I.

Introduction Chronic obstructive pulmonary disease is persistent obstruction of the airways occurring with emphysema, chronic bronchitis, or both disorders. In the United States, about 16 million people suffer from chronic obstructive pulmonary disease (COPD). It is second only to heart disease as a cause of disability that forces people to stop working. It is the fourth most common cause of death, accounting for more than 100,000 deaths per year in the United States; the number of deaths from COPD has increased by 40% over the last 20 years. More than 95% of all deaths from COPD occur in people older than age 55. COPD affects men more often than women and is more often fatal in men, although there has been a recent increase in the rate of deaths in women. COPD is also more often fatal in whites than in nonwhites and in blue-collar workers than in white-collar workers. COPD leads to chronic airflow obstruction, which is defined as a persistent decrease in the rate of airflow through the lungs when the person breathes out. Both emphysema and chronic bronchitis contribute to the airflow obstruction of COPD. Emphysema is irreversible enlargement of many of the 300 million air sacs (alveoli) that make up the lungs and destruction of the air sac walls. Chronic bronchitis is characterized by a cough that produces sputum for 3 months or more during 2 successive years; the cough is not due to another lung disease. The airflow obstruction of COPD leads to an increase in the effort required for a person to breathe. The obstruction causes air to become trapped in the lungs, so that the amount of air remaining in the lungs after a full exhalation is increased. The number of capillaries in the walls of the alveoli decreases. These abnormalities impair the exchange of oxygen and carbon dioxide between the alveoli and the blood. In the earlier stages of COPD, oxygen levels in the blood are decreased, but carbon dioxide levels remain normal. In the later stages, carbon dioxide levels increase and oxygen levels fall even further. The decrease in oxygen levels in the blood stimulates the bone marrow to send more red blood cells into the bloodstream, a condition known as secondary polycythemia.

Cigarette smoking is the most important cause of COPD, although only about 15 to 20% of smokers develop the disease. Pipe and cigar smokers develop COPD more often than nonsmokers but not as often as cigarette smokers. With age, susceptible cigarette smokers lose lung function more rapidly than nonsmokers. If a person stops smoking, there is little improvement in lung function. However, the rate of decline of lung function does return to that of nonsmokers when the person stops smoking, thus delaying the progression of symptoms. COPD tends to occur more often in some families, so there may be an inherited tendency. Working in an environment polluted by chemical fumes or dust may increase the risk of COPD). Exposure to air pollution and to smoke from nearby cigarette smokers (secondhand or passive smoke exposure) worsens a person's COPD and may cause COPD. A rare cause of COPD is a hereditary condition in which the body produces a markedly decreased amount of the protein alpha1-antitrypsin. The main role of this protein is to prevent neutrophil elastase from damaging the alveoli. Consequently, emphysema develops by early middle age in people with severe alpha1antitrypsin deficiency, especially in those who also smoke. This case study is all about Teofilo Aviles, 75 years old from Danao City, Cebu Province. He was admitted at Cebu Doctors University Hospital on June 6, 2006 and was diagnosed with Chronic Obstructive Pulmonary Disease with exacerbation. The student nurse chose this case since statistics show that 95% of deaths with COPD occur in people older than age 55 and this may be a cause for alarm. Because of this, the student nurse wants to increase her knowledge on the illness specifically aiming at its prevention, relieving the symptoms and prevention of complications. Through this study, the student nurse can help a patient diagnosed with this disease to improve his condition through the implementation of proper nursing interventions. From this case study, the student nurse expects to increase her knowledge about Chronic Obstructive Pulmonary Diseases. With the study done, she aims to give the utmost treatment to patients with this disease and health teachings on its prevention.

II. Objectives General Objectives: After one week of student nurse-patient interaction, the student nurse will be able to acquire knowledge, attitude and skills in the management of Chronic Obstructive Pulmonary Disease. Specific Objectives: After 2 days of student nurse patient interaction, the student nurse will be able to: 1. establish rapport with the patient. 2. perform and present a thorough nursing assessment of the patient with COPD using inspection, palpation, percussion and auscultation. 3. relate the effects of the disease to the functional health pattern of the patient. 4. review the normal anatomy and physiology of the respiratory system. 5. compare the classical and clinical manifestations of the actual COPD. 6. develop a comprehensive nursing care plan for the patient. 7. develop an objective with regards to how proper rehabilitation can be performed or facilitated. General Objectives: After one week of student nurse-patient interaction, the patient will be able to acquire knowledge, attitude and skills in the management of Chronic Obstructive Pulmonary Disease. Specific Objectives: After 2 days of student nurse patient interaction, the patient and family will be able to: 1. establish a trusting relationship with the student nurse. 2. cite the factors which caused his present health condition. 3. identify the clinical signs and symptoms of COPD. 4. verbalize feelings and concerns. 5. take appropriate measures for the management of symptoms. 6. follow specific treatment regimen ordered or taught. 7. demonstrate beginning skills in pursed lip breathing for patients with COPD.

