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I. Introduction Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible. This newest definition COPD, provided by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), is a broad description that better explains this disorder and its signs and symptoms (GOLD, World Health Organization [WHO] & National Heart, Lung and Blood Institute [NHLBI], 2004). Although previous definitions have include emphysema and chronic bronchitis under the umbrella classification of COPD, this was often confusing because most patient with COPD present with over lapping signs and symptoms of these two distinct disease processes. COPD may include diseases that cause airflow obstruction (e.g., Emphysema, chronic bronchitis) or any combination of these disorders. Other diseases as cystic fibrosis, bronchiectasis, and asthma that were previously classified as types of chronic obstructive lung disease are now classified as chronic pulmonary disorders. However, asthma is now considered as a separate disorder and is classified as an abnormal airway condition characterized primarily by reversible inflammation. COPD can co-exist with asthma. Both of these diseases have the same major symptoms; however, symptoms are generally more variable in asthma than in COPD. Currently, COPD is the fourth leading cause of mortality and the 12th leading cause of disability. However, by the year 2020 it is estimated that COPD will be the third leading cause of death and the firth leading cause of disability (Sin, McAlister, Man. Et al., 2003). People with COPD commonly become symptomatic during the middle adult years, and the incidence of the disease increases with age.

II. Objectives General objective: After the case presentation, I will be able to enhance our knowledge about the case, acquire skills towards presenting the case study and develop self-confidence in reporting the case of COPD to the class. Specific objectives: After the case presentation, I will be able to: a) have broader knowledge about the COPD; b) know the epidemiology, predisposing factors, precipitating factors , signs and symptoms and pathophysiology about the said disease; c) impart my knowledge to my fellow nursing student about my case; d) expose myself on various illnesses, thus, the experience would help us to overcome our doubts and boost our confidence in handling patient with this disease; and e) present the case clearly.

III. Baseline Data Name: N.A.F. Adress: D.C. Age: 32 years old No. of dependent/s: none Birthdate: January 13, 1979 Birthplace: D.C. Gender: Male Marital status: Single Religion: Roman Catholic Educational level: College level Occupation: Restaurant helper and waiter Nationality: Filipino Person next to kin: Brother Date and time of admission: July 15, 2011 10:20pm Attending physician: Dr. C. Hospital: MDH Ward of admission: Medical Ward Chief complaint: Chest tightness and DOB Admitting Diagnosis: COPD with exacerbation Pneumonia MR Source: Patient

IV. Definition of terms Chronic Obstructive Pulmonary Disease (COPD)- COPD may include diseases that cause airflow obstruction Exacerbation- an increase in the seriousness of a disease or disorder as marked by greater intensity in the signs or symptoms of the patient being treated. Emphysema is a chronic obstructive pulmonary. The small airways to collapse during forced exhalation, as alveolar collapsibility has decreased. Chronic bronchitis- effect of lung damage and inflammation in the large airways . 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.

Breathing the process of respiration, during which air is inhaled into the lungs through the mouth or nose due to muscle contraction and then exhaled due to muscle relaxation Young adult- a person age 18-35 years old. Ventilation- an exchange of air between the lungs and the atmosphere so that oxygen can be exchange for carbon dioxide in the alveoli. Alveoli- tiny sacs of the lungs. Pneumonia- infection of terminal airways and alveoli caused by various agent and causes infection.

