Case Study

Identification data

Introduction
 Name : Mrs. Ramashri
 Age &sex : 62 yrs. / female
 Ward : Chest female ward
 Bed no. : 03
 Address : Malihabaad, lucknow.
 Education : Illitrate.
 Occupation : House wife.
 Religion : Hindu
 Date of admission : 17/06/18
 Diagnosis : Chronic Obstructive Pulmonary Disease.
 Ward : Female medicine ward.

 Chief complaints:-

Mrs.nirmalawas admitted in the hospital with complaints of :-

 Shortness of breath x 1 week

 Chest pain x 1 week
 Cough since x 1 week.
 History of present illness:-

Patient is having chest pain cough since 1 week.

 History of past illness:-

Patient told about 6 month back she has same problem .

 Surgical history of the client

 Past surgical history -

There is no any past surgical history.

 Present surgical history

Not undergone through any surgery.

Family history–

My patient belongs to nuclear family.total 4 members are there in her family her husband 1sonand one daughter
. Her husband is a driver his monthly income is sufficient for his family.

Family tree –

Raghuraj 70 yrsRamashri 62 yrs.

Raghvendra 40yrs.Sheela 35yrs

Male Female death Male death

Male patient Female patient

Family composition:-

S.no Member Age/sex Relationship Education Health

1. Raghuraj 70/f Self Illiterate Sick

2. Ramashri 62/m Husband secondary Good

3. Raghvendra 40/f Son Graduate Good

4. Sheela 35/m daughter Graduate Good

Socio economic history

 Family income : 6000/-

 No. Of earning member : 1
 Per capita income : Rs 1500/-
  Education : Nil.
 Social support : Good.
 Relationship with neighbours : Good.
 Toilet facility : Available

Environmental history
 Type of house : Kaccha
 Ventilation : Adequate
 Electricity : Available
 Tape water : Not present
 Well : Present
 Hand pump : Present
 Tube well : Present
 Open drainage system : Present

Personal history
 Health facility near by home : Present
 Sleep pattern : Irregular
 Allergy : Not present
 Health habbits : Good
 Religion history : Superstitious
 Exercise : No.
 Dietary pattern : Vegeterian.

Physical examination:

 General appearance : Conscious.

 Height : 5’2”

 Weight : 54kg

 Temperature : Afebrile

 Pulse : 78 beats/min.

 Respiration : 20 breaths/min.

 Blood pressure : 130/70 mm of hg.

General appearance

 Behavior : Good
 Head : Normal in shape
  Hair : Normal white in color
 Face : Cleft lip & congenital abnormality is not observed
 Ear : Shape , hearing activity is normal. Discharge , wax foreign body & pain
not observed.
 Eyes : Pupil black in color , equal in size and reactive to light, corneal reflex observed .
 Nose : Running nose , polyp & bleeding not observed.
 Mouth/lips : Breath odors not present, cleft lip is not observed.
 Teeth : No discoloration observed.
 Gums : Texture is moist & bleeding not observed.
 Tongue : Normal ,moist& pink in color.
 Tonsil : Normal in size .
 Neck : Symmetrical ,veins and movement are normal carotid pulse present & palpable.
 Lymph nodes : Not observed
 Skin : Brown in color , wrinkles & dryness observed. Surgical wound observed.
 Nails : Normal in shape.
 Odema : No peripheral edema observed.

Vital signs –

 Temparature : Febrile
 Pulse : 78 beats /min
 Respiration : 20 breath /min.
 Ribs : Normal
 Abdomen : Abdominal reflexes are present. Distention &ascities is not observed.
 Bones : Deformity not observed.
 Back : Normal, spinabifea , kyphosis & scoliosis nit observed
 Extremities : Range of motion is normal
 Bowel activity : Regular once in a day/
 Bladder activity : Regular
 Rectum : Anatomical structure and opening is normal
 Sleep pattern : Regular

Systemic examination:

Central nervous system

 Consciousness : Lethargy
 Speech : Clear
 Coordination : Present
 Papillary reaction to light: Equal size reactive to light

Reflexes

 Biceps : Normal flexion is found

 Triceps : Normal
  Plantar reflex : Normal flexion is see

Respiratory system

 Respiratory rate : 20 breaths/min

 Pattern: : Normal abdomino thoracic
 Cyanosis : not observed
 Cough : present
 Flaring of nostrils : present
 Presence of wheezing / stridor : not present

Cardio vascular system

 Heart rare : 80 beats /min.

