you drink liquids during your meals, you may have a tendency to fill up quicker causing you to feel full or bloated. This can cause difficulty breathing. Try waiting until the end of your meal to drink your beverages. But, of course, if you need to, sip water while you eat to make the food go down easier.

6. Eat While Sitting UprightLying down or slumping while eating can cause pressure on your diaphragm. Sitting in an upright position while eating can help reduce pressure and allow you to breathe better.

7. Use Pursed-Lip BreathingWhile eating, if it becomes difficult to breathe, try using pursed-lip breathing until you catch your breath.

Supplements for the Treatment of COPD:

1. Vitamin C and Magnesium - Research conducted at the University of Maryland revealed that Vitamin C and Magnesium aid in the treatment of COPD. People with COPD often have low levels of magnesium due to poor nutrition. Magnesium promotes healthy lung function, thereby making it vital for COPD patients.

2. Carnitine - Research has also revealed that supplements like Carnitine is beneficial for COPD patients, who experienced improved breathing and fewer COPD symptoms.

Herbal Treatments for COPD:

1. Olive leaf - Olive leaf is one herb that eases symptoms of COPD. Olive leaf reduces inflammation and aids in the treatment of COPD-related infection. Olive leaf is a natural antibiotic with anti-inflammatory, anti-viral and anti-bacterial properties.

2. Serrapeptase - Research suggests that Serrapeptase is also helpful. There are many success stories using this miracle natural enzyme. According to Robert Redfern ."Serrapeptase is a naturally occurring, physiological agent with no inhibitory effects on prostaglandins and is devoid of gastrointestinal side effects."

3. Cayenne - Cayenne is used because it has the ability to increase circulation and improve breathing. A recipe for blood clearance: 1 cup of water, 1/4 teaspoon of cayenne, 1 tablespoon of apple vinegar and 2 teaspoons of honey. Drink this slowly throughout the day.

4. Other herbs that help ease COPD symptoms include astragalus, enchinacea, ginseng, quercetin, thyme, milk thistle, eucalyptus and lobelia.

REFLECTION

Our group was able to handle the case of Mr. R.B when we were assigned at Calamba Doctors’ Hospital for our Related Learning Experience last July 1 2010. After we were given consent by his family, we decided to take Mr. R.B’s case as a subject for study in order to expand our knowledge regarding his disease and be able to collect additional data that we seem necessary for us to progress in our quest to become effective nurses in the future.

THANK YOU SO MUCH!!

GROUP 7RLE

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