NURSING CARE PLAN

Patient name: A.B.R Age: 70 years old Sex: Male Civil Status: Married

Medical Diagnosis: COPD Emphysema in Acute Exacerbation

Attending Physician: Dr. Charles Yu

I. Chief complaint/ Other Complaints

“Difficulty of Breathing”

“Cyanotic”

II. Nursing History

History of Present Illness

Two hours prior to admission, patient has been complaining of difficulty of

breathing, wheezing and cyanosis. He was nebulized with Duavent but no relief
is obtained so he was brought to Estrella hospital somewhere in Trece. He was
given with Hydrocortisone IV and ultrasonic nebulization with one dose of
Duavent and one dose of Salbutamol. Still patient ABR is experiencing DOB and
he was cyanotic so they’ve decided to bring him to De La Salle University
Medical Center for further evaluation and management.

Past Medical History or Past Health

Patient has been diagnosed with COPD and Diabetes Mellitus Type II just
this year 2011. He was then prescribed with Ansimar 40mg once a day and
Seretide 2 puffs per day. For his DM Type II, he has a maintenance of
Glucovance 500mg. Patient didn’t undergo any operation. Patient’s family has a
history of Hypertension and Diabetes Mellitus from his father side then was
acquired by his siblings. His brother also has COPD at present. Furthermore one
of his siblings has a Cancer at present but it was not specified by the relative.
Patient doesn’t have any allergies on medications, pollens, food and other
chemicals. Also, patient is a smoker which consumes 20 stick per day and an
alcoholic drinker three times a week but stopped ten years ago.
 III. PATHOPHYSIOLOGY: CHRONIC OBSTRUCTIVE PULMONARY DISEASE
NON MODIFIABLE FACTORS: MODIFIABLE FACTORS:
• history of respiratory • smoking
function
• exposure to air
• heredity pollution and industrial
• decrease alpha1 pollutants
antitrypsin (AAT) • second hand smoke

stimulation of excess mucus destroys ciliary function loosening elastic ability of air sacs
production

cough infection

inflammation

CHRONIC BRONCHITIS
(cough of at least 3 mos. of the
year for 2 consecutive years)

progression to all airways

destruction of entire alveolus panacinar/panlobular

lung tissue damage (lower portion of the lung) emphysema

Dx: destruction of bronchioles

chest x-ray: over
EMPHYSEMA (upper lung regions)
centriacinar/centrilobular
emphysema
inflation and
flattened
diaphragm
ABG: respiratory hypoxemia Destruction o distal airway
acidosis structures, alveolar ducts, alveolar paraseptal/distal
ECG: R heart sacs emphysema
strain pattern
pulmonary
function test respiratory insufficiency
S/Sx:
*dyspnea on
exertion eventually
respiratory failure
becomes dyspnea at rest
*barrel chest
*hyperresonance
DEATH *cyanosis
*neck vein distention
*pitting peripheral edema
*V/Q mismatch
COPD (EMPHYSEMA) in Acute
Exacerbation

Chronic obstructive pulmonary disease (COPD) is one of the most common lung

diseases. It makes it difficult to breathe. There are two main forms of COPD which is

Chronic bronchitis defined by a long-term cough with mucus and Emphysema defined

by destruction of the lungs over time. Most people with COPD have a combination of

both conditions. Smoking is the leading cause of COPD. The more a person smokes,

the more likely that person will develop COPD although some people smoke for years

and never get COPD. In rare cases, nonsmokers who lack a protein called alpha-1

antitrypsin can develop emphysema. Other risk factors for COPD are exposure to

certain gases or fumes in the workplace, exposure to heavy amounts of secondhand

smoke and pollution and frequent use of cooking gas without proper ventilation.

Emphysema is enlargement of the alveoli due to the destruction of the walls

between alveoli. The destruction of the alveolar walls reduces the elasticity of the lung

overall. Loss of elasticity leads to the collapse of the bronchioles obstructing airflow out

of the alveoli. Air becomes "trapped" in the alveoli and reduces the ability of the lung to

shrink during exhalation. This trapped air takes up space and results in a reduced

amount of air that can be taken in during the next breath. As a result, less air gets to the

alveoli for the exchange of gasses. This trapped air also can compress adjacent less

damaged lung tissue, preventing it from functioning to its fullest capacity. The exchange

of carbon dioxide and oxygen between air and the blood in the capillaries takes place

across the thin walls of the alveoli. Destruction of the alveolar walls decreases the
number of capillaries available for gas exchange. This adds to the decrease in the

ability to exchange gases.