III. Nursing Assessment 1. Personal History 1.1 Patients Profile Name of Patient: Teofilo Aviles Age: 75 years old Sex: male Religion: Roman Catholic Date of Admission: June 6, 2006 Room No.: Male Medical Ward no. 1 Complaints: Dyspnea and cough Impression/ Diagnosis: Chronic Obstructive Pulmonary Disease (Chronic Bronchitis) Physician: Dr. Gerardo Ypil Dr. Julius Serrano 1.2 Family and Individual Information, Social and Health History Mr. Teofilo Aviles is a 75 year old widow, Roman Catholic and currently residing at National Road Dunggoan, Danao City, Cebu Province. The patient has 2 male children and both are currently residing in the United States. His wife died at age 60 due to Lung Cancer. The patient used to be a smoker for more than 20 years and smokes at least 1 2 packs per day. The patient is known to be hypertensive for 15 years with fair compliance of medications. His father was also hypertensive but not diabetic. The patient was also diagnosed last march 2006 with Chronic Obstructive Pulmonary Disease and was given Salmetrol/Seretide 250 mcg Diskus 1 puff twice a day. Mr. Aviles has been noted to have on and off dyspnea. About 2 weeks prior to admission, dyspnea was noted upon exertion associated with productive cough with frothy, white phlegm. Continuing with the medication given, no relief was noted. 3 days prior to admission, patient was seen by attending physician to have dyspnea at rest associated with orthopnea and productive cough, thus sought consultation again and was advised for admission.

1.3 Level of Growth and Development 1.3.1 Normal Development at Particular Stage NORMAL DEVELOPMENT (OLDER ADULTS OVER 65 YEARS) Physical Development As the person ages, a number of physical changes occur; some are visible, some are not. In general, lean body mass is reduced and fat tissue increases until around age 60. Bone mass decreases. Extracellular fluid remains constant, however, intracellular fluid decreases and leads to reduced total body fluid. Thus, elders are at risk for developing dehydration. Integumentary

increased skin dryness increased skin pallor increased skin fragility progressive wrinkling and sagging of the skin brown age spots on exposed body parts decreased perspiration thinning and graying of scalp, pubic, and axillary hair slower nail growth and increased thickening with ridges Decreased speed and power of skeletal muscle contractions Slowed reaction time Los of height Osteoporosis Joint stiffness Impaired balance Loss of visual acuity Increased sensitivity to glare and decreased ability to adjust to darkness Partial or complete glossy white circle around the periphery of the cornea

Neuromuscular

Sensory andPerceptual

Progressive loss of hearing Decreased sense of taste, especially the sweet sensations at the tip of the tongue Decreased sense of smell Increased threshold for sensations of pain, touch and temperature Decreased ability to expel foreign r accumulated matter Decreased lung expansion, less effective exhalation, reduced vital capacity, and increased residual volume Difficulty, short, heavy, rapid breathing (dyspnea) following intense exercise Reduced cardiac output and stroke volume, particularly during increased activity or unusual demands; may result in shortness of breath on exertion and pooling of blood in the extremities

Pulmonary

Cardiovascular

Reduced elasticity and increased rigidity of arteries Increase in diastolic and systolic blood pressure Orthostatic hypertension Delayed swallowing time Increased tendency for indigestion Increased tendency for constipation Reduced filtering ability of the kidney and impaired renal function Less effective concentration of urine Urinary urgency and urinary frequency Tendency for a nocturnal frequency and retention of residual urine Prostate enlargement (benign) in men Multiple changes in women (shrinkage and atrophy of the vulva, cervix, uterus, fallopian tubes and ovaries; reduction in secretions; and changes in vaginal flora)

Gastrointestinal

Urinary

Genitals

Cognitive development Changes in the cognitive structures occur as the person ages. It is believed that progressive loss of neurons occur. In addition, blood flow in the brain decreases, the meninges appear to thicken and brain metabolism slows. As yet, little is known about the effect of these physical changes on the cognitive functioning of the older adult. In older adults changes in cognitive abilities are more often a difference in speed than inability. Over all the older adult maintains intelligence, problem solving, judgment, creativity, and other well-practiced cognitive skills. Intellectual loss generally reflects a disease process such as atherosclerosis, which causes the blood vessels to narrow and diminishes perfusion of nutrients to the brain. Most older adults do not experience cognitive impairments. Moral development According to Kohlberg, moral development is completed in the early adult years. Most old people stay at Kohlbergs conventional level of moral development and some are at preconventional level. An older person at the preconventional level obeys rules to avoid pain and the displeasure of others. At stage 1, a person defines good and bad in relation to self, where as older people at stage 2 may act to meet anothers needs as well as their own. Older adults at the conventional level follow societys rules of conduct in response to the expectation of others. The value and belief patterns that are important to older adults may have little or no significance to younger people because they developed during a time that was very different from today. In addition, a large number of todays elders are either foreign-born or first-generation citizens. Cultural background, life experiences, gender, religion, and social economic status all influence ones values. The nurse must identify and consider the specific values of the older client when nursing care is planned. Spiritual development Older adults can contemplate new religions and philosophical views and try to understand ideas missed previously or interpreted differently. The older person also derives a sense of worth by sharing experiences or views. In contrast, the older adult who

has not matured spiritually may feel impoverishment or despair as the drive for economic and professional success wanes. Carson (1989) states that religion takes a new meaning for the elderly, who may find comfort, solace, and affirmation in religious activities. The older person knowledge becomes wisdom, an inner resource for dealing with both positive and negative life experiences. Many older people have strong religious convictions and continue to attend religious meetings or services. Involvement in religion often help the older adult to resolve issues related to the meaning of life, to adversity, or to good fortune. The oldold person who cannot attend formal services often continues religious participations in a more private manner. Many older adults watch television evangelists and some being vulnerable to fund raising ventures, send these organizations money that they can ill afford to spare. According to Fowler and Keen(1985), some people enter the sixth stage of spiritual development universalizing. People whose spiritual development reaches this level think and act in a way that exemplifies love and justice. 1.3.2 The Ill Person at Particular Stage In a person with COPD, a mild cough that produces clear sputum develops by around age 45, usually when the person first gets out of bed in the morning. Cough and sputum production persist for the next 10 years; shortness of breath may be noted with exertion. Sometimes, shortness of breath is first noted only with a lung infection, during which time the person coughs more and has an increased amount of sputum. The color of the sputum changes from clear to yellow or green. By the time the person reaches his middle to late 60s, especially with continued smoking, shortness of breath with exertion becomes more troublesome. A lung infection may result in severe shortness of breath even when the person is at rest and may require hospitalization. Shortness of breath during activities of daily living, such as toileting, washing, dressing and sexual activity may persist after the person has recovered from the lung infection.

