Patient profile:

Name of the patient: Mr.Shivan

Age

Sex

Religion

Marital
status

73years

Male

Hindu

Married

Educational
qualificatio
n
5th standard

Occupation

Teacher

Date and
time of
admission
15/03/2015

Diagnosis:

Chronic Obstructive Pulmonary Disease

History of present illness:

Chief complaints on admission:

breathlessness 2 days
cough 1 week
fever 3 days

Mr.Shivan came to the hospital with above complaints on 15/03/2015 at 10pm. On admission he
was conscious and oriented. PR- 62/mt, BP-100/80mm hg, respiratory rate 30/mt, SPO288%with out O2. He was seen by medicine on call department doctors. After doing primary
assessment, they advised for blood investigation and chest Xray.
On blood investigations his values were creatinine -0.4, potassium -4.9, and SWBC -15500,
ESR- 104.
He is conscious and oriented. Taking food orally. Sputum sent for culture and AFB staining. He
is getting the medications such as levofloxacin, fluconazole, pantium, lasix, ecospirin, amlodac,
aten, stator, cefotum, folic acid, and calcium gluconate. He has breathlessness, cough, anorexia.
History of past illness and hospitalization:
He is a known case of Chronic Obstructive Pulmonary disease since 1 year. And was on seroflo
inhaler SOS.
Surgical history:
There is no present surgical history.
Family history
Sl

Name

Age/se

Relation

Education Occupation

Health

no.
1
Shivan
2
Rama
3
Reeja
4
Shamon
Family tree

x
73/M
68/F
35/M
30/F

Patient
Wife
Daughter
Son

UP
UP
SSLC
degree

Personal history
Habit of smoking since 20 years, 2 packets per day
Nutritioinal history

Mixed diet pattern

No food or drug allergies

Social, economical and developmental history

Middle class family

He and his son are the breadwinners of the family

Physical examination:
General examination
Nourishment: moderately nourished
Health: healthy
Body built: moderate
Grooming and hygiene: adequate
Activity: dull
Look: anxious
Posture: erect
Gait: steady
Body odor: nil
Mental status
Consciousness: conscious

Farmer
House wife
Sales girl
Student

status
Patient
HTN
Healthy
Healthy

Orientation: oriented
Speech: normal
Memory: intact
Attitude: good
Mood and affect: appropriate
Vital signs
Temperature: 98.6*F
Pulse: 74/mt
Respiration: 30/mt
Blood pressure: 130/80 mm Hg
Skin
Colour: dark, no signs of cyanosis
Texture: normal
Skin turgour: normal
Skin temperature: cold, sweating
Discolouration: nil
Lesions: nil
Subjective symptoms: breathlessness and productive cough
Head
Skull
Size, shape and symmetry: normocephalic
Palpate the skull: normal
Trauma, mass, nodules: nil
Scalp and hair
Colour: black and white hairs
Texture: normal
Distribution and thickness: normal hair distribution
Subjective symptoms: nil
Infections and infestations: nil
Face
Inspection: normal
Distribution of hair: symmetric
Cranial nerve assessment (5th & 7th): intact
Temporal pulse: palpable
Eyes
Eyebrows: symmetrical
Eyelashes: equally distributed
Eyelids: normal
Conjunctiva: pallor
Cornea (corneal reflex 5th CN): intact
Papillary reaction (3rd CN) and accommodation: 2+ on both eyes

Pupil (size, shape): round

visual acuity and visual field (2ndCN): normal
(3rd, 4th, 6th CN):normal
Ear
Auricle/pinna: symmetrical
External ear canal: normal
Gross hearing test:
Hearing tone (8thCN): normal
Tuning fork test (Rinnes and Webbers test): normal
Nose and Sinuses
External nose: symmetrical, nasal flaring on respiration present
Patency of nasal cavity: patent
Nasal cavity/ septum: no deviated nasal septum
Smell(1st CN): normal
Frontal and maxillary sinuses: nontender
Mouth and oropharynx
Lips: normal
Teeth and gums: dental carries present, black stain on teeth
Tongue and floor of the mouth (12th CN): normal
Taste: normal
Palates and uvula (5th and 10th CN): normal
Oropharynx/ tonsils: normal
Gag reflex (9th and 10th CN): normal
Voice: normal
Neck
Neck muscles: equal size and shape
Range of motion: all movements possible
Muscle strength: equal
Lymph nodes: not palpable
Trachea: not deviated
Thyroid gland: not enlarged
Upper extrimities
Skin: dark colour
Nails: normal,grade I clubbing present, good capillary refill
Muscle size, tone: normal
Muscle strength: grade 5
Joint range of motion: possible
Brachial and radial pulse: palpable
Deep tendon reflex: normal
Sensation: normal
Coordination test: normal

