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Case presentation-1 COPD

Nursing (Padmashree Dr. D.Y. Patil Vidyapith)

Studocu is not sponsored or endorsed by any college or university

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DR. D.Y. PATIL COLLEGE OF NURSING PIMPRI, PUNE -18

CASE
PRESENTATION
ON
COPD

SUBMITTED TO : SUBMITTED BY :

MS. SUCHETA YANGAD MS. SONALI VAIDHYA

(ASSO.PROFESSOR) MSC 2nd YR STUDENT

SUBMISSION DATE

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HISTORY-TAKING
&
PHYSICAL-
EXAMINATION

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DEMOGRAPHIC DATA:

NAME :-Mr. GULUF DADUBHAI SHINDE

AGE :-72 YEAR

SEX :-MALE

ADDRESS : - ANNSAHEB NAGAR,CHINCHWAD, PUNE

IP NUMBER :-48967

EDUCATION : - ILLITERATE

OCCUPATION : - SHOPKEEPER

INCOME :-10000/MONTH

MARITAL STATUS: - MARRIED

RELIGION :-HINDU

MOTHER TONGUE:-MARATHI

WARD : - MEDICINE ICU.

DATE OF ADMISSION: - 28/02/2020

DIAGNOSIS :- COPD

HISTORY-TAKING
CHIEF COMPLIANTS:-

 COUGH WITH COPIOUS EXPECTORATION : SINCE 5 DAYS

 BREATHLESSNESS : SINCE 1 DAY.

PRESENT HISTORY OF ILLNESS: -

PATIENT WAS APPARENTLY ALRIGHT 15 DAYS BACK THEN DEVELOPED MILD, WHICH WAS REMAIN
UNTREATED AND PROGRESSIVLY CHANGED IN SEVER COUGH WITH EXPECTORATION, BREATHLESSNESS
WHICH IS MORE IN SUPINE POSITION. THE EXPECTORANT IS WHITE COLOUR AND MUCOID IN NATURE.
HE HAS SHOWN TO ONE LOCAL DOCTOR. FROM THERE HE IS REFERRED HERE FOR FURTHER
TREATMENT.

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PAST HISTORY OF ILLNESS:-

MEDICAL HISTORY: -PATIENT IS A KNOWN CASE OF BRONCHIAL ASTHEMA SINCE 5 YEARS, NOT ON
REGALAR TREATMENT WITH TAB ASTHALIN 50 MG.

SURGICAL HISTORY:-NO SIGNIFICANT HISTORY OF ANY MAJOR OR MINOR SURGICAL INTERVENTION

GIVEN BY PATIENT.

MENSTRUAL HISTORY [FEMALE]- NOT APPLICABLE

FAMILY HISTORY:-

NAME AGE/ SEX EDUCATION/OCCUPATION RELATIONSHIP HEALTH STATUS

MR. GULUF DADUBHAI 72 Y/ M 4TH STD/ SHOPKEEPER HIMSELF COPD
SHINDE
MRS. MAREMBI G. 68 Y/ F ILLITERATE/ HOUSEWIFE WIFE HEALTHY
SHINDE
MR. GURURAJ G SHINDE 42 Y/ M 12TH STD / SALESMAN SON HEALTHY

MRS. RUPA G.SHINDE 33Y/ M 10TH STD/ HOUSEWIFE DAUGHTER IN HEALTHY

LAW
MASTER JIJESH G.SHINDE 5Y/M NURSERY GRANDSON HEALTHY

PERSONAL HISTORY:-

HABITS : NON-ALCOHOLIC, CIGGRETE SMOKER BUT STOPED SINCE 5 YEARS.

DIET : NON- VEGETARIAN, APPATITE DECREASED, 4 MEAL/DAY.SLEEPING HABITS :

PATIENT SLEEPS 3 HRS AT DAY TIME AND 6 HRS AT NIGHT TIME, CURRENTLY
S SLEEP PATERN DISTRUBED DUE TO COUGH.

ALLERGY : NO HISTORY OF ALLERGY TO ANY FOOD/MEDICATIONS GIVEN BY PATIENT.

BOWEL AND BLADDER HABITS: BOWEL AND BLADDER MOVEMENT ARE NORMAL.

SOCIO- ECONOMIC STATUS:-

CONDITION OF THE HOUSE:PAKKA HOUSE& ADEQUATE VENTILATION 2ROOM&1 WINDOW, KITCHEN

WATER SUPPLY: CORPORATION WATER

DRAINAGE SYSTEM: CLOSED DRAINAGE

SURROUNDING ENVIRONMENT:THE ENVIRONMENT IS CLEAN AROUND THE HOUSE.

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PHYSICAL EXAMINATION

GENERAL APPEARANCE:

CONSTITUTION : MODERATELY BUILT

STATE OF NUTRITION : GOOD

PERSONAL APPEARANCE:GOOD AND MAINTAINED

POSTURE : NORMAL

SKIN AND HAIR : FAIR COMPLEX, BLUISH DISCOLORATION AND NO PEDICULI IN THE HAIR.

EMOTIONAL STATE : ANXIOUS

CO-COOPERATIVENESS : PATIENT IS CO-OPERATIVE

HEIGHT AND WEIGHT:

HEIGHT : 5.8 FEETs

WEIGHT : 65kgs.

VITAL SIGNS:

TEMPERATURE : 99.4F

PULSE : 122 B/ MINUTE

RESPIRATION : 26/MINUTE

BLOOD PRESSURE : 140/90 MM HG

HEAD AND FACE:

SKULL: ROUND IN SHAPE

SCALP: CLEAN, NO DANDRUFF, SCAR PRESENT

HAIR: BLACK AND WHITE COLOR, AND EQUALLY DISTRIBUTED

FACE: SYMMETRICAL

NODE: NOT PALPABLE

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EYES:

EYEBROWS: SYMMETRICAL

EYELASHES: EQUALLY DISTRIBUTED AND THERE IS NO INFECTION, LESION PRESENT.

EYELID : INTACT, NO DISCHARGE, DISCOLORATION, AND LIDS CLOSE SYMMETRICALLY

EYEBALLS: BOTH EYES COORDINATED; MOVE IN UNISON WITH PARALLEL ALIGNMENT.

CONJUNCTIVA:NO INFECTIONS

SCLERA:WHITE

PUPIL: REACTIVE TO LIGHT

LENS: DILATED

VISION:PATIENT HAS GOOD VISUAL CAPACITY; HE CAN READ AND SAW EASILY.

EARS:

EXTERNAL STRUCTURE: NO ANY TENDERNESS

CANAL : NO ANY DISCHARGE FROM EARS.

TYMPANIC MEMBRANE : INTACT

HEARING: WEBER TEST- PATIENT HEAR EQUAL IN BOTH

RINNIE TEST- SOUND CONDUCTED BY AIR IS HEARD IS MORE SOUND CONDUCTED BY BONE.AIR
CONDUCTION IS MORE THAN BONE CONDUCTION.

NOSE:-

EXTERNAL STRUCTURE – SYMMETRIC AND STRAIGHT

SEPTUM - NO DEVIATED NASAL SEPTUM

MUCOUS MEMBRANE -MOIST, INFLAMED, IRRITATION PRESENT

OLFACTORY SENSE -PRESENT

PATENCY –PATENT

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MOUTH AND PHARYNX:

LIPS-PALE IN COLOUR AND DRY

TEETH- NO DENTAL CARIES,SHINY TOOTH ENAMEL PRESENT.

GUMS -HEALTHY (NO BLEEDING)

PALATES – SMOOTH AND SOFT PALATE

VOICE – HOARSNESS AND AGREVATING COUGH TO SPEECH.

BREATHE – NO ANY BAD SMELL PRESENT.

TASTE –GOOD

NECK:

LYMPH NODES - NOT PALPABLE

MUSCLES –MUSCLES ARE IN EQUAL IN BOTH SIZE AND HEAD IN CENTERED.

TRACHEA -CENTRALLY SITUATED AND SPACE ARE EQUAL IN BOTH SIDE.

THYROID GLAND- LOBES ARE SMOOTH, SMALL, CENTRALLY LOCATED AND PAINLESS RISE FREELY WITH
SWALLOWING

RANGE OF MOTION- PRESENT

BREAST AND AREA NODES: -

INSPECTION:-NOT APPLICABLE

PALPATION:-NOT APPLICABLE

CHEST:

CHEST SHAPE: -BARREL SHAPE

TYPE OF RESPIRATION: - TRACHYCARDIA, IRREGULAR, BREATHLESNESS.

EXPANSIONS : -CHEST IS NOT FULLY EXPANDING DURING INSPIRATION.

INSPECTION:-NO ANY TENDER SCAR, MASS, NODE PRESENT, USE OF ASSESSORY MUSCLS

FOR BREATHING.

PALPATION :-BILATERAL SYMMETRICAL AND VOCAL FERMITUS.

PERCUSSION:-NO ANY DULL SOUND PRESENT AND NO ANY FLUID COLLECTION.

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AUSCULTATION -DURING AUSCULTATION CREPITATION SOUNDSPRESENT .

CARDIOVASCULAR SYSTEM:-

RATE AND RHYTHM: - REGULAR

APICAL AND RADIAL:-122/M AND REGULAR

CAROTID PULSE: - FULL PULSATION PRESENT AND NO BRUIT SOUND.