 Pulse : Rhythm normal.
 Radial : right present , pedal right present.
 Blood pressure : 130/70 mm of hg.
 Murmur : Not heard.

Gastro intestinal system

 Distended : Not observed.

 Ascities : Not observed.
 Visible peristalsis : Not observed.
 Palpable mass : Not palpable.
 Abdominal reflex : Present.
 Bowel sound : Audible.
 Liver : Palpable.
 Spleen : Not palpable.

Musculoskeletal system:

 Range of motion : Normal.

 Joint pain : Not observed.

Genitor urinary system:

 Urine : Normal.
 History of constipation : Not present

Reproductive system:

 Genitalia : Normal.
INVESTIGATION –

Day- 1,2,3,4

S.no. Parameters Client value Normal value Remark

1. Hb 12-14 gm 10.6gm/dl Below normal
2. Wbc 4-11u/dl 9000/u Normal
3. Lymph 20-40u/l 30u/dl Normal
4. Plt 150000-400000 200000 Normal
5. Sodium 135-145meq/dl 134meq/dl Normal
6 Potassium 3.5-5.5meq/dl 4.5meq/dl Normal
7. Calcium 9-11 mg/dl 9mg/dl Normal
8. Hiv Negative
9. Troponin Negative
10. PTT 20sec 10-14sec Normal
11. Bleeding time 2mt 2.3-9.5sec Normal
12. Clotting time 5:30mt 5-10mt Normal
DIAGNOSIS:- BRONCHIAL ASTHMA

DEFINITION:-

Asthma is a chronic inflammatory disease of the airway that causes airway hyper responsiveness,
mucosal edema, & mucus production. This inflammation ultimately leads to recurrent episodes of asthma
symptoms: cough, chest tightness, wheezing & dyspnea.

ANATOMY & PHYSIOLOGY OF RESPIRATORY SYSTEM

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 funnelled 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, it makes
it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide.

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. Travelling 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.

ETIOLOGY:-

 Chronic exposure to airway irritants or allergens e.g. Mold, dust, roaches or animal dander.
 Exercise, stress or emotional upsets.
 Sinusitis with postnasal drip.
 Medications.
 Viral respiratory tract infections.
 Gastroesophageal reflux.
PATHOPHYSIOLOGY:-

Clinical Manifestation:-

In book In patient
Three most common symptoms of asthma are  Cough & dyspnea is present in client
 Cough since 10 days.
 Dyspnea
 Wheezing  Has asthma attack early morning.
 Asthma attack often occur at night or
early in the morning, possibly due to
circadian variations that influence airway
receptor thresholds.  cough with mucus production is present.
  Cough with or without mucus production
 Generalised chest tightness & dyspnea
occurs
 Diaphoresis
 Tachycardia  Tachycardia is present heart rate is-
 Widened pulse pressure may occur along 102/mt
with hypoxemia & ventral cyanosis

MEDICAL MANAGEMENT

In book In patient
Two general classes of asthma medications are  Long acting control medication is not
used they are: given.
1. Long acting control medications.
2. Quick relief medications.
Long acting control medications
 Corticosteroids
 Cromolyn sodium &nedocromil are
 Quick relief medications are
mild to moderate anti inflammatory
administered such as injderiphylline 2ml
agents.
iv every 8 hourly.
 Long acting beta2 adrenergic agonists.
 methylxanthines are mild to moderate
bronchodilators.
Quick relief medications
 Short acting beta adrenergic agonists are
the medication of choice for relieving
acute symptoms.
 Anticholinergics e.g. Ipratropium
bromide may bring added benefits in
severe exacerbations.
MEDICATIONS

S Trade Pharmce Rou Dose Time Action Adverse Nursing responsibility

.n name utical te effect
o name

1. Taxim Cefotaxi Iv 1gm Q12h Anti- Frequent  Determine allergy to

m Biotic Oral cefotaxime.
sodium A third candidiasis,  Use caustiouly in
generation mild diarrhea, patient with renal
cephalospo abdominal impairment or gi
rin that cramps. disease.
binds to Occasional  Reconstitute drug.
bacterial Nausea,  Administer iv push
cell serum over 3 to 5 min.
memebrane sickness like  Monitor intake &
s& inhibits reaction. output.
cell wall Rare
synthesis. Allergic
reaction,
thrombophleb
itis.