Thorax and back

Posterior thorax
Inspection
Shape, symmetry: barrel chest
Spinal alignment: vertical
Palpation
Posterior chest: normal
Respiaratory excursion: symmetric
Fremitus: bilaterally symmetrical
Percussion
Resonant sounds
Auscultation
Breath sounds: bilateral rhonchi present
Anterior thorax
Inspection
Breathing pattern: rhythmic effortful respiration, supraclavicular hallowing
present
Sternum and ribs: retraction of intercostals space present
Palpation
Posterior chest: normal
Respiaratory excursion: symmetric
Fremitus: bilaterally symmetrical
Percussion
Resonant sounds
Auscultation
Breath sounds: rhonchi bilaterally
Heart
Inspection: no abnormal pulsation
Palpation: normal
Heart sounds: S1 S2 heard, no murmers
Carotid arteries: palpable pulsation, no abnormal sounds heard on auscultation
Jugular veins: not distended
Subjective symptoms: nil
Breast and axilla
Breast: symmetrical
Areola, nipple: normal
Axillary nodes: not palpable
Abdmen
Inspection
Skin, contour, symmetry: uniform colour, symmetric
Abdominal girth: 90cm

Auscultation: bowel sounds present

Percussion: tympanic sound, no signs of ascites
Palpation: normal
Lower extrimities
Skin: dark, no edema, normal
Toe nails: good capillary refill
Muscle size, tone: normal
Muscle strength: grade 5
Joint range motion: ROM possible
Plopliteal, posterior tibial pulse: palpable
Dorsalis pedis pulse: palpable
Deep tendon reflex: present
Plantar reflex: present
Sensation: normal
Coordination test: normal
Deformity: nil
Genitor urinary
Lesions/ scar: nil
Discharge/ infection: nil
Voiding: on CBD
Colour of urine: normal
Rectum and anus
Perianal skin integrity: intact
Bowel elimination pattern: constipated
Subjective symptoms: anorexia since 5days
Mass: nil
Respiratory system assessment
Day-1
General examination

Dyspnoea
cough
Grade I clubbing of fingers

Upper respiratory tract

Nasal flaring present

No tenderness over para nasal sinuses
No throat infection

Chest

Inspection
o No deviation of trachea(negative trails sign)
o Shape- barrel chest
o No drooping of shoulders
o Supra clavicular hallowing present
o No kyphosis or lordosois and scoliosis
o No swelling, visible veins and scars
o Respiratory rate- 34/mt
o Abdomino thoracic respiration
o Increased movement of chest
Palpation
o Position of trachea- normal
o Position of apex beat: 5th intercostals space 1.5cm medial to midclavicular line
o Increased chest movements on respiration
o Normal tactile fremitus
Percussion
o Anterior chest
Supraclavicular
Infra clavicular
Mammary
Inframammary
resonant
Axillary
Infra axillary
o Posterior chest
Supra scapular
Infrascapular
resonant
Inter scapular
Scapular
Auscultation
o Broncho vesicular sound heard
o Bilateral rhonchi
o Vocal resonance: normal

Day-2
General examination

Dyspnoea
coughing
Grade I clubbing of fingers

Upper respiratory tract

Nasal flaring present

Chest

Inspection
o Shape- barrel chest
o Supra clavicular hallowing present
o Respiratory rate- 28/mt
o Abdomino thoracic respiration
Palpation
o Position of trachea- normal
o Position of apex beat: 5th intercostals space 1.5cm medial to midclavicular line
o Normal tactile fremitus
Percussion
o Anterior chest
Supraclavicular
Infra clavicular
Mammary
Inframammary
resonant
Axillary
Infra axillary
o Posterior chest
Supra scapular
Infrascapular
resonant
Inter scapular
Scapular
Auscultation
o Broncho vesicular sound heard
o Bilateral rhonchi
o Vocal resonance: normal

Day-3
General examination

Grade I clubbing of fingers

Upper respiratory tract

Deviated nasal septum

Chest

Inspection
o Shape- barrel chest

o Respiratory rate- 24/mt

o Abdomino thoracic respiration
Palpation
o Position of trachea- normal
o Position of apex beat: 5th intercostals space 1.5cm medial to midclavicular line
o Normal tactile fremitus
Percussion
o Anterior chest
Supraclavicular
Infra clavicular
Mammary
Inframammary
resonant
Axillary
Infra axillary
o Posterior chest
Supra scapular
Infrascapular
resonant
Inter scapular
Scapular
Auscultation
o Broncho vesicular sound heard
o Bilateral rhonchi
o Vocal resonance: normal

Investigations
SL INVESTIGAT NORMAL VALUE
N
ION
O
13-16
Haemoglobin(
gm%
WBC
4500-11000
3)
(count/mm
Neutrophils
(%)
Lymphocytes
(%)
Monocytes (%)
ESR
0-20
Platelets
250000-450000
3)
(/mm

16/03/
15/03/15 15

17/03/15

14

13.6

10000
66
13
8
108
328000

Sodium mEq/L

130-145

140

138

138

Potassium
mEq/L
Creatinine
mg/dl

3.5-5.0

5.