About one third of people with severe COPD experience severe weight loss, in part because shortness of breath makes eating difficult and in part because of increased levels in the blood of a substance called tumor necrosis factor. Swelling of the legs often develops, which may be due to cor pulmonale. People with COPD may intermittently cough up blood, which is usually due to inflammation of the bronchi, but which always raises the concern of lung cancer. Morning headaches may occur because breathing decreases during sleep, which causes increased retention of carbon dioxide. As COPD progresses, some people, especially those who have emphysema, develop unusual breathing patterns. Some people breathe out through pursed lips. Others find it more comfortable to stand over a table with their arms outstretched and weight on their palms, a maneuver that improves the function of the diaphragm. Over time, many people develop a barrel chest as the size of the lungs increases because of trapped air. Low oxygen levels in the blood can give a blue tint to the skin (cyanosis). Clubbing of the fingers is rare and raises the suspicion of lung cancer. Symptoms may suddenly worsen during flare-ups of COPD. A flare-up is a worsening of symptoms of cough, increased sputum, and shortness of breath. Sputum color often changes from white to yellow or green. The patient had onset fever and body aches which sometimes occur. Shortness of breath was present when the patient was at rest. 2. Diagnostic Results Complete Blood Count: June 6, 2006 Diagnostic Test hemoglobin hematocrit WBC count neutrophil lymphocyte Normal Value 14.0 17.5 g/dl 41.5 50.4 % 4.4 11.0 x 10^9/ul 40 70 % 20 40 % Result 6.0 g/dl 32.8 % 17.8 x 10^9/ul 89 % 9% Significance Anemia Anemia Acute infections, emphysema, MI Acute infections, acute MI, COPD decreased w/ the use 9

of corticosteroids monocyte RBC MCH MCV MCHC Platelet 08% 4.5 5.9 10^12/L 27.5-33.2 pg 80 96 fL 33.4 35.5 % 150 45010^9/L 2% 2.64 x 10^12/L 22.72 68.18 22.72 150-450 Normal Anemia hypochromic RBCs microcytic RBCs Hemoglobin deficiency Normal

Urinalysis June 6, 2006 Diagnostic Test color appearance pH specific gravity protein glucose ketones blood leucocyte nitrite bilirubin urobilinogen RBC/ hpf WBC hpf Normal Value pale to dark color clear/slightly cloudy 4.6-8.0 1.001-1.030 negative negative negative negative negative negative negative 0.2 EU/dl 2-3 4-5 Result yellow slightly cloudy 6.0 1.011 +2 negative negative negative trace negative negative 0.2 EU/dl 0-2 1-5 Significance normal normal normal normal nephropathy normal normal normal bacteriuria normal normal normal normal normal

3. Present Profile of Functional Health Patterns 3.1 Health Perception/ Health Management Pattern

The patient describes his health as usually good. At this time, he feels weak and has a difficulty in breathing. He weighs 134 lbs. To keep healthy and prevent disorders, he has been taking vitamins like Pharmaton and Enervon C. The patient is now suffering from a chronic obstructive disease and is experiencing dyspnea upon exertion and even at rest. He has also been diabetic and hypertensive for 15 years now. 2 weeks before admission, patient has been experiencing dyspnea and productive cough with whitish phlegm. Patient was given Cefexine 200 mg BID with good compliance. However, patient persisted to have cough and dyspnea, thus sough admission. 3.2 Nutritional Metabolic Pattern The patient does not eat much since he has to take special precaution with regards to his diet. He is now on a soft diet, 1800 KCalories, 2 grams sodium chloride, low potassium, low purine, low phosphate, 40 grams protein, low cholesterol, low saturated fat, divided in 3 meals and 2 snacks with no fruit and no juices. His fluid intake is also limited to 800 cc per day. 3.4 Activity/ Exercise Pattern The patient is too weak to perform any exercise at the moment. He is not ambulatory and is even having a difficult time turning his body from one side to another. The doctor has ordered that he has to change position every 2 hours to prevent bed sores. He is able to raise his hand and foot but only to atleast an angle of 15 degrees. 3.5 Cognitive/ Perceptual Pattern The patient has a deficit in visual perception but is not wearing his eye glasses at the moment. He does not complain of vertigo and is able to read and write. 3.6 Rest/ Sleep Pattern The patient only has a maximum of atleast 2 hours of sleep now a day. He usually wakes up once in a while and just stares blankly. He is also easily awakened whenever someone would enter his room. 3.7 Self-perception Pattern The patient is concerned about his health and wants to recover as soon as possible. He also verbalized that he misses going to the beach and also drinking coffee. 3.8 Role Relationship Pattern

The patient speaks in vernacular. Speech is sometimes slurred but relevant. The patient does not use any gestures in speaking since his extremities are weak. The patient lives together with his 2 sons at Danao City. When he has problems, he turns to his neighbor, who has been his friend for 20 years now. His 2 sons are already married and are now residing in the United States, while his other 2 sons are still single and living in the same house. 3.9 Sexuality-Reproductive Pattern The patient is already a widow since his wife died at age 60 due to lung cancer. Since then, he did not re-marry and had no sexual contact. 3.10 Value-Belief System The patient finds strength from his family. He used to attend mass every Sunday together with his 2 sons but now he only prays at night and asks Gods guidance and healing power. 4. Pathophysiology and Rationale 4.1 Normal Anatomy and Physiology of Organ/ System Affected