JUGULAR VENOUS DISTENSION: -NO DISTENDED JUGULAR VEIN

DESCRIPTION OF PERIPHERAL PULSES:-

BRACHIAL RADIAL FEMORAL POPLITEAL DORSAL POST TIBIAL

PEDIAL
RATE 124/m 123/m 123/m 123/m 122/m 122/m
RHYTHAM Regular Regular Regular Regular Regular Regular

ABDOMEN AND INGUINAL AREAS:-

CONTOUR AND TONE : - CONVEX , SOFT, NOTENDERNESS, PAIN WHILE BREATHING.

SCAR : - NO ANY SCAR PRESENT

LIVER: - NOT PALPABLE AND NO HEPATOMEGALY

SPLEEN: - NOT PALPABLE AND NO SPLEENOMEGALY

KIDNEY: - NOT PALPABLE

BLADDER: - NO DISTENTION

MASSES: -NO MASS PALPABLE.

PALPATION : - THERE IS NO TENDERNESS, RELAX ABDOMEN WITH CONSISTENT TENSION.

PERCUSSION : - TYMPANY SOUND PRESENT, NO SIGN OF ASCITIS OR FLUID COLLECTION.

AUSCULTATION : - AUDIBLE BOWEL SOUND PRESENT.

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GENITALS AREA:

RECTAL EXAMINATION: - IT’S SMOOTH AND NOT TENDER.

MUSCULOSKELETAL SYSTEM:

UPPER EXTREMITIES : NO ANY DEFORMITY NORMAL ROM PRESENT

LOWER EXTREMITIES:NO ANY DEFORMITY NORMAL ROM PRESENT

DEFORMITIES : NO ANY DEFORMITY

JOINT EVALUATION : NO ANY TENDERNESS, CREPITATION, NODULES etc

MUSCLE STRENGTH:- ACCORDING TO GRADING SYSTEM- GRADE-5 , 100% NORMAL STRENGTH –

NORMAL MOVEMENT AGAINST GRAVITY&RESISTENCE-PRESENT

MUSCLE MASS : NO ANY MASS PRESENT

NODE: NOT PRESENT

RANGE OF MOTION : PRESENT

NERVOUS SYSTEM:-

MENTAL STATUS:- PATIENT IS ORIENTED TO TIME , PLACE AND PERSON.

HE CAN CALCULATE THE NORMAL VALUE LIKE 12+17=29

HE HAS GOOD JUDGMENT QUALITY.

PATIENT HAS GOOD IMMEDIATE, RECENT AND RECALL MEMORY.

CRANIAL NERVES:- PRESENT THE SENSORY AND MOTOR RESPONSE OF THE NERVES.

DEEP TENDON REFLEX: - DEEP TENDON REFLEX PRESENT, BICEP’S, TRICEPS, PATELLAR, BRACHIO-

RADIALIS ETC.

SUPERFICIAL SENSORY REFLEX:-THE REFLEXS ARE REACTIVE TO LIGHT, PAIN, VIBRATION, AND TOUCH.

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INVESTIGATION:-

TYPE PATIENT REPORT NORMAL VALUES IMPRESSION

HEMOGRAM
HB 7.2 MG/DL 13-18 MG/DL DECRESED

TLC 15500/ CUMM 4000-11000/CUMM INCREASED

PLATELET 2.63 LAKH/CUMM 1.5-4.5 LAKH/CUMM NORMAL

COUNT

RBC. MICROCYTIC HYPOCHROMIC NORMOCYTIC INDICATING SEVER ANAMIAE

RBC SEEN,FEW PENCIL CELL ,NORMOCHROMIC
SEENS

BSL RANDOM 90 MG% 70-100 MG% NORMAL

LFT
SR.BILURUBINE
TOTAL 0.8 0.2-1.0 gm%
DIERECT 0.2 0-0.3gm% NORMAL
SR.PROTIEN 6.6 6-8 GM%
ALBUMIN 3.8 3.5-4.5 GM%
GLOBULIN 2.8 2-3.5 GM%

SGPT 18 0-40

SGOT 53 18-112
SERUM
ELECTROLYTE

SERUM SODIUM 138meq/l 135-145meq/l NORMAL

SERUM 3.7meq/l 3.5-5.5 meq/l NORMAL

POTASSIUM

RFT
BLOOD UREA 30 mg% 15-50mg% NORMAL

SERUM 1.2 mg% 0.6-1.4 mg% NORMAL

CREATININE

URIC ACID 4.6 2.5-6.5MG/DL NORMAL

CHEST X -RAY: THERE ARE BILATERAL LOWER LOBE INFILTRATE

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DISEASE
CONDITION

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INTRODUCTION:
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) IS A PREVENTABLE AND TREATABLE
DISEASE STATE CHARACTERISED BY AIRFLOW LIMITATION THAT IS NOT FULLY REVERSIBLE. THE
AIRFLOW LIMITATION IS USUALLY PROGRESSIVE AND ASSOCIATED WITH AN ABNORMAL
INFLAMMATORY RESPONSE OF THE LUNGS TO NOXIOUS PARTICLES OR GASES, PRIMARILY
CAUSED BY CIGARETTE SMOKING.SOME CLINICIANS CONSIDER ASTHMA AS PART OF COPD, BUT
DUE TO ITS REVERSIBILITY, IT IS CONSIDERED BY MOST TO BE A SEPARATE ENTITY.

COPD MAY INCLUDE DISEASES THAT CAUSE AIRFLOW OBSTRUCTION (EG, EMPHYSEMA,
CHRONIC BRONCHITIS) OR A COMBINATION OF THESE DISORDERS. OTHER DISEASES SUCH AS
CYSTIC FIBROSIS, BRONCHIECTASIS, AND ASTHMA WERE PREVIOUSLY CLASSIFIED AS TYPES OF
CHRONIC OBSTRUCTIVE LUNG DISEASE. HOWEVER, ASTHMA IS NOW CONSIDERED A SEPARATE
DISORDER AND IS CLASSIFIED AS AN ABNORMAL AIRWAY CONDITION CHARACTERIZED
PRIMARILY BY REVERSIBLE INFLAMMATION. COPD CAN COEXIST WITH ASTHMA. BOTH OF
THESE DISEASES HAVE THE SAME MAJOR SYMPTOMS; HOWEVER, SYMPTOMS ARE GENERALLY
MORE VARIABLE IN ASTHMA THAN IN COPD.

CHRONIC BRONCHITIS IS A CHRONIC INFLAMMATION OF THE LOWER RESPIRATORY TRACT

CHARACTERIZED BY EXCESSIVE MUCOUS SECRETION, COUGH, AND DYSPNEA ASSOCIATED WITH
RECURRING INFECTIONS OF THE LOWER RESPIRATORY TRACT.

PULMONARY EMPHYSEMA IS A COMPLEX LUNG DISEASE CHARACTERIZED BY DESTRUCTION OF

THE ALVEOLI, ENLARGEMENT OF DISTAL AIRSPACES, AND A BREAKDOWN OF ALVEOLAR WALLS.
THERE IS A SLOWLY PROGRESSIVE DETERIORATION OF LUNG FUNCTION FOR MANY YEARS
BEFORE THE DEVELOPMENT OF ILLNESS.

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RELATED ANATOMY AND PHYSIOLOGY:

LUNGS LIE ON EACH SIDE OF THE MIDLINE IN THE THORACIC CAVITY. THEY ARE CONE
SHAPED & HAVE AN APEX, A BASE, COSTAL SURFACE & MEDIAL SURFACE.

THE RIGHT LUNG IS DIVIDED INTO THREE DISTINCT LOBES & THE LEFT LUNG HAS TWO LOBES.
PLEURAL SPACE IS THE SPACE BETWEEN THE INNER & OUTER LAYER OF PLEURA WHICH
NORMALLY CONTAINS A SMALL VOLUME OF LUBRICATING FLUID TO ALLOW THE LUNGS TO
EXPAND WITHOUT FRICTION.

THE INTERIOR OF THE LUNGS ARE COMPOSED OF THE BRONCHI & SMALLER AIR PASSAGE,
ALVEOLI, CONNECTIVE TISSUE, BLOOD VESSELS, LYMPH VESSELS & NERVES, ALL EMBEDDED IN
AN ELASTIC CONNECTIVE TISSUE MATRIX.

EACH LOBE IS MADE UP OF A LARGE NUMBER OF LOBULES. EACH LOBULE IS SUPPLIED WITH AIR
BY A TERMINAL BRONCHIOLE, WHICH FURTHER SUBDIVIDES INTO RESPIRATORY BRONCHIOLES,
ALVEOLAR DUCTS, & LARGE NUMBERS OF ALVEOLI (AIR SACS) THERE ARE ABOUT 150 MILLION
ALVEOLI IN THE ADULT LUNG, IN THIS STRUCTURES THAT THE PROCESS OF GAS EXCHANGE
OCCURS.

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AS AIRWAYS PROGRESSIVELY DIVIDE & BECOME SMALLER AND SMALLER, THEIR WALLS BECOME
GRADUALLY THINNER UNTIL MUSCLE & CONNECTIVE TISSUE DISAPPEAR, LEAVING A SINGLE
LAYER OF SQUAMOUS EPITHELIAL CELLS IN THE ALVEOLAR DUCT & ALVEOLI.

THE ALVEOLI ARE SURROUNDED BY A DENSE NETWORK OF CAPILLARIES. EXCHANGE OF GASES

IN THE LUNG (EXTERNAL RESPIRATION) TAKES PLACE ACROSS A MEMBRANE MADE UP OF THE
ALVEOLAR WALL & THE CAPILLARY WALL FUSED FIRMLY TOGETHER.