Usually, energy is only required for inhalation to inflate the lungs. The stretch of

the lungs and distension of the chest cavity springs back to rest during exhalation, a

passive process that does not require energy. However, in emphysema, inefficient

breathing occurs because extra effort and energy has to be expended to empty the

lungs of air due to the collapse of the airways. This essentially doubles the work of

breathing, since now energy is required for both inhalation and exhalation. In addition,

because of the reduced capacity to exchange gases with each breath (due to the

collapse of the bronchioles and loss of capillaries), it is necessary to breathe more

frequently.

In COPD, there is less air that comes in and out because the airways and air
sacs lose their elastic ability; the walls between the air sacs become destroyed; airways
produce mucus more than normal; and the airways and air sacs are thickened and
inflamed. Smoking is the primary risk factor for the occurrence of COPD. Other
modifiable factors included are exposure to air pollution, secondhand smoke as well as
to industrial pollutants. History of respiratory tract infections and heredity can also
potentiate an individual to develop such disorders. When exposed to the numerous
irritants and other risk factors, enlargement and hyperactivity of the mucus secreting
glands happened. An inflammatory response then would occur throughout the airways,
parenchyma and pulmonary vasculature. Chronic coughing, destroyed ciliary function
and eventual scarring of the bronchial lining results from the initial inflammation of the
bronchi. This can continue for at least 3 months of the year for 2 consecutive years and
is known as chronic bronchitis. Because of the inflammation and the body’s attempt to
repair it, narrowing of the small airways occur reducing the ciliary efficiency. Over time,
this injury and repair process scar tissue formation and may eventually lead to lung
tissue damage (emphysema).
 In emphysema, when the alveolar walls are further destroyed along with the
distal airways, this leads to permanent over distention of the air space. Air passages
then are obstructed. This disorder may also result from a breakdown in the lung’s
normal defense mechanisms (alpha1-antitrypsin) against enzymes protease and
elastase that can attack and destroy the tissues of the lungs. When there is destruction
of the entire alveolus of the lower portion of the lungs, because of AAT it is known as
panacinar/panlobular emphysema. If damage occurs in the bronchioles or upper lung
regions, it is termed as centriacinar/centrilobular emphysema and lastly, destruction of
the distal airway structures such as alveolar ducts and alveolar sacs is coined as
paraseptal/distal acinar emphysema.

Destruction of the walls between the alveoli, partial airway collapse and loss of
elastic recoil result to difficult expiration in emphysema. Increased ventilatory dead
space from the areas that do not participate in gas or blood exchange occurs as the
alveoli and septa collapse. The work of breathing is increased because there is less
functional lung tissue for exchange of gases. Pulmonary capillaries are also destructed
further decreasing oxygen perfusion and ventilation.

Individuals with emphysema may manifest clinical signs such as dyspnea on

exertion that eventually leads to dyspnea at rest, barrel chest, hyperresonance to
percussion, cyanosis, neck vein distention, pitting peripheral edema, sleep-onset
dyspnea and ventilation-perfusion mismatch. Hypoxemia may result from emphysema
which may then cause respiratory insufficiency, then respiratory failure and eventually
death.

These are some complications of COPD:

• Irregular heart beats (arrhythmias)

• Need for breathing machine and oxygen therapy
• Right-sided heart failure or cor pulmonale (heart swelling and heart
failure due to chronic lung disease)
• Pneumonia
• Pneumothorax
• Severe weight loss and malnutrition
IV. Laboratory and Diagnostic Result, Interpretation and Nursing Implication