The lung is the essential organ of respiration in air-breathing vertebrates. Its principal function is to transport oxygen from the atmosphere into the bloodstream, and to excrete carbon dioxide from the bloodstream into the atmosphere. This it accomplishes with the mosaic of specialized cells that form millions of tiny, exceptionally thin-walled air sacs where gas exchange takes place. Lungs also have nonrespiratory functions. Respiratory function Energy production from aerobic respiration often requires oxygen and produces carbon dioxide as a by-product, creating a need for an efficient means of oxygen delivery to cells and carbon dioxide excretion from cells. In smaller organisms, such as singlecelled bacteria, this process of gas exchange can take place entirely by simple diffusion. In larger organisms, this is not possible; only a small proportion of cells are close enough to the surface for oxygen from the atmosphere to enter them through diffusion. Two major adaptations made it possible for organisms to attain great multicellularity: an efficient circulatory system that conveyed gases to and from the deepest tissues in the body, and a large, internalised respiratory system that centralized the task of obtaining oxygen from the atmosphere and bringing it into the body, whence it could rapidly be distributed to all tissues via the circulatory system. In air-breathing vertebrates, respiration occurs in a series of steps. Air is brought into the animal via the airways in reptiles, birds and mammals this often consists of the nose; the pharynx; the larynx; the trachea; the bronchi and bronchioles; and the terminal branches of the respiratory tree. The lungs of mammals are a rich lattice of alveoli, which provide an enormous surface area for gas exchange. A network of fine capillaries allows transport of blood over the surface of alveoli. Oxygen from the air inside the alveoli diffuses into the bloodstream, and carbon dioxide diffuses from the blood to the alveoli, both across thin alveolar membranes. The drawing and expulsion of air is driven by muscular action; in early tetrapods, air was driven into the lungs by the pharyngeal muscles, whereas in reptiles, birds and mammals a more complicated musculoskeletal system is used. In the mammal, a large muscle, the diaphragm (in addition to the internal intercostal muscles), drive ventilation by periodically altering the

intra-thoracic volume and pressure; by increasing volume and thus decreasing pressure, air flows into the airways down a pressure gradient, and by reducing volume and increasing pressure, the reverse occurs. During normal breathing, expiration is passive and no muscles are contracted.. (the diaphragm relaxes). Nonrespiratory functions In addition to respiratory functions such as gas exchange and regulation of hydrogen ion concentration, the lungs also: influence the concentration of biologically active substances and drugs used in medicine in arterial blood filter out small blood clots formed in veins serve as a physical layer of soft, shock-absorbent protection for the heart, which the lungs flank and nearly enclose. The environment of the lung is very moist, which makes it a hospitable environment for bacteria. Many respiratory illnesses are the result of bacterial or viral infection of the lungs. Breathing is largely driven by the muscular diaphragm at the bottom of the thorax. Contraction of the diaphragm vertically expands the cavity in which the lung is enclosed. Relaxation of the diaphragm has the opposite effect. The rib cage itself is also able to expand and contract to some degree, through the action of other respiratory and accessory resipratory muscles. As a result, air is sucked into or expelled out of the lungs, always moving down its pressure gradient. Air enters through the oral and nasal cavities; it flows through the larynx and into the trachea, which branches out into bronchi. In humans, it is the two main bronchi (produced by the bifurcation of the trachea) that enter the roots of the lungs. The bronchi continue to divide within the lung, and after multiple generations of divisions, give rise to bronchioles. Eventually the bronchial tree ends in alveolar sacs, composed of alveoli. Alveoli are essentially tiny sacs in close contact with blood filled capillaries. Here

oxygen from the air diffuses into the blood, where it is carried by hemoglobin, and carried via pulmonary veins towards the heart. Deoxygenated blood from the heart travels via the pulmonary artery to the lungs for oxidation. The lungs are located inside the thoracic cavity, protected by the bony structure of the rib cage. Each is enclosed by a double-layered sac called pleura. The inner layer of the sac (visceral pleura) adheres tightly to the lung and the outer layer (parietal pleura) is attached to the inner wall of the thoracic cavity. The two layers are separated by a thin space called the pleural cavity that is filled with pleural fluid; this allows the inner and outer layers to slide over each other, and prevents them from being separated easily. The left lung is smaller than the right one, to provide room for the heart. The lungs are attached to the heart and trachea through structures that are called the "roots of the lungs." The roots of the lungs are the bronchi, pulmonary vessels, bronchial vessels, lymphatic vessels, and nerves. These structures enter and leave at the hilus of the lung. The lungs are divided into lobes by the horizontal and oblique fissures. The right lung has three lobes and the left lung has two. A unique feature of the left lung is the cardiac notch, which helps create the lingula (Latin for "tongue") of the left lung. The lungs are connected to the upper airway by the trachea and bronchi. The trachea runs down the neck and divides into left and right bronchi behind the sternal angle ( at the level of the fourth thoracic vertebra T4). The right main bronchus is shorter, wider and runs more vertically than the left. For this reason, it is more common to aspirate foreign objects into the right lung. The right bronchus gives rise to the superior lobe bronchus before entering the hilum and dividing into the middle and inferior lobe bronchi. The left bronchus enters the hilum and gives rise to the superior and inferior lobe bronchi.