THIS IS CALLED THE RESPIRATORY MEMBRANE. SURFACTANT, A PHOSPHOLIPIDS FLUID

SECRETED BY SEPTAL CELLS PREVENTS THE ALVEOLI FROM DRYING OUT, IT ALSO PREVENTS
ALVEOLAR WALLS COLLAPSING DURING EXPIRATION.

DEFINITION:
COPD IS A DISEASE STATE CHARACTERISED BY AIRFLOW LIMITATION WHICH IS NOT FULLY
REVERSIBLE. INCLUDES CHRONIC BRONCHITIS, EMPHYSEMA AND SMALL AIRWAY DISEASE.

SIGNIFICANT OBSTRUCTION IS ALWAYS PRESENT:

• IT IS CHRONIC

• IT IS PROGRESSIVE

• MOSTLY FIXED AIRWAY OBSTRUCTION

• NON REVERSIBLE BY BRONCHODILATORS

• EXPOSURE TO NOXIOUS AGENT IS A MUST

TWO ENTITIES IN COPD ARE:

1. CHRONIC BRONCHITIS:

CHRONIC BRONCHITIS IS DEFINED CLINICALLY AS PERSISTENT COUGH WITH SPUTUM

PRODUCTION FOR AT LEAST 3 MONTHS IN AT LEAST 2 CONSECUTIVE YEARS, IN THE ABSENCE OF
ANY OTHER IDENTIFIABLE CAUSE

 SMALL AIRWAY DISEASE: CONDITION IN WHICH SMALL BRONCHIOLES ARE NARROWED

2. EMPHYSEMA.

IT IS ACONDITION CHARACTERISED BY PERMANENT AND ABNORMAL DILATION OF AIRSPACES

OWING TO DESTRUCTION OF LUNG PANACINAR: IN THIS TYPE, THE ACINI ARE UNIFORMLY

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ENLARGED FROM THE LEVEL OF THE RESPIRATORY BRONCHIOLE TO THE TERMINAL BLIND
ALVEOLI. SEEN IN ALPHA 1 AT DEFICIENCY. COMMON IN LOWER LOBES

1. CENTRIACINAR: THE CENTRAL OR PROXIMAL PARTS OF THE ACINI, FORMED BY RESPIRATORY

BRONCHIOLES, ARE AFFECTED, WHEREAS DISTAL ALVEOLI ARE SPARED. MORE COMMON IN
UPPER LOBES.MOST COMMON IN SMOKERS.
2. PARASEPTAL (DISTAL): THE PROXIMAL PORTION OF THE ACINUS IS NORMAL, AND THE
DISTAL PART IS PREDOMINANTLY INVOLVED.
3. IRREGULAR: IRREGULAR EMPHYSEMA, SO NAMED BECAUSE THE ACINUS IS IRREGULARLY
INVOLVED, IS ALMOST INVARIABLY ASSOCIATED WITH SCARRING

INCIDENCE:
IT IS MORE COMMON IN MEN THAN WOMEN. IT IS MORE FREQUENT IN CLIENTS LIVING IN
URBAN ENVIRONMENT AND AMONG THE SOCIEO-ECONOMICALLY DISADVANTAGES. 30% OF
SMOKERS DEVELOP COPD 20% OF ADULT MALES HAVE COPD 15% OF COPD PATIENTS ARE
SEVERELY SYMPTOMATIC 4TH LEADING CAUSE OF DEATH (USA). MORTALITY RATE STILL
RISING.INCREASE PREVALENCE IN LOW BIRTH WEIGHT AND LOW SOCIO ECONOMIC STATUS.

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ETIOLOGY AND RISKS FACTORS:

BOOK PICTURE PATIENT

PICTURE
 CIGARETTE SMOKING: WHEN CIGARETTE IS INHALED, WHICH CONTAINS
APPROXIMATELY 4000 CHEMICLAS. OVER 60 CARCINOGENS HAVE BEEN ISOLATED FROM
CIGARETTE SMOKE, INCLUDING CYANIDE, FORMALDEHYDE, AND AMMONIA.IT ALSO PRESENT
HAS DIRECT EFFECT ON RESPIRATORY TRACT. THE IRRITATING EFFECT OF THE SMOKE
CAUSES HYPERPLASIA OF CELLS, INCLUDING GOBLET CELLS WHICH SUBSEQUENTLY
RESULTS IN INCREASED PRODUCTION OF MUCUS, COUGHING, DESTRUCTION OF
CILIARY FUNCTION AND INFLAMMATION AND DAMAGE OF BRONCHIOLAR AND
ALVEOLAR WALLS.
 PASSIVE SMOKERS: ALSO KNOWN AS ENVIRONMENTAL TOBACCO SMOKE (ETS). IN
ADULTS INVOLUNTARY SMOKE EXPOSURE IS ASSOCIATED WITH DECREASED
PULMONARY FUNCTION. INCREASED RESPIRATORY SYMPTOMS,AND SEVERE LOWER PRESENT
RESPIRATORY TRACT INFECTION RESULTING IN PNEUMONIA.
 OCCUPATIONAL CHEMICALS AND DUSTS: PROLONGED EXPOSURE TO VARIOUS DUSTS, ABSENT
VAPOURS, IRRITANTS OR FUMES IN THE WORK PLACE.
 AIR POLLUTION ABSENT

 CHRONIC RESPIRATORY INFECTION SUCH AS SINUSITIS. COMMON CAUSATIVE ABSENT

ORGANISM ARE H. INFLUENZA, STREPTOCOCCUS PNEUMONIA ETC.

ABSENT

 ALLERGY, AUTOIMMUNITY.
 HEREDITY: ALPHA1-ANTITRYPSIN (AAT) DEFICIENCY IS A GENETICALLY DETERMINED
CAUSE OF EMPHYSEMA AND OCCASIONALLY LIVER DISEASE. ALPHA1-ANTITRYPSIN
SERVES PRIMARILY AS AN INHIBITOR OF NEUTROPHIL ELASTASE, AN ELASTIN-
DEGRADING PROTEASE RELEASED BY NEUTROPHILS. WHEN ALVEOLAR STRUCTURES ARE ABSENT
LEFT UNPROTECTED FROM EXPOSURE TO ELASTASE, PROGRESSIVE DESTRUCTION OF
ELASTIN TISSUES RESULTS IN THE DEVELOPMENT OF EMPHYSEMA. EMPHYSEMA
OCCURS BECAUSE OF AAT DEFICIENCY.
 AGING: IT RESULTS IN CHANGING OF THE LUNG STRUCTURE, THE THORACIC CAGE AND
RESPIRATORY MUSCLE. AS PEOPLE AGE THERE IS GRADUAL LOSS OF RESPIRATORY PATIENT IS 65
RECOIL OF THE LUNG. THE LUNGS BECOME MORE ROUNDED AND SMALLER. THE YEARS OLD
NUMBER OF FUNCTIONAL ALVEOLI DECREASES AS A RESULT OF ALVEOLAR SUPPORTING
STRUCTURE AND LOSS OF INTRA ALVEOLAR SEPTUM, THESE CHANGES ARE SIMILAR TO
THOSE SEEN IN THE PATIENT WITH EMPHYSEMA.

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 CHRONIC UNCONTROLLED ASTHMA PRESENT

 LOW SOCIOECONOMIC STATUS HER FAMILY

INCOME IS RS
10,000/
MONTH.

 BIO MASS FUEL SMOKE, OPEN FIRES ABSENT

 LOW BIRTH WEIGHT ABSENT

PATHOPHYSIOLOGY:-

IN COPD, THE AIRFLOW LIMITATION IS BOTH PROGRESSIVE AND ASSOCIATED WITH AN

ABNORMAL INFLAMMATORY RESPONSE OF THE LUNGS TO NOXIOUS PARTICLES OR GASES. THE
INFLAMMATORY RESPONSE OCCURS THROUGHOUT THE AIRWAYS, PARENCHYMA, AND
PULMONARY VASCULATURE. BECAUSE OF THE CHRONIC INFLAMMATION AND THE BODY’S
ATTEMPTS TO REPAIR IT, NARROWING OCCURS IN THE SMALL PERIPHERAL AIRWAYS. OVER
TIME, THIS INJURY-AND-REPAIR PROCESS CAUSES SCAR TISSUE FORMATION AND NARROWING
OF THE AIRWAY LUMEN. AIRFLOW OBSTRUCTION MAY ALSO BE DUE TO PARENCHYMAL
DESTRUCTION AS SEEN WITH EMPHYSEMA, A DISEASE OF THE ALVEOLI OR GAS EXCHANGE
UNITS.

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Noxious particle & gases

(e.g. tobacco smoke, air
pollution)

Inflammation of Peripheral airway Parenchymal destruction Pulmonary vascular

central airways: changes
• Remodeling • Imbalance between
• Inflammatory proteinase
• Thick vessels
cells &antiproteinase.
• Inflammatory
(lymphocytes, cells infiltrate.
macrophages, • Collagen
neutrophils) deposit.
• Inflammatory • Destruction of
mediators. capillary bed.

COPD

• Mucus hypersecretion
• Cilia dysfunction
• Airflow limitation
• Hyperinflexion of lungs
• Gas exchange abnormalities
• Pulmonary hypertension
• Corpulmonale

CLINICAL MANIFESTATION:-

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CHRONIC BRONCHITIS
USUALLY INSIDIOUS, DEVELOPING OVER A PERIOD OF YEARS

 PRESENCE OF A PRODUCTIVE COUGH LASTING AT LEAST 3 MONTHS A YEAR FOR 2

SUCCESSIVE YEARS.
 PRODUCTION OF THICK, GELATINOUS SPUTUM; GREATER AMOUNTS PRODUCED
DURING SUPERIMPOSED INFECTIONS.
 WHEEZING AND DYSPNEA AS DISEASE PROGRESSES

EMPHYSEMA
GRADUAL IN ONSET AND STEADILY PROGRESSIVE

 DYSPNEA, DECREASED EXERCISE TOLERANCE.