Procedure Indication Normal Actual Nursing Responsibilities

Values Findings
05-16-11
Hematology Hemoglobin PRE:
Indicates 150 Check for the doctor’s order;
relative 127-183 g/L NORMAL identify the patient.
proportion of • Establish rapport with
RBC and the patient and to the
plasma in significant others.
blood. • Tell the pt. the
purpose and the
procedure of the
Indicates Hematocrit : 0.46 examination.
presence of 0.37-0.54 NORMAL
infection and INTRA:
dehydration • Prepare equipment
for puncture.
• Clean and dry site for
puncture using sterile
Indicates the White blood 19.1 cotton and alcohol.
presence of cells HIGH
• Collect ample
bacteria in 4.5-10 x 10
amount of blood
the body and g/L
sample.
abnormal • After extraction of
decrease in blood, press the
level puncture site with
impedes cotton.
phagocytosis
. Differential
POST:
count
• Dispose needle
properly.
• Ensure correct
Segmenters 0.90 labelling, storage and
Essential for : HIGH transportation of
phagocytosis 0.50 – 0.70 specimen to avoid
and invalid test results.
proteolysis • Explain the results of
by which the exam and
bacteria, reassure that the
cellular doctor will
debris and furthermore discuss
solid the results of the said
particles are test.
• Monitor and check
removed the site for bleeding
and Lymphocyt 0.08 and swelling.
destroyed. es LOW • Check the vital signs
0.20 – 0.40 for any danger or
complication that
Determine might have occurred.
bacterial or • Document data
viral obtained.
infections 0.02
and Monocytes : NORMAL
autoimmune 0.0 – 0.05
disorders

Determine Platelet 240

infections count : NORMAL
and 150 - 400
inflammator
y response

Measure
how many
platelets in
the blood. It
helps the
blood clot.
Identify
bleeding
disorders.
Procedure Indication Normal Actual Nursing Responsibility
Findings Findings
5-16-11 05-16-11
Blood Urea • To confirm PRE
Nitrogen bactericemia • Tell the patient that the BUN test
• To identify 2.10 - 7.10 4.90 is used to evaluate kidney
causative mmol/L function.
NORMAL • Inform the patient that he need
organism in
bactericemia not to restrict food and fluids, but
should avoid diet high in meat.
and
• Tell the patient that the test
septicemia.
requires a blood sample. Explain
who will perform the
venipuncture and when.
• Explain to the patient that he may
experience slight discomfort from
the tourniquet and needle
puncture.
• Notify the laboratory and
physician of medications the
patient is taking that may affect
test results; they may need to be
restricted.
INTRA
• Clean the venipuncture site first
with an alcohol swab and then
with a providone-iodine swab,
starting at the site and working
outward in a circular motion.
• Wait at least 1 minute for the skin
to dry.
• Perform a venipuncture and draw
10 to 20 ml of blood for an adult,
or 2 to 6 ml for a child.
• Clean the diaphragm tops of the
culture bottles with alcohol or
iodine and change the needle on
the syringe.
• If using broth, add blood to each
bottle until achieving a 1:5 or
1:10 dilution. For example, add
10 ml of blood to a 100-ml bottle.
Note that the size of the bottle
may vary depending on hospital
protocol.
• If using a special resin, add blood
to the resin in the bottles
according to facility protocol, and
invert gently to mix it.
• Draw the blood directly into
special collection processing
tube if using lysis-centrifugation
technique (Isolator).
• Document the tentative diagnosis
and current or recent
antimicrobial therapy on the
laboratory request.
• Send each sample to the
laboratory immediately.
• Collect blood cultures before
V. Medications and Treatment

1. Procedure (USN, Gavage, CPT, Surgery, etc.)

Procedure/Date Indication/Analysis Nursing

Responsibilities
(pre, intra, post)