The bronchi enter the lung and branch out to form the bronchial tree. The bronchi divide into smaller bronchioles, which terminate into alveoli. An alveolus is composed of respiratory tissue and is the site of gas exchange in the lung. The inner walls of the alveoli are covered in surfactant, a fluid which reduces the surface tension of the alveoli, allowing them to expand and recoil with inspiration and expiration and preventing them from collapsing. The blood supply to the lungs is from two sources: the pulmonary vessels and the bronchial vessels. The bronchial vessels support the nonrespiratory tissue and the pulmonary vessels provide support to the respiratory tissue. The pulmonary arteries carry deoxygenated blood, which has returned to the heart from the systemic venous system, to the lungs to be reoxygenated. The pulmonary veins carry oxygenated blood back to the heart to go to the systemic arterial system. The right and left pulmonary arteries arise from the pulmonary trunk and carry deoxygenated blood to their respective lungs. The pulmonary veins, two on each side, carry oxygenated blood to the left atrium of the heart. The bronchial arteries that supply the nonrespiratory tissue of the lung arise from different sources. The left bronchial arteries come off of the thoracic aorta, however, the right bronchial artery has a variable source.

4.2 Schematic Diagram Predisposing Factors: - increasing age (older than 40 years) - male gender - alpha 1 antitrypsin deficiency Precipitating Factors: - smoking - occupational exposure to inhaled chemicals - pollution - lower economic status - work environment

CHRONIC BRONCHITIS - inflammation of airways irritation of the lung tissues increase in goblet cells increase in mucous glands reduce numbers of ciliated cells

Signs and symptoms: Productive cough, with progression over time to intermittent dyspnea Frequent and recurrent pulmonary infections Progressive cardiac/respiratory failure over time, with edema Frequent cough and expectoration Use of accessory muscles of respiration Coarse rhonchi and wheezing heard on auscultation.

Pharmacologic: - corticosteroids - beta agonists - anti-cholinergic agents - antibiotics

Nursing Management: - good nutrition for patient - encourage exercise programs - advise patient to quit smoking - environmental changes

4.3 Disease Process and its Effects on Different Organ/ System Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in this country. Patients typically have symptoms of both chronic bronchitis and emphysema, but the classic triad also includes asthma. Most of the time COPD is secondary to tobacco abuse, although cystic fibrosis, alpha-1 antitrypsin deficiency, bronchiectasis, and some rare forms of bullous lung diseases may be causes as well. Patients with COPD are susceptible to many insults that can lead rapidly to an acute deterioration superimposed on chronic disease. Quick and accurate recognition of these patients along with aggressive and prompt intervention may be the only action that prevents frank respiratory failure. Pathophysiology: COPD is a mixture of 3 separate disease processes that together form the complete clinical and pathophysiological picture. These processes are chronic bronchitis, emphysema and, to a lesser extent, asthma. Each case of COPD is unique in the blend of processes; however, 2 main types of the disease are recognized. Chronic bronchitis In this type, chronic bronchitis plays the major role. Chronic bronchitis is defined by excessive mucus production with airway obstruction and notable hyperplasia of mucus-producing glands. Damage to the endothelium impairs the mucociliary response that clears bacteria and mucus. Inflammation and secretions provide the obstructive component of chronic bronchitis. In contrast to emphysema, chronic bronchitis is associated with a relatively undamaged pulmonary capillary bed. Emphysema is present to a variable degree but usually is centrilobular rather than panlobular. The body responds by decreasing ventilation and increasing cardiac output. This V/Q mismatch results in rapid circulation in a poorly ventilated lung, leading to hypoxemia and polycythemia.

Eventually, hypercapnia and respiratory acidosis develop, leading to pulmonary artery vasoconstriction and cor pulmonale. With the ensuing hypoxemia, polycythemia, and increased CO2 retention, these patients have signs of right heart failure and are known as "blue bloaters." What causes COPD? Smoking is responsible for COPD in our country. Although not all cigarette smokers will develop COPD, it is estimated that 15% will. Smokers with COPD have higher death rates than nonsmokers with COPD. They also have more frequent respiratory symptoms (coughing, shortness of breath, etc.) and more deterioration in lung function than non-smokers. Effects of passive smoking or "second-hand smoke" on the lungs are not wellknown; however, evidence suggests that respiratory infections and symptoms are more common in children who live in households where adults smoke. Cigarette smoking damages the lungs in many ways. For example, the irritating effect of cigarette smoke attracts cells to the lungs that promote inflammation. Cigarette smoke also stimulates these inflammatory cells to release elastase, an enzyme that breaks down the elastic fibers in lung tissue. Air pollution can cause problems for persons with lung disease, but it is unclear whether air pollution contributes to the development of COPD. Some occupational pollutants such as cadmium and silica do increase the risk of COPD. Persons at risk for this type of occupational pollution include coal miners, construction workers, metal workers, cotton workers, etc. (Most of this risk is associated with cigarette smoking and these occupations, an issue not well controlled for. These occupations are more often associated with interstitial lung diseases, especially the pneumoconoses) Nevertheless, the adverse effects of smoking cigarettes on lung function is far greater than occupational exposure.