 COUGH MAY BE MINIMAL, EXCEPT WITH RESPIRATORY INFECTION.
 SPUTUM EXPECTORATION€”MILD.
 INCREASED ANTEROPOSTERIOR DIAMETER OF CHEST (BARREL CHEST) DUE TO AIR
TRAPPING WITH DIAPHRAGMATIC FLATTENING.

BOOK PICTURE PATIENT PICTURE

COUGH WITH EXPECTORATION, SPUTUM IS

 INTERMITTENT COUGH WHICH IS THE EARLIEST SYMPTOM, WHITE IN COLOUR. IT IS MORE IN NIGHT.
USUALLY OCCURS IN THE MORNING WITH THE
EXPECTORATION OF SMALL AMOUNT OF STICKY MUCOUS
RESULTING FROM BOUTS OF COUGHING.
 DYSPNEA , USUALLY OCCURS WITH EXERTION. PRESENT, MORE IN SUPINE POSITION.

 WHEEZING AND CHEST TIGHTNESS MAY BE PRESENT, BUT PRESENT.

MAY VARY BY TIME OF THE DAY OR FROM DAY TO DAY,
ESPECIALLY IN PATIENT WITH MORE SEVERE DIASEASE. THE
WHEEZE MAY ARISE FROM LARYNGEAL AREA, OR MAY NOT
BE PRESENT ON AUSCULTATION.
 PROLONGED EXPIRATORY PHASE OF RESPIRATION(>6 SEC) PRESENT.

 BARREL CHEST: THE ANTERIOR-POSTERIOR DIAMETER OF PRESENT.

THE CHEST IS INCREASED FROM THE CHRONIC AIR
TAPPING.
 DECREASED MOVEMENT OF CHEST PRESENT.

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 POOR DIAPHRAGM EXCURTION PRESENT.

 DECREASED BREATH SOUND ABSENT
 OBLITERATION OF CARDIAC AND LIVER DULLNESS ABSENT
RONCHI- IN EARLY DISEASE PRESENT ON FORCED PRESENT.
EXPIRATION, LATER PRESENT IN INSPIRATION AND
EXPIRATION
 HEMOPTYSIS ABSENT
 HYPOXAEMIA (PAO₂<60MMHG OR O₂ SATURATION <88%) SATURATION IS 94% WITH OXYGEN
 HYPERCAPNIA (PAO₂>45MMHG) ABSENT
 HYPERINFLATION: ¯ CARDIAC DULLNESS, LIVER DULLNES, A-P CHEST DIAMETER, ¯ HEART AND BREATH
A-P CHEST DIAMETER, ¯ HEART AND BREATH SOUNDS SOUNDS ARE PRESENT.
 CYANOSIS ABSENT
 WEIGHT LOSS AND ANOREXIA PRESENT

 CACHEXIA ABSENT

 FATIGUE PRESENT.

 ANKLE EDEMA IN RIGHT SIDED HEART INVOLVEMENT ABSENT

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CLASSIFICATION OF SEVERITY OF COPD:-

STAGE SYMPTOMS Pulmonary function tests

FEV1/FVC FEV1% PREDICTED

0: AT RISK CHRONIC SYMPTOMS NORMAL

(COUGH,SPUTUM SPYROMETRY
PRODUCTION)
1: MILD WITH OR WITHOUT <70% LESS THAN OR EQUAL
SYMPTOMS TO 80%
2: MODERATE WITH OR WITHOUT <70% 50%-80%
SYMPTOMS
3: SEVERE WITH OR WITHOUT <70% 30%- 80%
SYMPTOMS
4: VERY SEVERE WITH OR WITHOUT <70% <30% OR <50% AND
SYMPTOMS CHRONIC ESPIRATORY
FAILURE.
DIAGNOSTIC EVALUATION:-

BOOK PICTURE PATIENT PICTURE

 HISTORY OF SMOKING, OCCUPATIONAL HISTORY, PERSONAL DONE

HISTORY, RESPIRATORY DISEASE.

 PHYSICAL EXAMINATION MAY REVEAL: DONE
 WHEEZING SOUND AND RHONCHI IN AUSCULTATION.
 BARREL SHAPED CHEST.
 EDEMA AND CYANOSIS
 CHEST X-RAY: DONE
 HYPERINFLATION
 INCREASED TRANSLUCENCY OF LUNGS
 BULLA MAY BE SEEN

 PULMONARY FUNCTION TEST:

PFTS DEMONSTRATE AIRFLOW OBSTRUCTION REDUCED NOT DONE
FORCED VITAL CAPACITY (FVC), FEV1, FEV1 TO FVC RATIO;
INCREASED RESIDUAL VOLUME TO TOTAL LUNG CAPACITY

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(TLC) RATIO, POSSIBLY INCREASED TLC

DONE
 ABG LEVELS DECREASED PAO2, PH, AND INCREASED CO2.

 ALPHA1-ANTITRYPSIN ASSAY USEFUL IN IDENTIFYING NOT DONE

GENETICALLY DETERMINED DEFICIENCY IN EMPHYSEMA
 BODY MASS INDEX NORMAL BODY INDEX

 SPUTUM CULTURE AND SENSITIVITY NOT DONE

 COMPLETE BLOOD COUNT DONE

 ECG NOT DONE

 PULSE OXEMETRY 94%

MANAGEMENT:
THE TREATMENT GOALS FOR COPD ARE AS FOLLOWS:

1) THE PREVENTION OF DISEASE PROGRESSION;

2) THE RELIEF OF SYMPTOMS

3) IMPROVEMENT IN EXERCISE TOLERANCE;

4) THE PREVENTION AND TREATMENT OF EXACERBATIONS;

5) THE PREVENTION AND TREATMENT OF COMPLICATIONS;

TREATMENT OPTIONS FOR COPD EXACERBATION INCLUDE SMOKING CESSATION,

OXYGENATION, BRONCHODILATORS, ANTICHOLINGERICS, ANTIBIOTICS& CORTICOSTEROIDS.

1. RISK REDUCTION:

SMOKING CESSATION IS THE SINGLE MOST EFFECTIVE INTERVENTION TO PREVENT COPD OR

SLOW ITS PROGRESSION. REFERRAL TO A SMOKING CESSATION PROGRAM MAY BE HELPFUL.
SMOKING CESSATION CAN BEGIN IN A VARIETY OF HEALTH CARE SETTINGS— OUTPATIENT
CLINIC, PULMONARY REHABILITATION, COMMUNITY, HOSPITAL, AND THE PATIENT’S HOME.

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REGARDLESS OF THE SETTING, THE NURSE HAS THE OPPORTUNITY TO TEACH THE PATIENT
ABOUT THE RISKS OF SMOKING AND THE BENEFITS OF SMOKING CESSATION.

2. OXYGENENATION:
INITIAL THERAPY SHOULD FOCUS ON MAINTAINING OXYGEN SATURATION AT 90 PERCENT
OR HIGHER. OXYGEN SUPPLEMENTATION BY NASAL CANNULA OR FACE MASK IS
FREQUENTLY REQUIRED. ADMINISTERING SUPPLEMENTAL OXYGEN RAISES THE RISK OF
PARTIAL PRESSURE OF OXYGEN.
WITH MORE SEVERE EXACERBATIONS, INTUBATION OR A POSITIVE-PRESSURE MASK
VENTILATION METHOD (E.G., CONTINUOUS POSITIVE AIRWAY PRESSURE [CPAP] IS OFTEN
NECESSARY TO PROVIDE ADEQUATE OXYGENATION).
3. BRONCHODILATORS:
BRONCHODILATORS RELIEVE BRONCHOSPASM AND REDUCE AIRWAY OBSTRUCTION BY
ALLOWING INCREASED OXYGEN DISTRIBUTION THROUGHOUT THE LUNGS AND IMPROVING
ALVEOLAR VENTILATION. THESE MEDICATIONS, WHICH ARE CENTRAL IN THE MANAGEMENT OF
COPD ARE DELIVERED THROUGH A METERED-DOSE INHALER, BY NEBULIZATION, OR VIA THE
ORAL ROUTE IN PILL OR LIQUID FORM. BRONCHODILATORS ARE OFTEN ADMINISTERED
REGULARLY THROUGHOUT THE DAY AS WELL AS ON AN AS-NEEDED BASIS. THEY MAY ALSO BE
USED PROPHYLACTICALLY TO PREVENT BREATHLESSNESS BY HAVING THE PATIENT USE THEM
BEFORE AN ACTIVITY, SUCH AS EATING OR WALKING. BRONCHODILATORS USED ARE:

a) BETA-ADRENERGIC AGONIST AGENTS:

a. ALBUTEROL (PROVENTIL, VENTOLIN, VOLMAX), BITOLEROL (TORNATE),
LEVALBUTEROL (XOPENAX), METAPROTERENOL (ALUPENT), PIRBUTEROL
(MAXAIR), SALBUTAMOL (ASMAVENT), SALMETEROL (SEREVENT),
b. TERBUTALINE (BRETHAIRE)
b) ANTICHOLINERGIC AGENTS:
a. IPRATROPIUM BROMIDE (ATROVENT), OXITROPIUM BROMIDE (OXIVENT) ETC.
c) METHYLXANTHINES:
a. AMINOPHYLLINE (PHYLLOCONTIN), THEOPHYLLINE (SLO-BID, THEO-DUR)

4. CORTICOSTEROIDS:
A SHORT TRIAL COURSE OF ORAL CORTICOSTEROIDS MAY BE PRESCRIBED FOR PATIENTS WITH
STAGE II OR III COPD TO SEE IF PULMONARY FUNCTION IMPROVES AND SYMPTOMS DECREASE.
INHALED CORTICOSTEROIDS VIA MDI MAY ALSO BE USED. EXAMPLES OF CORTICOSTEROIDS IN
THE INHALED FORM ARE BECLOMETHASONE (BECLOVENT, VANCERIL), BUDESONIDE
(PULMICORT), FLUNISOLIDE (AEROBID), FLUTICASONE (FLOVENT), AND TRIAMCINOLONE
(AZMACORT).