4.6

4.4

0.5-1.4

0.8

0.6

0.6

Blood urea

<40 mg/dl

196

200

Chest X-ray(16/03/15)

Pulmonary calcification in the upper zone bilaterally

Subtle ill defined pulmonary opacities in right mid and lower zone
Bilateral pulmonary emphysema
Aortic arch calcification
Degenerative changes in vertebrae

Medications
Drug name

Dosage
and
frequen
cy

Inj.
Cefotum
plus
Inj.
Levoflox
Inj.
Fluconazol
e
Inj.
Pantium
Inj. Lasix

1.5gm
BD

Tab.
Amlodac
Tab stator
Tab. Olic

Route 15/
of
03
admini
strario
n
IV
Y

16/
03

17/
03

Mechanism of action

Antibiotic

500 mg
OD
200 mg
OD

IV

Antibiotic

IV

40mg
OD
40mg
OD
5mg
BD
10 mg
HS
5mg
OD

IV

H2 receptor antagonist

IV

Diuretic

Oral

Antihypertensive

Oral

Oral

Folic acid supplement

Duoilin
nebulizatio
n
Tab.
Metaprolol
Sodium
bicarb
infusion
Tab.
Montair
LC
Inj.
Hydrocort

Q6H

Inhalat Y
ion

Bronchodialator

Antihypertensive

25mg
Oral
OD
75ml/hr IV

1 HS

Oral

100mg
TID

IV

Anti inflammatory

Nursing care plan

Nursing diagnoses

Ineffective breathing pattern related to acute exacerbation of COPD as evidenced by low

saturation level.
Activity intolerance related to fatigue followed by effortful respiration as evidenced by
facial expression.
Insomnia related to cough during night as evidenced by fatigued face
Imbalanced nutrition less than body requirement related to less food intake as evidenced
by fatigued face
Ineffective individual coping related to hospitalization as evidenced by lack of interest in
activities
Risk for cardiac arrhythmias as evidenced by increased serum Pottassium value
Risk for infection related to low Hb value
Anxiety related to the outcome of disease comdition as evidenced by facial expression

Progress notes
Day-1

Temperature- 98.6*F

Pulse rate- 70/mt

Respiration- 30/mt
Blood pressure- 100/80mmHg
SPO2- 88% with out O2

Mr. Mathai was conscious and oriented. On oral foods and fluids. CBD onflow. Had food in
the morning. He hadnt slept well during the night due to cough. Bilateral ronchi present on
auscultation. No history for fever. Due medicines given. He was on 4L O2 via simple mask.
Saturation was 99% while in O2.
Day-2

Pulse rate-74/mt
Respiratory rate- 28/mt
Blood pressure- 120/80mmHg
Temperature- 98.6*F
SPO2- 92% without O2

He was conscious and oriented. On oral foods and fluids. Had food in the morning. Complaints
of constipation. On 4L O2 via nasal prongs. No history of fever last night. Patient slept well
during the night. Due medicines given. CBD on flow.
Day-3

Pulse rate-70/mt
Respiratory rate- 26/mt
Blood pressure- 110/80mmHg
Temperature- 98.6*F
SPO2- 95% without O2

Mr. Shivan was conscious and oriented. On oral foods and fluids. On CBD. No history of fever
last night. Patient felt well. General condition is satisfactory. He slept well during the night.
Patient was not on O2 supplementation. Saturation was 96% without O2. Due medicines given.
After consultation, doctors planned for discharge on the next day if condition is stable. Had food
in the morning.
Diet plan

Salt reduced diet

Small and frequent foods
Fiber content foods were given to the patient
Hydrated the patient adequately

Self evaluation & Conclusion

Constant monitoring is needed for the nurse to assess what are all the changes occurring during
the course of the disease and will help in monitoring the improvements.
BIBLIOGRAPHY
1. Lewis medical surgical nursing ,Elsevier publications,Page no903.
2. Brunner and Sundares ,Text book of medical surgical nursing 10th edition,Elsevier
Publications.
3. Nursing Care Plan by maryler.Jaypee publications 7th edition Page no;359.

CARE PLAN OF

MR.SHIVAN
WITH
COPD

Submitted To

Submitted By

Mrs.Sonia Abraham

Finu M Paul

Assot.Professor

1st Year MSC Nsg

MOSC CON

MOSC CON