Another well-established cause of COPD is a deficiency of alpha-1 antitrypsin (AAT). AAT deficiency is a rare genetic (inherited) disorder that accounts for less than 1% of the COPD in the United States. As discussed previously, normal function of the lung is dependent on elastic fibers surrounding the airways and in the alveolar walls. Elastic fibers are composed of a protein called elastin. An enzyme called elastase that is found even in normal lungs (and is increased in cigarette smokers) can break down the elastin and damage the airways and alveoli. Another protein called alpha-1 antitrypsin (AAT) (produced by the liver and released into the blood) is present in normal lungs and can block the damaging effects of elastase on elastin. The manufacture of AAT by the liver is controlled by genes which are contained in DNA-containing chromosomes that are inherited. Each person has two AAT genes, one inherited from each parent. Individuals who inherit two defective AAT genes (one from each parent) have either low amounts of AAT in the blood or AAT that does not function properly. The reduced action of AAT in these individuals allows the destruction of tissue in the lungs by elastase to continue unopposed. This causes emphysema by age 30 or 40. Cigarette smoking accelerates the destruction and results in an even earlier onset of COPD. Individuals with one normal and one defective AAT gene have AAT levels that are lower than normal but higher than individuals with two defective genes. These individuals are not believed to have an increased risk of developing COPD if they do not smoke cigarettes; however, their risk of COPD probably is higher than normal if they smoke. What are the symptoms of COPD? Typically, after smoking 20 or more cigarettes a day for more than twenty years, patients with COPD develop a chronic cough, shortness of breath (dyspnea) and frequent respiratory infections.

In patients affected predominantly by emphysema, shortness of breath may be the major symptom. Dyspnea usually is most noticeable during increased physical activity, but as emphysema progresses, dyspnea occurs at rest. In patients with chronic bronchitis as well as bronchiectasis, chronic cough and sputum production are the major symptoms. The sputum is usually clear and thick. Periodic chest infections can cause fever, dyspnea, coughing, production of purulent (cloudy and discolored) sputum and wheezing. (Wheezing is a high pitched noise produced in the lungs during exhalation when mucous, bronchospasm, or loss of lung elasticity obstructs airways.) Infections occur more frequently as bronchitis and bronchiectasis progress. In advanced COPD, patients may develop cyanosis (bluish discoloration of the lips and nail beds) due to a lack of oxygen in blood. They also may develop morning headaches due to an inability to remove carbon dioxide from the blood. Weight loss occurs in some patients, primarily (other possibility is reduced intake of food) because of the additional energy that is required just to breathe. In advanced COPD, small blood vessels in the lungs are destroyed, and this blocks the flow of blood through the lungs. As a result, the heart must pump with increased force and pressure to get blood to flow through the lungs. (The elevated pressure in the blood vessels of the lungs is called pulmonary hypertension.) If the heart cannot manage the additional work, heart failure results and leads to swelling of the feet and ankles. Patients with COPD may cough up blood (hemoptysis). Usually hemoptysis is due to damage to the inner lining of the airways and the airways' blood vessels; however, occasionally, hemoptysis may signal the development of lung cancer. How is COPD diagnosed? COPD usually is first diagnosed on the basis of a medical history which discloses many of the symptoms of COPD and a physical examination which discloses signs of COPD. Other tests to diagnose COPD include chest x-ray, computerized tomography (CT

or CAT scan) of the chest, tests of lung function (pulmonary function tests) and the measurement of oxygen and carbon dioxide levels in the blood. COPD is suspected in chronic smokers who develop shortness of breath with or without exertion, chronic persistent cough with sputum production, and frequent infections of the lungs such as bronchitis or pneumonia. Sometimes COPD is first diagnosed after a patient develops a respiratory illness necessitating hospitalization. Some physical findings of COPD include enlarged chest cavity, wheezing, faint and distant breathing sounds when listening to the chest by stethoscope. In patients affected predominantly with emphysema, the chest x-ray may show an enlarged chest cavity and decreased lung markings reflecting destruction of lung tissue and enlargement of air-spaces. In patients with predominantly chronic bronchitis, the chest x-ray may show increased lung markings which represent the thickened, inflamed and scarred airways. Computerized tomography (CT or CAT scan) of the chest is a specialized x-ray that can accurately demonstrate the abnormal lung tissue and airways in COPD. Chest x-rays and CT scans of the chest also are useful in excluding lung infections (pneumonia) and cancers. CT scan of the chest usually is not necessary for the routine diagnosis and management of COPD. The most commonly used pulmonary function test is spirometry, a test which quantitates the amount of airway obstruction. During spirometry, the patient takes a full breath and then exhales fast and forcefully into a tube connected to a machine that measures the volume of expired air. The FEV1 (the volume of air expired in 1 second) is a reliable and useful measure of airflow obstruction; the lower the FEV1, the greater the airway obstruction. The FEV1 can be determined again after treatment with bronchodilators. Improvement in FEV1 after bronchodilator treatment means that airway obstruction is reversible. Demonstrating improvement in FEV1 also helps doctors select the proper bronchodilators for patients. Measurements of FEV1 can be repeated over time to determine how rapidly airway obstruction is progressing.

Spirometry also can measure the maximal volume of air that can be inhaled and exhaled with each breath. This maximal volume is called the forced vital capacity or FVC By comparing the FEV1 with FVC, airway obstruction can be even more accurately quantified than FEV1. The normal ratio of FEV1/FVC is 70%, but it is reduced in patients with COPD. Oxygen and carbon dioxide levels can be measured in samples of blood obtained from an artery, but this requires inserting a needle into an artery. A less invasive method to measure oxygen levels in the blood is called pulse oximetry. Pulse oximetry works on the principle that the degree of redness of hemoglobin (the protein in blood that carries oxygen) is proportional to the amount of oxygen, that is, the more oxygen there is in blood, the redder the blood. A probe (oximeter) is placed around a fingertip. On one side of the finger the probe shines a light. Some of the light is transmitted through the fingertip, and the transmitted light is measured on the opposite side of the finger by the probe. Depending on the redness of the blood within the fingertip (that is, the amount of oxygen in the blood) more or less light is transmitted through the fingertip. Thus, by measuring the amount of light transmitted, it is possible to determine the amount of oxygen in the blood. Complications:

Some complications that must be anticipated in COPD treatment include the following: o Incidence of pneumothorax due to bleb formation is relatively high; consider pneumothorax in all patients with COPD who have increased shortness of breath.
o

In patients who require long-term steroid use, the possibility of adrenal crisis is very real; at a minimum, patients with steroid-dependent COPD should receive stress dosing in the event of an exacerbation or any other stressor.

o o o o o o o

Infection (common) Cor pulmonale Secondary polycythemia Bullous lung disease Acute or chronic respiratory failure Pulmonary hypertension Malnutrition

4.4 Comparative Chart of Classical and Clinical manifestations CLASSICAL SYMPTOM COUGH CLINICAL SYMPTOM Manifested - the patient has been coughing for 2 weeks now RATIONALE Cough results from the irritation of the mucous membranes anywhere in the respiratory tract. Medical Surgical Nursing by Brunner and Suddarth SPUTUM PRODUCTION Manifested - the patient has a whitish sputum p.472 Sputum production is the reaction of the lungs to any constantly recurring irritant. Medical Surgical Nursing by Brunner and Suddarth p. DYSPNEA Manifested - the patient has a respiratory rate of 30 breaths per minute and has dyspnea at rest 473 Dyspnea occurs due to the obstruction of airflow in the narrowed lumen resulting from the inflammatory process. Medical surgical nursing by Brunner and Suddarth BARREL CHEST THORAX CONFIGURATION Manifested p.569-571 Barrel chest occurs as a result of over inflation of the lungs. There is an increase anteroposterior diameter of the thorax. Medical surgical nursing by WHEEZING Manifested - crackles with slight wheezing was herd upon Brunner and Suddarth p.476 Wheezing is often the major finding in a patient with bronchoconstriction or 2

ausculation

airway narrowing. Medical surgical nursing by Brunner and Suddarth p.474 Weight loss occurs in some patients (other possibility is reduced food intake) because of the additional energy that is required just to breathe. www.medicinenet.com The bluish discoloration of the lips and nail beds is due to the lack of oxygen in the blood. www.medicinenet.com Occurs when there is inability to remove carbon dioxide from the blood. www.medicinenet.com Swelling is due to the additional workload of the heart resulting to failure. www.medicinenet.com

WEIGHT LOSS

Manifested - the patient currently weighs 134 lbs. and weighed 155 lbs. before

CYANOSIS

Not manifested

MORNING HEADACHES

Not manifested

SWELLING OF FEET AND ANKLES

Not manifested

Nursing Intervention 1. Care Guide of Patient with Disease Condition Treatment for COPD is based on the patient's general medical condition and severity of the disease. Options usually include a combination of the following 2

treatments. Proper treatment of COPD can result in improvements in exercise capacity, activity levels, quality of life, less hospitalization, and longer survival. Stop smoking By far, the most important and effective treatment for COPD is smoking cessation, which results in improvement in lung function during the first year after quitting and a return to a normal rate of change in lung function thereafter. The benefits of quitting smoking apply regardless of age, amount smoked or severity of COPD. Quitting smoking also reduces the risk of sudden cardiac death, heart attacks, strokes and lung cancer. People with COPD live longer and have a better quality of life if they stop smoking. Despite the best efforts to stop smoking, many patients do not succeed in quitting. Many doctors are reluctant to prescribe treatment for patients with COPD who continue to smoke. That is unwarranted. There is good evidence that bronchodilators and inhaled corticosteroids are as beneficial for smokers as for nonsmokers. Medications 1. Short-acting bronchodilators, both beta agonists and anticholinergics, are the mainstay of therapy for COPD. 2. Long-acting bronchodilators are indicated for moderate to severe COPD. Currently two beta agonists are available. A long-acting anticholinergic is under consideration for approval by the U.S. Food and Drug Administration. 3. Inhaled corticosteroids are recommended for patients with moderate to severe COPD with frequent exacerbations (incidents which worsen symptoms). 4. Systemic corticosteroids (IV or pills) are beneficial for treatment of severe exacerbations. 5. Antibiotics may be beneficial for treatment of exacerbations. 6. Theophylline in low doses may reduce frequency of exacerbations in patients who tolerate it (it has many side effects).

Home oxygen therapy Supplemental oxygen is prescribed to correct hypoxemia (low blood oxygen) to improve the physical and mental functioning of patients. Several studies have shown greater long-term survival in patients with severe COPD who received oxygen therapy. Pulmonary rehabilitation For those who have difficulty completing daily tasks, pulmonary rehabilitation may be very beneficial. The program can improve exercise capacity, reduce the hospitalization rate and improve overall quality of life for patients. It is conducted by a multidisciplinary team of specialists, including pulmonary physicians, respiratory therapists, physical therapists, occupational therapists and dietitians with expertise in the care of people with chronic pulmonary diseases. The comprehensive evaluation, educational and exercise components are covered on an outpatient or inpatient basis. Surgery Bullectomy- removing a part of the lung which is damaged. Lung Volume Reduction Surgery- parts of the lung are removed to stop the lung from overly increasing in size. This procedure has limited effectiveness and is not widely used. Lung Transplantation- replacing a damaged lung or lungs with healthy donor lungs.