5. ANTIBIOTIC CHOICES FOR COPD:

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1. MILD TO MODERATE EXACERBATIONS

FIRST-LINE ANTIBIOTICS:

DOXYCYCLINE (VIBRAMYCIN), 100 MG TWICE DAILY

TRIMETHOPRIM-SULFAMETHOXAZOLE (BACTRIM DS, SEPTRA DS), ONE TABLET TWICE DAILY

AMOXICILLIN-CLAVULANATE POTASSIUM (AUGMENTIN), ONE 500 MG/125 MG TABLET THREE

TIMES DAILY OR ONE 875 MG/125 MG TABLET TWICE DAILY

ALTERNATIVE ANTIBIOTICS

CLARITHROMYCIN (BIAXIN), 500 MG TWICE DAILY

AZITHROMYCIN (ZITHROMAX), 500 MG INITIALLY, THEN 250 MG DAILY

FLUOROQUINOLONES, LEVOFLOXACIN (LEVAQUIN), 500 MG DAILY, GATIFLOXACIN (TEQUIN), 400

MG DAILY, MOXIFLOXACIN (AVELOX), 400 MG DAILY

2. MODERATE TO SEVERE EXACERBATIONS: RECOMMEND IV ANTIBIOTICS:

CEFTRIAXONE (ROCEPHIN), 1 TO 2 G IV DAILY

CEFOTAXIME (CLAFORAN), 1 G IV EVERY 8 TO 12 HOURS

CEFTAZIDIME (FORTAZ), 1 TO 2 G IV EVERY 8 TO 12 HOURS

ANTIPSEUDOMONAL PENICILLINS

PIPERACILLIN-TAZOBACTAM (ZOSYN), 3.375 G IV EVERY 6 HOURS

TICARCILLIN-CLAVULANATE POTASSIUM (TIMENTIN), 3.1 G IV EVERY 4 TO 6 HOURS

FLUOROQUINOLONES

LEVOFLOXACIN, 500 MG IV DAILY

GATIFLOXACIN, 400 MG IV DAILY

HUMIDIFICATIONS NAD NEBULISATION:

O2 OBTAINED FROM CYLINDERS OR WALL IS DRY. DRY O2 HAS AN IRRITATING EFFECT ON MUCUS
MEMBRABES AND DYR SECRETIONS. THEREFORE IT IS IMPORTANT TO HUMIDIFY O 2 WHEN

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ADMINISTERED EITHER BY HUMIDIFICATIONS OR NEBULISATION. A COMMON HUMIDIFICATION

WHEN PATIENT HSA A CATHETER, CANNULA OR LOW FLOW MASK IS BUBBLE THROUGH
HUMIDIFIER. IT IS SMALL PLASTIC JAR FILLED WITH STERILE DISTILLED WATER THAT IS ATTACHED
TO THE O2 SOURCE BY MEANS OF A FLOW METER. O2 PASSES INTO THE JAR, BUBBLES THROUGH
THE WATER AND THEN GOES THROUGH THE PATIENT’S CATHETER, CANNULA OR MASK. THE
PURPOSE OF HUMIDIFIER IS TO RESTORE HUMIDITY CONDITIONS OF ROOM AIR.THE FLOW RATE
SHOULD BETWEEN 1 AND 4L/MIN IS DEPENDENT ON PATIENT PREFERENCE.

NEBULISATION DELIVERS PARTICULATE WATER MIST (AEROSOLS) WITH NEARLY 100% HUMIDITY.
WHEN NEBULISATION IS USED LARGE SIZE TUBING SHOULD BE USED TO CONNECT THE DEVICE
TO A FACE MASK OR T BAR.

SURGICAL MANAGEMENT:

BULLECTOMY:A BULLECTOMY IS A SURGICAL OPTION FOR SELECT PATIENTS WITH BULLOUS

EMPHYSEMA. BULLAE ARE ENLARGED AIRSPACES THAT DO NOT CONTRIBUTE TO VENTILATION
BUT OCCUPY SPACE IN THE THORAX; THESE AREAS MAY BE SURGICALLY EXCISED. MANY TIMES
THESE BULLAE COMPRESS AREAS OF THE LUNG THAT DO HAVE ADEQUATE GAS EXCHANGE.
BULLECTOMY MAY HELP REDUCE DYSPNEA AND IMPROVE LUNG FUNCTION. IT CAN BE DONE
THORACOSCOPICALLY (WITH A VIDEO-ASSISTED THORACOSCOPE).
OR VIA A LIMITED THORACOTOMY INCISION.
LUNG VOLUME REDUCTION SURGERY: TREATMENT OPTIONS FOR PATIENTS WITH END-STAGE
COPD (STAGE III) WITH A PRIMARY EMPHYSEMATOUS COMPONENT ARE LIMITED, ALTHOUGH
LUNG VOLUME REDUCTION SURGERY IS AN OPTION FOR A SPECIFIC SUBSET OF PATIENTS. THIS
SUBSET INCLUDES PATIENTS WITH HOMOGENOUS DISEASE OR DISEASE THAT IS FOCUSED IN
ONE AREA AND NOT WIDESPREAD THROUGHOUT THE LUNGS. LUNG VOLUME REDUCTION
SURGERY INVOLVES THE REMOVAL OF A PORTION OF THE DISEASED LUNG PARENCHYMA. THIS
ALLOWS THE FUNCTIONAL TISSUE TO EXPAND, RESULTING IN IMPROVED ELASTIC RECOIL OF
THE LUNG AND IMPROVED CHEST WALL AND DIAPHRAGMATIC MECHANICS. THIS TYPE OF
SURGERY DOES NOT CURE THE DISEASE, BUT IT MAY DECREASE DYSPNEA, IMPROVE LUNG
FUNCTION, AND IMPROVE THE PATIENT’S OVERALL QUALITY OF LIFE
LUNG TRANSPLANTATION:
PATIENTS WHO ARE LESS THAN 65 YEARS OLD WITH END-STAGE COPD IN THE ABSENCE OF
OTHER SIGNIFICANT DISEASE SHOULD BE CONSIDERED FOR LUNG TRANSPLANT EVALUATION
AND REFERRAL.LUNG TRANSPLANTATION IS A VIABLE ALTERNATIVEFOR DEFINITIVE SURGICAL
TREATMENT OF END-STAGE EMPHYSEMA. ITHAS BEEN SHOWN TO IMPROVE QUALITY OF LIFE
AND FUNCTIONAL CAPACITY.

RESPIRATORY AND PHYSICAL THERAPY:

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RESPIRATORY AND PHYSICAL THERAPY SHOULD BE GIVEN REPIARATORY AND PHYSICAL

THERAPIST DEPENDING ON THE INSTITUTIONS. RESPIRATORY AND PHYSICAL THERAPY INCLUDE
BREATHING RETRAINING,EFFECTIVE COGH TECHNIQUES, RESPIRATORY AND CHEST
PHYSIOTHERAPY.

1. BREATHING RETRAINING:
 PURSED LIP BREATHING : THE PATIENT IS TAUGHT TO INHALE SLOWLY THROUGH THE
NOSE AND THEN TO EXHALE SLOWLY, THROUGH PURSED LIP, ALMOST AS IF
WHISTLING. EXHALATION SHOULD ATLEAST 3 TIMES AS LONG AS INHALATION.
 DIAPHRAGMATIC BREATHING.

2. EFFECTIVE COUGHING:
 THE MAIN GOAL IS TO CONSERVE ENERGY, REDUCE FATIGUE AND REMOVAL OF
SECRETION.
 HUFF COUGHING

3. CHEST PHYSIOTHERAPY:
INDICATED TO THE PATIENT WITH EXCESSIVE BRONCHIAL SECRETION WITH EXPECTORATED
SPUTUM PRODUCTION GREATER THAN 25ML/DAY.EVIDENCE OF RETAINED SECRETION IN
THE PRESENCE OF ARTIFICIAL AIRWAY, LOBAR ATELECTASIS CAUSED BY MUCOUS PLUGGING.
CHEST PHYSIOTHERAPY CONSISTS OF PERCUSSION, VIBRATION AND POSTURAL DRAINAGE.
PERCUSSION AND VIBRATION ARE MANUAL OR MECHANICAL TECHNIQUES USED TO
AUGMENT POSTURAL DRAINAGE. PERCUSSION AND VIBRATION ARE USED AFTER POSTURAL
DRAINAGE TO ASSIST IN LOOSENING THE MOBILIZED SECRETION.