2. Amika Amikaci Iv 500m Q12h Antibiotic- Frequent  Monitor intake &

n g an Pain, output to maintain
aminoglyc induration hydration.
osides phlebitis.  Monitor peak serum
antibiotic Occasional amikacin levels.
that Hypersensitiv  Alert for ototoxic &
irreversibly e reactions neurotoxic side
binds to Rare effects.
protein on Neuromuscul  Inspect skin for
bacterial ar blockade. rashes.
ribosomes  Use cautiously in
& patient with 8th
interferes cranial nerve
with impairment,
protein myasthenia gravis.
synthesis
of
microorgan
ism.
3. Inj. Theophy Iv 3.2m Q8h Bronchodil Frequent  Assess bp& apical
Deriph lline & g/ml ators Fatigue, pulse before giving
ylline theophyl dizziness drug.
line Occasional  Teach patient to take
Diarrhoea, with food.
bradycardia,  Urge client to limit
rhinitis, back alcohol & salt
pain. intake.
Rare  Assess clients
Orthostatic tolerance to drug.
hypertension,
uti, viral
infection.

4. Aciloc Ranitidi IV 50mg Q12h Antiulcer Occasional  Use cautiously in

ne agent Diarrhoea elderly patient &
hydrochl It inhibits those with impaired
oride histamine Rare hepatic & renal
action at h2 Constipati function.
receptor of on,  Give regard to
gastric headache. meals.
parietal  Do not administer
calls & with in 1 hour of
inhibits magnesium or
gastric acid aluminium
secretion containing antacids.
when  Infuse iv infusion
fasting at over 24 hrsim.
night or
when
stimulated
by food
caffeine or
insulin.

5. Metron Metroni Iv 500m Q8h Antibacteri Frequent Determine

dazole g al Anorexia, hypersentivity.
It disrupts nausea, dry Use cautionsly in blood
bacterial mouth, dyscrasias, cns
&protozoal uterine disorders, hepatic
dna cramps. failure.
inhibiting Occasional Use without regard to
 nucleic Diarrhoea, food.
acid constipation. Explain to patient that
synthsis. Rare urine may become
Transient reddish brown during
leucopenia, metronidazole therapy.
thrombophleb
itis.

NURSING MANAGEMENT

According to book Done for the patient

 Administers medications as  Administered medications as
prescribed. prescribed.
 Fluid may be administered if  Client was well hydrated.
dehydrated.
 If the patient requires intubation  Nil significant.
because of respiratory failure, the
nurse assist with intubation
procedure.

NURSING CARE PLAN

NURSING DIAGNSIS

1. Ineffective airway clearance, dypnea related to inflammatory process as manifested by observation.

2. Pain related to disease condition as manifested by observation.
 3. Activity intolerance related to confinement to bed as manifested by observation.
4. Imbalance nutrition pattern less than body requirement related to loss of appetite as manifested by
observation.
5. Disturbed sleeping pattern related to unfamiliar environment as evidenced by patient verbalization.

6. Excess Fluid volume related to decreased organ perfusion (renal) as evidenced by

increased sodium/water retention in patients reports.

7. Ineffective therapeutic regimen related to complexity of treatment as evidenced by verbalization by

patient that he or she did not follow prescribed regimen.

8. Anxiety related to hospitalization as evidenced by patient asking too many questions.

ASSESSMENT

Subjective Data:

Client stated that she is having difficulty in breathing.

Objective Data: -

Client is looking restless & irritated.

Day 1,2,3,4,5

Nursing Diagnosis Goal Planning Implementation Evaluation

1.Ineffective Client will  Assess the general  Assessed the Client stated
airway clearance, have condition of the general condition of that his pain
dypnea related to effective patient. the patient. is reduced.
inflammatory airway
process as clearance as  Provide comfort  Provided comfort
manifested by evidenced by devices such as devices such as
observation. verbalization. pillows. pillows.

 Provide propped up  Provided propped

position. up position.

 Advice to take  Adviced to take

adequate rest & adequate rest &
sleep. sleep.

 Administer  Administered
bronchodilator drug bronchodilator drug
as prescribed. as prescribed.