Oxygen Therapy To deliver relatively low • Check the order of

oxygen, including
(nasal cannula) concentration of oxygen the administering
when only minimal O2 device and the liter
flow rate or the
May 16, 2011 support is required, percentage of
preventing hypoxia. oxygen.
• Prepare the
needed
equipments.
• Assess skin and
mucous membrane
color.
• Note depth of
respirations and
presence of
tachypnea,
bradypnea, or
orthopnea.
• Obtain vital signs,
especially pulse
rate and quality,
respirations.
• Prepare client and
support people.
• Assist the client
into a semi-
Fowler’s position if
possible.
• Explain that
oxygen is not
dangerous when
safety precautions
are observed.
• Explain also the
procedure, why it is
necessary and how
 the client can
cooperate.
• Discuss how the
effects of oxygen
therapy will be
used in planning
further care or
treatment.
• Perform hand
hygiene.
• Provide privacy.
• Set up the oxygen
equipment and the
humidifier.
• Turn on the oxygen
at the prescribed
rate and ensure
proper functioning.
• Apply the
appropriate oxygen
delivery device
(nasal cannula).
• Assess the client
regularly and the
oxygen saturation
to evaluate
adequate
oxygenation.
• Document the
procedure and the
flow rate.
 Brand name/ Dosage/ Indication/ Side Nursing
Generic name Frequency Contraindicati effects/Adver Responsibilities
/ Route on se Reaction
PRE:
generic name:
indication: • Check the
Adverse doctor’s order.
dosage:
ipratropium reaction: • Identify the
1 neb Management of
bromide + patient.
salbutamol sulfate reversible hives, difficulty
• Follow the 10
breathing;,
bronchospasm Rights in Drug
brand name: frequency swelling of
Administration.
associated w/ your face, lips,
: tongue, or • Assess
Duavent obstructive hypersensitivity
every 8 throat.
to salbutamol,
classification: airway
hours Side effects: tachyarrythmias,
diseases (e.g. and assess for
antiasthmatic headache, dry weight, skin
bronchial
nose, color, turgor,
asthma, nosebleeds; orientation,
or blurred reflexes and
COPD).
vision. affect.
• Tell the
contraindication: patient about the
drug and its
Patient with possible side
narrow-angle effects.
glaucoma, or INTRA:
an enlarged • Advise patient to
use minimal
prostate or doses for
bladder minimal periods
for as drug
obstruction tolerance may
occur with
prolonged use.
• Advise patient
not to exceed the
recommended
dose, adverse
reaction or loss
of effectiveness
may result.

POST:
• Advise patient to
report these side
effects of the
drug such as
headache, pain,
influenza, chest
pain; nausea.
Bronchitis,
dyspnea,
coughing,
pneumonia,
bronchospasm,
VI. Nursing Priorities

Problem no. Problem Date Identified

1 “(+) lung secretions” May 17, 2010

2 “(+) lung secretion May 17, 2010

and bronchospasm”

“low oral fluid

3 intake” May 17,2010

VIII. DISCHARGE HEALTH TEACHING PLANS

Content Strategy
1.Compliance • infection control in COPD health teaching/
a. hand hygiene education
b. flu vaccination
c. cleaning and maintenance
of respiratory equipment

• assessment of clinical
manifestations of
pulmonary infection
- change in color/volume of
sputum
- fever
- chills
- malaise
- productive cough
- confusion
- dyspnea

• determining of factors that

elicit stress response
- noise
- infection
- inflammation
- pain
- heat, cold
- trauma
- prolonged exertion
- response to life
events
- old age
Medication pharmacological: health
• naming of medications teaching
- antiasthmatic
- xanthines
- antihypertensive drugs
- oral antidiabetic agents
• purpose
• side effects
• contraindications
• administration instructions
- frequency/timing
- route
- dosage
Diet
nutritional counseling/
• COPD
- small frequent feedings (6
meals a day)
- increase protein intake
- low carbohydrates
- avoid gas producing foods
(e.g. beans, cabbage
- maintenance of hydration
and oral fluid balance
• DM
- avoid refined sugars
- diabetic diet
Exercise
health teaching/
• deep breathing exercises
education
• coughing exercises
• initiate exercise programs
 gradually, slowly,
increasing the intensity
and duration of activity as
the body becomes more
defined
Activity/Lifestyle
Changes • restriction of alcohol strategic nursing
consumption enhancement
• caffeine restriction
• relaxation techniques
• maintenance of ideal body
weight

2. Follow up/Check-up • compliance to the follow- health teaching/

up/check up education
• drug prescriptions
• BP checked regularly
• evaluation of treatment

Angeline Marie S. Dulce, SN12

De La Salle Health Sciences Institute

College of Nursing and School of Midwifery
 Dasmariñas, Cavite

Nursing Care Plan

(Chronic Obstructive
Pulmonary Disease:
Emphysema in Acute
Exacerbation)

Submitted by: Angeline Marie S. Dulce

Submitted to: Ms. Rose Salazar RN, MAN
Date Submitted: May 20, 2011