V. Health History Past health History N.A.F. a 32 year old male, had fever and take BioFlu 1 tab every 4 hours without prescription. Everytime he have cough he drinks glass water mixed with 10 pieces of calamansi. He had his circumcision at the age of 9. History of present illness N.A.F. a 32 year old male, has been smoking for 15 years. 2 days prior to admission, N.A.F. experienced dry cough and drinks a glass of water but still continue to smoke a pack of cigarette a day. A night prior to admission, N.A.F. experienced difficulty of breathing and chest tightness. N.A.F. was rushed to the nearest hospital via van by his brother. N.A.F. was seen and examined in the MDH Emergency room by Dr. C. Started IVF of PLRS 1 liter + 1 ampule Vit. B complex inserted as venoclysis at the right cephalic vein and regulated to KVO. Administered the following medication as ordered: Initial dose of furosemide 20 mg. IVTT, hydrocortisone 200 mg. IVTT, and salbutamol 1 nebule inhalation. Oxygen inhalation given of 2 Lpm as nasal cannula. Request for CBC with platelet count, Sodium chloride, Creatinine, Chest X-ray PA, urinalysis. ECG 12 leads done and Foley Catheter was inserted. Skin test for piperacillin + tazobactam 0.1cc at the left inner forearm. Psychosocial Profile N.A.F wakes up 5:oo in the morning, fixes his bed and put on his slippers and walk almost 1 km every day. After his morning exercise he rest for about 10 minutes and take a bath after. At breakfast, he eats 1 egg, cup of rice and a cup of coffee. Then off to his work as a waiter and helper in his brothers restaurant. He buys a pack of cigarette(20 sticks) and consume 2 sticks after breakfast. At lunch, he eats 2 slices of fish in tinolang isda with kangkong and labanos, 2 cups of rice and a glass of water. Then after meal he lights up almost 3 sticks. After work, he often goes to his friends and drink beer, approximately he consume more than half of the pack. At dinner he eats 1 slice of fish a 1 cup of rice. Approximately he consumed 9 glasses of water the whole day. Before he sleeps he light up his cigarette while watching television or talking to his family. N.A.F sleeps around 9 in the evening.

VI. Anatomy and Physiology The respiratory system consists of all the organs involved in breathing. These include the nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important things: it brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes wrong with part of the respiratory system, such as an infection like pneumonia, chronic obstructive pulmonary diseases, it makes it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide. Common respiratory symptoms include breathlessness, cough, and chest pain. The Upper Airway and Trachea When you breathe in, air enters your body through your nose or mouth. From there, it travels down your throat through the larynx (or voicebox) and into the trachea (or windpipe) before entering your lungs. All these structures act to funnel fresh air down from the outside world into your body. The upper airway is important because it must always stay open for you to be able to breathe. It also helps to moisten and warm the air before it reaches your lungs. The Lungs Structure The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen into the body, which we need for our cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We each have two lungs, a left lung and a right lung. These are divided up into lobes, or big sections of tissue separated by fissures or dividers. The right lung has three lobes but the left lung has only two, because the heart takes up some of the space in the left side of our chest. The lungs can also be divided up into even smaller portions, called

bronchopulmonary segments. These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment receives its own blood supply and air supply. How they work Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream. Traveling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide.

Blood Supply The lungs are very vascular organs, meaning they receive a very large blood supply. This is because the pulmonary arteries, which supply the lungs, come directly from the right side of your heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs so that the carbon dioxide can be blown off, and more oxygen can be absorbed into the bloodstream. The newly oxygen-rich blood then travels back through the paired pulmonary veins into the left side of your heart. From there, it is pumped all around your body to supply oxygen to cells and organs. The Work of Breathing The Pleurae The lungs are covered by smooth membranes that we call pleurae. The pleurae have two layers, a visceral layer which sticks closely to the outside surface of your lungs, and a parietal layer which lines the inside of your chest wall (ribcage). The pleurae are important because they help you breathe in and out smoothly, without any friction. They also make sure that when your ribcage expands on breathing in, your lungs expand as well to fill the extra space.

The Diaphragm and Intercostal Muscles When you breathe in (inspiration), your muscles need to work to fill your lungs with air. The diaphragm, a large, sheet-like muscle which stretches across your chest under the ribcage, does much of this work. At rest, it is shaped like a dome curving up into your chest. When you breathe in, the diaphragm contracts and flattens out, expanding the space in your chest and drawing air into your lungs. Other muscles, including the muscles between your ribs (the intercostal muscles) also help by moving your ribcage in and out. Breathing out (expiration) does not normally require your muscles to work. This is because your lungs are very elastic, and when your muscles relax at the end of inspiration your lungs simply recoil back into their resting position, pushing the air out as they go.