ASSESSMENT

Subjective Data: -
Client stated that she is having pain in the whole body.
Objective Data: -
 Client is looking restless & irritated.

Nursing Diagnosis Goal Planning Implementation Evaluation

2.Pain related to client will have  Assess the

disease condition adequate comfort condition.  Assessed the Client stated that
as manifested by as evidenced by condition. his pain is reduced.
observation. verbalization.  Provide
comfort  Provided
devices such as comfort
pillows. devices such as
pillows.
 Provide
comfortable  Provided
bed. comfortable
bed.
 Provide
comfortable  Provided
position. comfortable
position.

 Advice to take  Adviced to take

adequate rest & adequate rest &
sleep. sleep.

 Administer  Administered
analgesic drug analgesic drug
as prescribed. as prescribed.

ASSESSMENT

Subjective Data:

Client stated that she is having not able to do her activities.

Objective Data: -

Client is not able to do activities of daily living.

Nursing Diagnosis Goal Planning Implementation Evaluation

3. Activity client will be able  Assess the  Assessed the client is able to do
intolerance related to do some of her condition condition some of her daily
to confinement to daily activity as activities.
bed as manifested evidenced by  Assist the  Assisted the
by observation. verbalization. client in client in
activities of activities of
daily living. daily living.

 Promote  Promoted
ambulation. ambulation.

 Change  Changed
position position
timely. timely.

 Encourage
client  Encouraged
participation client
in daily participation in
activities. daily activities.

ASSESSMENT

Subjective Data: -
Client stated that she is not feeling to eat food.

Objective Data: -

Client is looking weak & tired.

Nursing Diagnosis Goal Planning Implementation Evaluation

4.Imbalancenutrition Client will have  Asses the  Assessed the Client started taking
pattern less than normal nutritional condition. condition. food orally & has
body requirement pattern as normal appetite.
related to loss of evidenced by  Provide small  Provided small
appetite as observation. & frequent & frequent
manifested by feed. feed.
observation.
 Provide of  Provided of
food items of food items of
likings. likings.

 Provide neat &  Provided neat

clean & clean
environment environment
for eating. for eating.

 Promoted
 Promote
hydration.
hydration.

 Teach about  Taught about

importance of importance of
nutritious diet. nutritious diet.

ASSESSMENT

Subjective Data:-
Patient is complaining of inability to perform daily activities.

Objective Data:-

On the close observation it was observed that patient is unable to perform daily activity.

Nursing Goal Planning Implementation Evaluation

Diagnosis
5.Activity Patient  Assess the level of  Assessed the level of Expected
Intolerance will be activity that can be activity that can be outcome
related to able to performed by patient. performed by patient. partially met
disease perform as evidenced
 Assist in performance  Assisted in performance
condition as certain by patient is
of daily activities. of daily activities.
evidenced by level of able to
patient unable activity. perform
to perform  Provide alternate  Provided alternate certain daily
activity. periods of activity and periods of activity and activities.
rest. rest.

 Provide hygienic care  Provided hygienic care

to then patient. to then patient.

 Provide balance diet  Provided balanced diet

to the patient. to the patient.

 Encourage patient to  Encouraged patient to

perform range of perform range of motion
motion exercises. exercises.

ASSESSMENT
Subjective data:

Patient is complaints of not able to sleep.

Objective data:

On the assessment it was found that patient is unable to sleep and looks dull.

Nursing Goal Planning Implementation Evaluation

Diagnosis
6.Disturbed Patient’s  Assess the condition  Assessed the Expected outcome
sleeping pattern sleeping of patient. condition of is partially met as
related to pattern will patient. evidenced by
unfamiliar be improved patients sleeping
 Provide comfort  Provided comfort
environment as devices to the patient. pattern is
devices to the
evidenced by patient. improved.
patient
verbalization.  Provide quiet and  Provided quiet and
calm environment. calm environment.

 Provide well  Provided well

ventilated room to ventilated room to
the patient. the patient.

 Provide one glass  Provided one glass

milk before sleep. milk before sleep.

ASSESSMENT

Subjective data:

Patient is having less confidence about him.

Objective data:

On the assessment it was found that patient has low confidence level.

Nursing Goal Planning Implementation Evaluation

Diagnosis
8.Risk of To  Assess the condition of  Assessment was Expected outcome
situational low increase patient. done. is partially met as
self-esteem the self- evidenced by self-
related to esteem of esteem is
disease patient.  Help patient to identify  Helped the patient to increased as
environmental factors which identify
condition. patient
increase risk for low self- environmental
esteem. factors. verbalization.