4. NUTRITIONAL THERAPY:
 SHOULD REST AT LEAST FOR 30 MINUTES BEFORE EATING.
 USE BRONCHODILATORS BEFORE MEAL AND SELECT FOOD THAT CEN BE PREPARED
IN ADVANCED.
 SHOULD EAT FIVE TO SIX SMALL, FREQUENT MEAL TO AVOID FEELING OF BLOATING
AND EARLY SATIETY WHEN EATING.
 FOOD THAT REQUIRE GREAT DEAL OF CHEWING SHOULD BE AVOIDED. COLD FOOD
MAY GIVE LESS OF SENSE OF A FULLNESS THAN HOT FOOD.
 THEY MAY NEED 25 – 45 KCAL/KG AND1.2 -1.9G OF PROTEIN KILOGRAM TO
MAINTAIN THEIR WEIGHT.
 HIGH CALORIE AND HIGH PROTEIN DIET IS RECOMMENDED.
 MEGESTROL HAS BEEN USED TO STIMULATE AND INCREASE APPETITE.
 FLUID INTAKE SHOULD BE AT LEAST 3L/DAY UNLESS CONTRA-INDICATED.

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DRUG
STUDY

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MEDICATION:-

NAME OF DOSAGE/ MODE OF ACTION SIDE EFFECT NSG RESPONSIBILITY

DRUG ROUTE
INJ. 1GM CEFTRIAXONE IS A THIRD- CENTRAL NERVOUS SYSTEM- TAKE HISTORY OF CEPHALOSPORIN
CTRIAXONE /IV/BD GENERATION DIZZINESS, ALLERGY.
CEPHALOSPORIN HEADACHE.
ANTIBIOTIC; IT HAS BROAD
SPECTRUM ACTIVITY GASTROINTESTINAL- TAKE HISTORY OF LACTATING
AGAINST GRAM POSITIVE DIARRHEA, WOMEN BECAUSE IT CAN ENTER
AND GRAM NEGATIVE NAUSEA AND VOMITING. INTO BREAST MILK.
BACTERIA. IN MOST CASES,
IT IS CONSIDERED TO BE BLOOD- ASSESS PATIENT OF FEVER FOR
EQUIVALENT TO HIGH CONCENTRATION OF EOSINOPHILS, DIARRHOEA BECAUSE IT CAUSES
CEFOTAXIME IN TERMS OF PLATELET COUNTS IN THE BLOOD, COLITIES.
SAFETY AND EFFICACY. DECREASE IN WHITE BLOOD CELLS,
LOW PROTHROMBIN LEVELS, ASSESS FOR PATACHY, ECHIMOSIS
BLEEDING. NOSE BLEEDING AND ANY UNUSUAL
BLEEDING WITHOUT SPECIFIC
LAB TESTS- REGIONS.
INCREASE IN LIVER ENZYME,
ELEVATED BUN (BLOOD UREA, NITROGEN).
LOCAL- INDURATIONS/TIGHTNESS/WARMTH.

GENITOURINARY-
VAGINAL INFLAMMATION.

MISCELLANEOUS- FATAL CEFTRIAXONE-CALCIUM

PRECIPITATES IN LUNG AND KIDNEYS OF
NEONATES.

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NAME OF DOSAGE/ MODE OF ACTION SIDE EFFECT NSG RESPONSIBILITY

DRUG ROUTE
INJ. 50MG BLOCK HISTAMINE H2 INTERFERE WITH ABSORPTION, - DRUG IS GIVEN BY FOLLOWING
RANTAC ORALLY RECEPTOR IN STOMACH AND HEADACHE, FIVE R’S.
BD PREVENT HISTAMINE- DIZZINESS, - IT SHOULD NOT BE GIVEN WITH
MEDIATED GASTRIC ACID HYPERSENSITIVITY, FOOD OR IMMEDIATELY AFTER
SECRETION. ACID SECRTION AND CONFUSION. TAKING FOOD AS IT INTERFERES
IN RESPONSE TO WITH ABSORPTION.
PENTAGASTRIN AND FOOD - BEFORE GIVING FIRST DOSE,
IS ALSO INHIBITED. CHECK FOR HYPERSENSITIVITY
REACTION.
- NOTE FOR ANY SIDE EFFECTS LIKE
HEADACHE, DIZZINESS, CONFUSION
ETC

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NAME OF DOSAGE/ MODE OF ACTION SIDE EFFECT NSG RESPONSIBILITY

DRUG ROUTE
NEBULISATIO 100µGM/6 IT STIMULATES BET TREMORS, SHOULD REDUCE THE DOSE IN
TH
N SALBUTA- HOURLY ADRENERGIC RECEPTORS TO HYOKINESA, CARDIAC PATIENT.
MOL PRODUCE NAUSEA VOMITING,
SYMPATHOMIMETICNACTIO HEADACHE,
NS IN SMOOTH MUSCLES. TACHYCARDIA,
ARRHYTHMIAS,
MUSCLE CRAMPS
AND PALPITATION.
NAME OF DOSAGE/ MODE OF ACTION SIDE EFFECT NSG RESPONSIBILITY
DRUG ROUTE
SYRUP 2 TSP POTENT MUCOLYTIC AND RHINORRHOEA, USE CAUTIOUSLY IN RENAL AND
MUCOLITE MUCOKINETIC AGENT, LACRIMATION, HEPATIC PATIENT.
CAPABLE OF BRINGING OUT GASTRIC IRRITATION
BRONCHIAL SECREATION AND HYPERSENSITIVITY.
ESPECIALLY MUCOUS PLUGS.
NAME OF DOSAGE/ MODE OF ACTION SIDE EFFECT NSG RESPONSIBILITY
DRUG ROUTE
INJ. 500MG/SO IT BLOCKS PROSTAGLANDIN NAUSEA, VOMITING, USE CAUTIOUSLY IN RENAL AND
PARACETAMO S SYNTHESIS BY LEUKOPENIA, , HEPATIC PATIENT. USE IN UNDER 3
L. CYCLOXYGENASE PATHWAY. LIVER DMAGE FOLLOWING OVERDOSE. MONTHS WITH EXTREME CAUTION.
INHIBITS THROMBOXANE A2 REDUCED DOSE NECESSARY UPTO
FORMATION IN PLATELETS 12 YEARS.
REDUCING PLATELET
AGGREGATION.

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NURSING
CARE -PLAN

NURSING DIAGNOSIS:

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1. INEFFECTIVE AIRWAY CLEARANCE RELATED TO BRONCHO CONSTRICTION, INCREASED MUCUS PRODUCTION, INEFFECTIVE
COUGH AS EVIDENCED BY COUGH WITH SPUTUM, PRESENCE OF ABNORMAL BREATH SOUNDS, SPO2 90% WITH OXYGEN,
INCREASED RESPIRATORY RATE.

2. INEFFECTIVE BREATHING PATTERN RELATED TO CHRONIC AIRFLOW LIMITATION, ALVEOLAR HYPOVENTILATION AS EVIDENCED BY
DYSPNOEA, INCREASED RESPIRATORY RATE, DECREASED OXYGEN SATURATION.

3. IMPAIRED GAS EXCHANGE RELATED TO CHRONIC PULMONARY OBSTRUCTION, ABNORMALITIES DUE TO DESTRUCTION OF
ALVEOLAR CAPILLARY MEMBRANE AS EVIDENCED PACO2 ≥45MMHG, PAO2<60MMHG, SPO2 90%.

4. IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS RELATED TO INCREASED WORK OF BREATHING, AIR SWALLOWING,
DEPRESSION AS EVIDENCED BY HB-7.2GM%, PALLOR OF SKIN, WEIGHT 65KG.

5. ACTIVITY INTOLERANCE RELATED TO COMPROMISED PULMONARY FUNCTION, RESULTING IN SHORTNESS OF BREATH AND
FATIGUE.
6. DISTURBED SLEEP PATTERN RELATED TO HYPOXEMIA, DYPSNEOA, COUGH, ANXIETY AND HYPERCAPNIA AS EVIDENCED BY
FREQUENT AWAKENING, PROLONGED ONSET OF SLEEP, LETHARGY.

7. HYPERTHEMIA RELATED TO INCREASED WBC COUNTS SECONDARY TO RESPIRATORY INFECTION

8. INEFFECTIVE COPING RELATED TO THE STRESS OF LIVING WITH CHRONIC DISEASE, LOSS OF INDEPENDENCE.

APPLICATION OF ROYS ADAPTATION MODEL:-

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STIMLI EFFECTORS

INEFFECTIVE AIRWAY CLEARANCE.

FOCAL
INEFFECTIVE BREATHING PATTERN.
BRONCHO CONSTRUCTION
PRESENT. PHYSIOLOGICAL IMPAIRED GAS EXCHANGE,
BRONCHIALINFLAMATORY FUNCTION IMBALANCED NUTRITION: LESS THAN BODY
PROCESS.
ACTIVITY INTOLERANCE
HYPERMUCOSAL SERETION.
DISTURBED SLEEP PATTERN
DESTRUCTION OF ALVEOLAR SELF-CONCEPT INTERVENTIONS
CAPILLARY MEMBRANE HYPERTHEMIA
WBC COUNT-15500/CUMM.
ROLE-FUNCTION
LOW HB LEVEL-7.6 GM %.