VII. Pathophysiology

Predisposing Factors Age: Elderly and children

Precipitating Factors Environment exposure to allergens Smoking

Bacteria, irritants other foriegn matter

Routes of entry(oral, inhalation, Intravenous)

Activation of defense mechanism (cough reflex)

Loses effectiveness of defense mechanism

Penetrate the sterile lower respiratory tract lungs. The alveoli greatly distend, diminished lung capacity. Colonization of bacteria.

Damage bronchial mucous membranes and alveolo capillary membranes: Acini and terminal bronchioles filled with infective debris and exudate.

Fever, chills, productive or dry cough, crackles

If treated y Antibacterial Therapy completed y Bronchodilators y Mucolytics y Chest physical therapy y Adequate hydration y Oxygen inhalation

If Untreated

Difficulty of breathing y Increased respiratory rate y Cyanosis y Retraction of the chest y

Complications Recovery

VIII. Assessment I. GENERAL APPEARANCE: N.A.F is awake sitting on bed with #3 PLRS 1L+ 1 amp Vit B complex 40cc/hr at the level of 200cc at the Right Cephalic vein patent and infusing well. Oriented to date, time, place and person. Responsive to verbal and painful stimuli.

II. SKIN, HAIR, AND NAILS Skin: Skin is dry, warm to touch. Hair evenly distributed, black i color. With good skin turgor. No edema noted.. Hair: Hair is not evenly distributed, black in color. Hair is thick in texture and dry. No scalp lesions noted. No presence of lice and dandruff. No discharges identified. Negative for tenderness, lesions, and deformities on scalp. Nails: Nails shape is convex curvature. Nails are cleaned and trimmed. Nail angle is 160r. Negative for clubbing or cyanosis. Capillary refill of 1 second after blanched test. III. HEAD, FACE, AND LYMPHATIC Rounded (normocephalic and symmetric with frontal, parietal, and occipital prominences). Rough skull contour, no nodules or masses noted. With wrinkles due to dryness. Symmetrical facial expression. IV. EYES, EARS, NORSE, MOUTH Eyes: Eyebrow is black, evenly distributed, symmetrically aligned and skin intact. Eyelashes equally distributed and curled slightly outward. Lids closely symmetrically. Pale conjunctiva of the eyes noted. Sclera appears white. Palpebral conjuntiva are nshiny, smooth and pink. Cornea is transparent,shiny and smooth. Client blinks 16 times for 1 minute and voluntary blinks when the cornea is tried to touch. Iris is flat and round. Pupils is equally rounded and reactive to light and accomodation and dilated 3mm in diameter. Ears: Color same as facial skin. Ear is line with the outer corner of the eye and ears looks symmetrical. Nose: External nose symmetric, straight, and uniform in color. Nasal septum intact and in midline position. Mouth and throat:

Lips are pinkish, symmetrical and without lesions. Oral mucosa is pale. Gums are moist with one tooth below. No unusual odor noted. No sores or other lesions noted.Totalof 30 teeth. V. NECK Neck: Head centered. Trachae is in the midline. VI. CHEST, BREAST AND AXILLA Chest is brown in color and skin is intact. Chest movement is symmetric without impairment. No lesion on chest noted. Hair is evenly disrtibuted and thick in texture. VII. RESPIRATORY SYSTEM Presence of stridor upon auscultation during admission and rales during care. Chest movement is symmetric without impairment. Presence of productive cough with whitish to yellowish secretions noted. Respiration rate is 23 breaths per minute. VIII. CARDIOVASCULAR SYSTEM The carotid artery appears to have a brisk, localized pulsation. Blood Pressure is 130/80 mmHg. Cardiac Rate is 83 beats per minute. IX. Abdomen Flabby abdomen. Rash, lesions, tenderness not noted. Spleen is not felt. Bladder not palpable. No pain or tenderness in four quadrant regions. Able to have regular bowel movement. X. GENITO-URINARY SYSTEM With foley catheter attached to urobag with adequate urine output. XI. Upper and lower extremities Performs active range of motion in bpth upper and lower extrimities.