 Encourage patient to  Encouraged patient

 verbalize thoughts and to verbalize thoughts
feelings. and feelings.

 Encourage client to create a  Encouraged client to

sense of competence create a sense of
through short term goal competence through
setting and goal short-term goal
achievement. setting and goal
achievement.

ASSESSMENT

Subjective Data: -

Client stated that she is not aware of her disease condition.

Objective Data: -
Client is not knowing about her disease condition.

Nursing Diagnosis Goal Planning Implementation Evaluation

9.Knowledge deficit Client will have  Assess the  Assess the Client & relatives
related to disease adequate knowledge condition. condition understood about
condition as as evidenced by the disease
manifested by
verbalization.  Explain about  Explain about condition & its
verbalization.
diseaseconditio disease management.
n. condition.

 Mention about  Mention about

its management its management
& its preventive & its preventive
measures. measures.

 Explain about  Explain about

complications complications &
& its its preventions.
preventions.
 Clarify all
 Clarify all doubts of client
doubts of client & relatives.
& relatives.

ASSESSMENT

Subjective Data: -

Client stated that she is worried about her disease

Objective Data: -
Client is looking frightened & tensed.

Nursing Diagnosis Goal Planning Implementation Evaluation

10.Fear& anxiety Client will be  Assess the  Assessed the clients said that her
related to disease relieved from fear condition. condition. fear & anxiety is
condition as & anxiety as reduced.
manifested by
evidenced by  Provide  Provided
observation &
verbalization. verbalization. psychological psychological
support. support.

 Provide calm  Provided calm

and healthy and healthy
environment environment
to the patient. to the patient.

 Clarify all  Clarifiedall

doubts. doubts.

 Explain about  Explained

disease about disease
condition in condition in
detail. detail.

COMPLICATION:-

According to book Developed in the patient.

 Status asthmaticus.  Status asthmaticus.
 Respiratory failure  Respiratory failure
 Pneumonia  Pneumonia
 Atelectasis  Atelectasis
HEALTH EDUCATION

 Personal hygiene
 Personal hygiene has an important role to prevent infection.
 Patient have to take a through bath, brush teeth, cut short nails & change cloth daily.
 Diet therapy
 Advice to take well balanced diet of good nutritive value.
 Explain importance of balanced diet.
 Rest & sleep
 Advice to take adequate rest & sleep.
 Ask to do active & passive exercise.
 Disease condition: - bronchial asthma
 Definition
 Causes
 Pathophysiology
 Clinical manifestations
 Diagnosis
 Management
 Care & prevention
 Follow up
 Advice to take medicine in time.
 Do not discontinue medicine without doctors.
 Advice for timely follow up checkups.

SUMMARY

Case study on Chronic Obstructive Pulmonary Disease was great learning experience for me. I learned about
the disease condition of the client & also how to take care of client with Chronic Obstructive Pulmonary
Disease. I thank my patient & his relatives for their valuable cooperation & also staffs of Era Hospital .

CONCLUSION

COPD is a progressive and (currently) incurable disease, but with the right diagnosis and treatment, there are
many things you can do to manage your COPD and breathe better. People can live for many years
with COPD and enjoy life.
Bibliography

 Suzanne c. Smeltzerbrenda g. Bare, medical surgical, eighth edition, pb-lippincott

 Brunner and suddarth.medical surgical nursing, 8th edition,
 Luckmen,” medical surgical nursing”pbsaunders
 Joyce m. Black,“ medical surgical nursing”, clinical management for positive outcome,vol.1,
pbsaunders, 7th edition.
 C.r.w. edwards,” davidson’s principal and practice of medicine”, pbchurchilllivingstone 3rd edition.
 Barbara c. Long “medical surgical nursing” ,mosby, 3th edition

ERA UNIVERSITY

ERA COLLEGE OF NURSING

CARE PLAN ON :-CHRONIC OBSTRUCTIVE PUL MONARY DISEASE

SUBMITTED TO: SUBMITTED BY:

Ms.Swastika Das Priyanka Yadav

Assistant professor M.Sc. Nursing 1st Year

Era College Of Nursing Era College Of Nursing

Submitted on-13/08/18