CONTEXTUAL: INEFFECTIVE FAMILY COPING

INTERDEPENDENCE
CHRONIC SMOKER

ADVANCED AGE-72 Y

MALE

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NURSING CARE PLAN-1

ASSESSMENT OF ASSESSMENT OF NURSING GOAL INTERVENTION EVALUATION
BEHAVIOUR STIMULI DIAGNOSIS
SUBJECTIVE:- FOCAL: INEFFECTIVE THE PATIENT ASSESSED THE GENRAL CONDITION OF THE GOAL WAS
PATIENT SAYS HE CAN’T BRONCHO AIRWAY WILL HAVE THE PATIENT.
PARTIALLY MET AS
INSPIRE AIR INTO CONSTRUCTION CLEARANCE CLEAR AIRWAY DYSPOEA PRESENT,RR-22/M.
PRESENT. RELATED TO AS EVIDENCE BY OXYGENATION-82% ON O2 4 L/M. EVIDENCE BY
LUNGS.
PRSENCE OF ABSENCE OF PERIPHERAL CYNOSIS-PRESENT.
ABSENCE OF
BRONCHIAL SECRETION, SECRITION, AUSCULTATION-WHEEZING PRESENT.
INFLAMATORY BRONCHO- SPo2-95-100%, EXCESS SECRITION –PRESENT. SECRETION
PROCESS. CONSTRUCTION AND ABSENCE
,REDUCTION OF
SECONDARY TO OF WHEEZING. SEMI-FOWLER POSITION GIVEN TO
EXCESS MUCOSL C.O.P.D. THE PATIENT. WHEEZING AND
OBJECTIVE DATA:- SECRETION.
SPO2-100% ON
ADMINISTERED OXYGEN TO THE
 DYSPONEA-
CONTEXTUAL: PATIENT, 4 L/M. 4L/MINUTE OXYGEN.
PRESENT.
RESPI. INFECTION
 USE ASSESSORY
WBC COUNT- NEBULISATION GIVEN TO THE PATIENT
MUSCLE FOR
15500/CUMM. (WITH DUOLIN & BUDOCORT).
BREATH.
 HYPOXIA-SPo2-
PROVIDED CHEST PHYSIOTHERAPY TO
82%.
THE PATIENT.
 CYNOSIS-
PRESENT.
TAUGHT PATIENT ABOUT EFFECTIVE
 LOOK
COUGHING MECHANISUM.
REATLESSNESS&
WEAK.
 INEFFECTIVE
MONITORE VITAL SIGNS OF THE
COUGH
PATIENT.
RESPONSE.

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NURSING CARE PLAN-2

ASSESSMENT OF ASSESSMENT OF NURSING GOAL INTERVENTION EVALUATION
BEHAVIOUR STIMULI DIAGNOSIS
SUBJECTIVE:- FOCAL: THE PATIENT ASSESSED THE GENRAL CONDITION OF THE GOAL WAS
PATIENT SAYS THAT HE BRONCHO INEFFECTIVE WILL HAVE THE PATIENT.
PARTIALLY MET AS
CAN’T BREATH CONSTRUCTION BREATHING NORMAL DYSPOEA PRESENT,RR-22/M.
PROPERLY. PRESENT. PATTERN RELATED BREATHING OXYGENATION-82% ON O2 4 L/M. EVIDENCE BY
TO CHRONIC PATTERN AS PERIPHERAL CYNOSIS-PRESENT.
RR-25/M
BRONCHIAL AIRFLOW EVEDENCE BY AUSCULTATION-WHEEZING PRESENT.
INFLAMATORY LIMITATION, NORMAL EXCESS SECRITION –PRESENT. AND SPO2-100% ON
OBJECTIVE DATA:- PROCESS. ALVEOLAR RR-16-20.
4L/MINUTE OXYGEN.
DYSPONEA-PRESENT. HYPERMUCOSAL HYPOVENTILATION OXYGENATION- SEMI-FOWLER POSITION GIVEN TO
SERETION, AS EVIDENCED BY SPo2-95-100%. THE PATIENT. AND REDUCTION OF
USE ASSESSORY MUSCLE DYSPNOEA AND ABSENCE
FOR BREATH. ASSOSSORY MUSCLE
ALVEOLAR DAMAGE INCREASED OF ASSOSSORY ADMINISTERED OXYGEN TO THE
RESPIRATORY MUSCLE USE. PATIENT, 4 L/M. USE.
CYNOSIS-PRESENT.
RATE, DECREASED
INEFFECTIVECOUGH CONTEXTUAL: OXYGEN
RESPONSE. RESPI. INFECTION SATURATION. PROVIDED CHEST PHYSIOTHERAPY TO
WBC COUNT- THE PATIENT.
RR-35/M. 15500/CUMM.
PROVIDED DEEP BREATHING
IRREGULAR RESPIRATION LOW HB LEVEL- EXERCISE&SPIROMETERY TO PATIENT.
7.6 GM %.
NOT EXPANDING FULL MONITORED VITAL SIGNS OF THE
LUNG DURING PATIENT EVERY 1 HOURLY.
INSPIRATION.

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NURSING CARE PLAN-3

ASSESSMENT OF ASSESSMENT OF NURSING GOAL INTERVENTION EVALUATION

BEHAVIOUR STIMULI DIAGNOSIS
SUBJECTIVE:- FOCAL: THE PATIENT ASSESSED THE GENRAL CONDITION OF THE GOAL WAS
PATIENT SAYS THAT HE BRONCHO IMPAIRED GAS WILL HAVE THE PATIENT.
PARTIALLY MET AS
FEELS RESTLESSNESS , CONSTRUCTION EXCHANGE NORMAL GAS DYSPOEA PRESENT,RR-22/M.
FATIGUE. PRESENT. RELATED TO EXCHANGE AS OXYGENATION-82% ON O2 4 L/M. EVIDENCE BY
AND GIDINESS. CHRONIC EVIDENCE BY PERIPHERAL CYNOSIS-PRESENT.
RR-25/M
BRONCHIAL PULMONARY SPO2 100% AND AUSCULTATION-WHEEZING PRESENT.
INFLAMATORY OBSTRUCTION, ABSENCE OF EXCESS SECRITION –PRESENT. AND SPO2-100% ON
PROCESS. ABNORMALITIES PERIPHERAL
4L/MINUTE OXYGEN.
OBJECTIVE DATA:- DUE TO CYNOSIS AND SEMI-FOWLER POSITION GIVEN TO
HYPERMUCOSAL DESTRUCTION OF NORMAL-RR THE PATIENT. AND NORMAL ABG
PERIPHERAL CYNOSIS- SERETION AND ALVEOLAR (16-20).
PRESENT. ANALYSIS VALUE.
ACCUMLATION IN CAPILLARY ADMINISTERED OXYGEN TO THE
ALVEOLI. MEMBRANEAS PATIENT, 4 L/M.
HYPOXIA:-SPO2-82%. EVIDENCED PACO2
DESTRUCTION OF ≥45MMHG, MONITORED ABG ANALYSIS- PACO2
RR-35/M.
ALVEOLAR PAO2<60MMHG, ≥45MMHG, PAO2<60MMHG
CAPILLARY SPO2 90%.
NOT EXPANDING FULL
LUNG DURING MEMBRANE PROVIDED DEEP BREATHING
INSPIRATION. CONTEXTUAL: EXERCISE&SPIROMETERY TO PATIENT.
RESPI. INFECTION
X-RAY: BOTH SIDE WBC COUNT- MONITORED VITAL SIGNS OF THE
INFILTRATION OF LUNG 15500/CUMM. PATIENT EVERY 1 HOURLY.
TISSUE.
ABG:PACO2 ≥45MMHG, LOW HB LEVEL-
ADMINISTER ANTIBIOTICS AS
7.6 GM %.

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PAO2<60MMHG BP- 100/70. PRESCRBED TO REDUCE LUNG

CRP- 2 SEC. DAMAGE

PATIENT NAME: - Mr. GULUF DADUBHAI SHINDENURSE’S NOTE-1DIAGNOSIS:-CO.P.D..

AGE:- 72 YEAR D.O.A:- 28/02/2020

SEX:- MALE SURGERY:-NOT DONE

WARD:- MEDICINE I.C.U. STUDENT NAME-SONALI VAIDHYA

DATE DIET MEDICATION TIME NURSING OBSERVATION NURSING CARE REMARK SIGN.

29/02/20 9am INJ.C-TRIE 1 GM, IV, 9am My patient mr.gulufdadubhaishinde, Assessed the Patient was co- SONALI
Breakfast:- BD 10, 10. 72 yr. male admitted with complaints general condition of operative
of breathlessness cough with copious the patient
POHA 1 PLATE INJ. RANTAC 50 MG
expectoration and diagnosed as
Tea-50 ml ,IV,
C.O.P.D.
TDS, 6,2,10.

INJ. EMSET 4 MG IV Patient was not slept at last night

TDS.6, 2, 10. because of breathlessness&cough.

INJ FEBRINIL 500 MG Patient has activity intolerance due to

IV BD & SOS.
dyspnea& low HB level.
TAB FOLVIT 5 MG PO,
OD, 10 AM. Patient’s personal hygiene is
maintained
CAP. AUTRIN PO, OD,
2PM. Patient has loss of appetite due to
reastlesness&fever.

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SYP ASCORYL 2 TSF, Patient bowel and bladder movement

TDS, PO, 9, 3,9. is normal.
Intracath was present on left hand
NEBU WITH Bed making done Bed looks clean and SONALI
DOULINE,QID 6, tidy.
12,6,12.
Patient bed looks unclean and untidy
NEBU WITH
BUDOCORT, QID 6, Vital signs checked Patient is febrile,
12,6,12. T -99.4F, BP-100/70 trachypoea present
P -88/m ,RR-35/m
Vital sign has to be check
Medication given to No local
the patient. complication
occurred.
Tepid sponge and Temp-98.6 f.
Medication has to be give Inj. febrinil 500 mg.
is given

Patient has fever (99.4 f) Nebulization with Patients secretion

douline& budocort removed & cough is
is given. relived

History taking Patient is coperative

&physical
Patient cough with expectorant lead
examination is done
to abdominal pain.