IX. Laboratory and Radiology A. Hematology July 16, 2011 Name and date of Examination WBC Hemoglobin Platelet Result Normal Values Significance of the abnormal result Indicates infection from most of bacteria, death of tissue Increased

10.1 10^9/L 16.3:0 g/L 387 x 10^9/L

5-10 Male: 14-16 g/L 150-350 x 10^9/L 20-25 %

Increased Increased level indicates bacterial infection.

Lymphocytes

45 %

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B. Urinalysis July 15, 2011 Urinalysis Result Normal Values Significance of the abnormal result

Macroscopic Amber yellow

Color

Straw Slightly hazy

Presence of bacteria

Transparency

Reaction pH

5.0

4.5-8

normal

Specific gravity

1.010

1.010-1.020

normal

Microscopic RBC/hpf 0-2 0-3 hpf Pus cells Absent May indicate infection Absent May indicate infection

Epithelial cells Few Bacteria few

occasional

May indicate infection May indicate infection

C. Chest Xray July 18,2011 Infiltrates are seen in the right lung field. IMPRESSION: Pneumonia right lung field.

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XI. Drugs 1. furosemide 20 mg. IVTT q 12h as diuretics to increase urine output. 2. hydrocortisone 100 mg. IVTT q8h as immunosuppresor to decrease inflammation and suppresses immune system. 3. salbutamol+ ipatropium 1 neb q4h as bronchodilator. 4. acetylcysteine 600 mg/tab dissolve in glass of water OD as mucolytic. This is indicated to the patient because it liquefies mucus secretions in the tracheobronchial tree. 5. pipercillin + tazobactam 2.25 gms IVTT q8h as antibiotic use to treat bacterial infection.

XII. Health Teaching and discharge planning Medications: y y Instruct the folks and patient to comply with the prescribe medications. Review information about medications to be taken at home including name, dosage, route, frequency, possible side effects and the administration in correct dosage, route and time. y Discuss the importance of continuing taking medications even signs and symptoms have decreased or subscribed. y Home medications: furosemide 40mg 1 tab OD x 5 days acetylcysteine 600 mg/tab dissolve in glass of water OD x 7 days Kalium Durule 1 tab TID x 6 doses Levofloxacin 750mg 1 tab OD x 4 days Cefpodoxime 200mg 1tab BID x 7 days Exercise: y Encourage patient to do normal activities as tolerated and avoid doing strenuous one until treatment is complete. y Continue walking as a form of exercise. Treatment: The patient to eat three regular meals a day in relaxed setting. Instruct patient to slowly quit smoking by substituting cigarette smoking into chewing gum or by omitting one stick per day until smoking is stop. Hygiene: y Advice the patient to observe proper hygiene practices. y Emphasize the importance of frequent hand washing as the universal precaution. Out patient: y Advice the patient to follow strictly the prescribed medications for the patient. y Instruct the patient to visit his doctor for follow-up check up on July 26. 2011. Diet: y y y y Small frequent feeding Instruct patient to eat non-irritating foods and avoid skipping meals. Advice to eat nutritious foods.

1. 2. 3. 4. 5.

y y

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Spiritual: y Advice folks to pray for the fast relief of the patient. Remind folks to give adequate moral support to comfort the patient

XIII. Prognosis If the patient completes the prescribed medication and follow the health teaching he weill recover faster and coughing will be minimize.