Patient is sited alone

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PATIENT NAME: - Mr. GULUF DADUBHAI SHINDE NURSE’S NOTE- 2DIAGNOSIS:-CO.P.D..

AGE:- 72 YEAR D.O.A:- 28/02/2020

SEX:- MALE SURGERY:-NOT DONE

WARD:- MEDICINE I.C.U. STUDENT NAME-SONALI VAIDHYA

DATE DIET MEDICATION TIME NURSING OBSERVATION NURSING CARE REMARK SIGN.

2/3/2020 9am INJ.C-TRIE 1 GM, IV, 9am Patient is oriented to time place, Assessed the Patient was co- SONALI
Breakfast:- BD 10, 10. person. general condition of operative
Patient is restless and looks weak. the patient
POHA 1 PLATE INJ. RANTAC 50 MG
Tea-50 ml ,IV, Patient was not slept at last night
TDS, 6,2,10. because of breathlessness & cough.

INJ. EMSET 4 MG IV Patient has activity intolerance due to

TDS.6, 2, 10. dyspnea& low HB level.

INJ FEBRINIL 500 MG Patient’s personal hygiene is

IV BD & SOS. maintained

TAB FOLVIT 5 MG PO, Patient has loss of appetite due to

OD, 10 AM. restlessness &fever.

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CAP. AUTRIN PO, OD, Patient bowel and bladder movement

2PM. is normal.
Intracath was present on left hand

SYP ASCORYL 2 TSF,

TDS, PO, 9, 3,9.
Patient bed looks unclean and untidy Bed making done Bed looks clean and
NEBU WITH DOULINE, tidy.
QID 6, 12,6,12.
SONALI
NEBU WITH
BUDOCORT, QID 6, Vital sign has to be check Vital signs checked Patient is febrile,
12,6,12. T -100F, BP-100/70 trachypoea present
P -88/m ,RR-35/m

Medication has to be give Medication given to No local

the patient. complication
occurred.
Patient has fever (100 f) Tepid sponge and Temp-98.6 f.
Inj. febrinil 500 mg.
is given

Patient cough with expectorant lead Nebulization with Patients secretion

to abdominal pain. douline& budocort removed & cough is
is given. relived

Patient is sited alone Health education Patient is positive

regarding his disese
condition and its
management is
given

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NURSE’S NOTE- 3
PATIENT NAME: - Mr. GULUF DADUBHAI SHINDE DIAGNOSIS:-CO.P.D..
AGE:- 72 YEAR D.O.A:- 28/02/2020

SEX:- MALE SURGERY:-NOT DONE

WARD:- MEDICINE I.C.U. STUDENT NAME-SONALI VAIDHYA

DATE DIET MEDICATION TIME NURSING OBSERVATION NURSING CARE REMARK SIGN.

3/3/2020 9am INJ.C-TRIE 1 GM, IV, 9am Patient is oriented to time place, Assessed the Patient was co- SONALI
Breakfast:- BD 10, 10. person. general condition of operative
the patient
POHA 1 PLATE INJ. RANTAC 50 MG Patient was slept at last night because
Tea-50 ml ,IV, of breathlessness & cough is reduced.
TDS, 6,2,10.
Patient has activity intolerance due to
INJ. EMSET 4 MG IV dyspnea& low HB level.
TDS.6, 2, 10.
Patient’s personal hygiene is
INJ FEBRINIL 500 MG maintained
IV BD & SOS.
Patient’s appetite is improved due to
TAB FOLVIT 5 MG PO, reduction in fever.
OD, 10 AM.

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Patient bowel and bladder movement

CAP. AUTRIN PO, OD, is normal.
2PM. Intracath was present on left hand

SYP ASCORYL 2 TSF,

TDS, PO, 9, 3,9. Patient bed looks unclean and untidy
Bed making done Bed looks clean and
NEBU WITH DOULINE, tidy.
QID 6, 12,6,12.

NEBU WITH Vital sign has to be check

BUDOCORT, QID 6, Vital signs checked Patient is febrile,
12,6,12. T -100F, BP-100/70 trachypoea present
P -88/m ,RR-35/m

Medication has to be give

Medication given to No local
the patient. complication
occurred.

Patient cough with expectorant lead

to abdominal pain. Nebulization with Patients secretion
douline& budocort removed & cough is
is given. relived
Patient’s ABG analysis has to monitor.
ABG sample taken Patient is
from femoral artery. cooperative

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PROGNOSIS NOTE:-

FIRST-DAY:-
 Patients vital signs checked its tachycardia (105),trachypnoea(35),bp(100/70),and febrile
(99.4 f.).
 Continuous cough with expectorant preset.
 Patient looks breathless on activity, fatigue &restlessness is there due to fever.
 Peripheral cyanosis is present,SPo2-82%.
 ABG value shows respiratoy acidosis.

SECOND-DAY:-

 Patients vital signs checked its tachycardia (105),trachypnoea(35),bp(100/70),and febrile

(99.4 f.).
 Continuous cough with expectorant preset.
 Patient looks breathless on activity, fatigue & but restlessness& fever are reduced.
 Peripheral cyanosis is absent, SPo2-90%.ON 4 L/M oxygen.
 ABG value is normal.

THIRD DAY:-

 Patients vital signs checked its pulse (88),trachypnoea(30),bp(110/70),and afebrile (98.6

f.).
 cough with expectorant preset but reduced in intensity
 Patent’s breathlessness is reduced, appetite is improved.
 patient is showing improvements as compare to first day of admission.

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HEALTH EDUCATION:
1. TO CONTROL COUGH AND PHLEGM

 DRINK PLENTY OF WATER (8 TO 10 GLASSES PER DAY) TO KEEP PHLEGM THIN.

 USE INHALERS ON A REGULAR BASIS AS PRESCRIBED:

o BRONCHODILATORS, SUCH AS PROVENTIL, TO OPEN UP THE AIRWAYS.

o ATROVENT TO DECREASE COUGH AND MUCOUS PRODUCTION.
o CORTICOSTEROIDS TO REDUCED SWELLING.

 AVOID IRRITANTS TO THE LUNGS, SUCH AS CIGARETTE SMOKE, DUST, SMOG, PERFUME,
COLD AIR, AND VERY HOT AIR.
 REPORT CHANGE IN COLOR, AMOUNT, OR THICKNESS OF PHLEGM THAT COULD
INDICATE AN INFECTION.

 TRY TO AVOID RESPIRATORY INFECTIONS BY LIMITING CONTACT WITH PEOPLE DURING

COLD AND FLU SEASON. GET THE INFLUENZA AND PNEUMONIA VACCINES AND WASH
HANDS FREQUENTLY.

2. TO CONTROL SHORTNESS OF BREATH

 PRACTICE PURSED-LIP BREATHING BY BREATHING IN THROUGH THE NOSE AND OUT

THROUGH PURSED LIPS (LIKE YOU ARE WHISTLING), WITH A LONG, SLOW EXPIRATION.
 POSITION YOURSELF FOR BETTER BREATHING BY LEANING FORWARD WHILE SITTING
WITH ELBOWS ON TABLE OR RESTING ON KNEES.
 USE RELAXATION TECHNIQUES, SUCH AS LISTENING TO SOFT MUSIC, IMAGINING YOU
ARE IN A QUIET PEACEFUL PLACE, OR HAVING SOMEONE GIVE YOU A MASSAGE.
 IF PRESCRIBED, USE OXYGEN AS DIRECTED, ESPECIALLY WHILE PERFORMING SUCH
ACTIVITIES AS BATHING, DRESSING, EATING, AND WALKING.
 3. TO CONTROL FATIGUE

 DO NOT STOP DOING PHYSICAL ACTIVITY; INSTEAD, LEARN HOW TO MANAGE BY

PLANNING ACTIVITIES TO CONSERVE ENERGY.
 START WITH AN EXERCISE PROGRAM THAT IS EASY, AND PROGRESS SLOWLY TO
INCREASE YOUR ACTIVITY.
 TALK TO YOUR HEALTH CARE PROVIDER ABOUT JOINING A PULMONARY REHABILITATION
PROGRAM.
 EAT A WELL-BALANCED DIET.
 SLEEP WITH HEAD ELEVATED USING SEVERAL PILLOWS OR IN A RECLINING CHAIR TO
REDUCE SHORTNESS OF BREATH AND INCREASE REST.
 IF AWAKENED BY COUGH, SIT UP, SIP FLUID, AND USE INHALER TO TRY TO CLEAR LUNGS
OF PHLEGM.
 AVOID OVERUSE OF INHALERS, WHICH MAY CAUSE SHAKINESS AND INSOMNIA

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4. TO COMPENSATE FOR POOR APPETITE

 EAT SIX OR MORE SMALL MEALS AND SNACKS PER DAY RATHER THAN TWO OR THREE
LARGE MEALS.
 EAT SLOWLY; PLAN AT LEAST 30 MINUTES PER MEAL. SIT FORWARD WITH ELBOWS
PROPPED ON TABLE.
 UNLESS OTHERWISE DIRECTED, TRY A HIGH-PROTEIN, MODERATE-FAT, AND LOWER-
CARBOHYDRATE DIET OF SUFFICIENT CALORIES TO COVER THE INCREASED WORK OF
BREATHING.
 CONSIDER A HIGH-CALORIE, HIGH-PROTEIN DRINK IF YOU DO NOT FEEL LIKE EATING.

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