2. Actual patient care 2.1 Physical assessment

Body part

Skin

Fair complexion with red blotches on right arm normocephalic, no irregularities gray hair, without parasites absence of dandruff & parasites

Senile, warm to touch

Head

no lumps or masses noted

Hair

Scalp

no lumps or mass noted

Face Eyebrows

symmetrical facial features

warm to touch

hair evenly smooth distributed, aligned together Pupils Equally Round Reactive To Light & Accommodatio n, papillary high reflexes, equal reactions of both sides black followed moving objects properly short,curves outward

Pupils

Iris Muscle Function Lashes

Upper & Lower lids are color

Lids Sclera Conjunctiva Lacrimal ducts Cornea

brown, closes symmetrically white pale palpebral no discharges corneal light reflexes equal on both sides can read clearly at near or far distance, without eyeglasses not obstructed, no occlusion when transillumination was done not painful not painful not painful

Visual Acuity

Nose Frontal & Maxillary Sinuses Lips Gums Teeth Hard Palate Soft Palate Uvula Tonsils Ears

dark brown, dry smooth blackish gums no teeth left but uses dentures pink pink straight & hanging non-visible no occlusion, symmetrical on both sides, hard & stable hard soft, gag reflex present soft

upper auricle in line with outer contour of eye, hearing is clear Neck Lymph Nodes Trachea same as normal skin tone no lumps/mass not palpable located at midline, no masses Tachypnea: 30 breaths per minute (+)Crackles with slight wheezing in the apex of the lungs(left side) Normal & Regular Rhythm:76 bpm barrel shape no suture present, flat smooth, warm to touch, no pain not palpable Male, with Condom Catheter weak muscle strength but able to give resistance, with IV infusing well at left arm D5. 3%NaCl@10 Radial pulse: 76bpm BP: 160/90mmhg tympanic sound Bowel sounds= 3-5 gurgling sounds ( normal intervals)

Lungs

Heart

Chest Abdomen

Spleen Genitalia

Upper Extremities

gtts/min. Lower Extremities not able to walk, needs assistance weak muscle tone

2.3 DTR

DRUG/ DOSE/ FREQ/ROUTE

CLASSIFICATION/ MECHANISM

INDICATIONS/ CONTRAINDICATIONS/ ADVERSE REACTIONS

PRINCIPLES OF CARE

TREATMENT

EVALUATION

COMBIVENT 1 neb every 6 hours (10am-4pm10pm)

Anti-asthmatic preparation - Bronchodilators - relaxes bronchial vascular smooth muscles by stimulatory B2 receptors

Indications: - bronchospasm Contraindications: - hypersensitivity Adverse reactions: - fine tremors - palpitations - headache

1. Perform oral inhalation correctly 2. Wash inhaler in warm soapy water at least once a week

SERETIDE DISKUS 250 mcg 1 puff BID (8am 6pm)

FELODIPINE (PLENDIL ER) 5 mg 1 tablet OD (8am)

Anti-asthmatic - Beta 2 selective adrenergic agent - long acting agonist that binds to beta 2 receptors in the lungs, causing bronchodilation, also inhibits release of inflammatory mediators in the lungs, blocking swelling and inflammation Anti-hypertensive - leads to arterial and coronary vasodilation and decreased peripheral vascular resistance

Indications: - prevention and maintenance therapy of bronchospasm in patients with COPD Contraindications: - acute airway obstruction Adverse reactions: - headache, tremor, tachycardia

1. instruct patient in the proper use if diskus 2. monitor use of inhaler

a. monitor vital signs b. position patient properly in Semi Fowlers position c. encourage deep breathing exercises a. monitor I and O b. monitor vital signs c. gargle with water after use d. moderate high back rest

Patient was placed in a Semi Fowlers position and was able to do deep breathing.

Patient was placed on a moderate high back rest and was able to gargle with water.

Indications: - essential hypertension Contraindication: - hypersensitivity Adverse reactions: - dizziness, lightheadedness, peripheral edema, flushing, rash

1. have patient swallow whole tablet 2. administer drug without regard to meals

a. monitor vital signs b. hold medication if bp is equal or less than 90/60

Patient was able to swallow the whole tablet and BP dropped from 150/90 to 130/80.

2.5. Health teaching plan OBJECTIVES CONTENTS METHODOLOGY EVALUATION 4

General objectives: After one week of student nurse-client interaction, the client will be able to acquire knowledge, attitude and skills in the care of patients with chronic obstructive pulmonary disease. Specific objectives: After 30-45 minutes of student nurseclient interaction, the client will be able to: 1. discuss why he should quit smoking Quitting smoking makes a difference right away in the way you feel. You can taste and smell food better. Your breath smells better. Your cough goes away. These benefits happen for men and women of all ages, even those who are older. They happen for healthy people as well as those who already have a disease or condition caused by smoking. Even more importantly, in the long run, quitting smoking cuts the risk of lung cancer, many other cancers, heart 4 Informal discussion

disease, stroke, and other lung or breathing (respiratory) diseases (e.g., bronchitis, have better pneumonia, health than and current emphysema). Moreover, ex-smokers smokers. For example, ex-smokers have fewer days of illness, fewer health complaints, and less bronchitis and pneumonia than current smokers. Finally, quitting smoking saves money.It appears that the price of cigarettes will continue to rise in coming years, as will the financial rewards of quitting. Getting Ready to Quit 2. enumerate the steps in quitting Informal Set a date for quitting. If possible, plan to have a friend discussion quit smoking with you. Notice when and why you smoke. Try to find the things in your daily life that you often do while smoking (such as drinking your morning cup of coffee or driving a car). Change your smoking routines: Keep your cigarettes in a different place. Smoke with your other hand. Don't do anything else when you are smoking. Think about how you feel when you smoke. Smoke only in certain places, such as outdoors. When you want a cigarette, wait a few minutes. Try to 4

think of something to do instead of smoking. For example, you might chew gum or drink a glass of water. Buy one pack of cigarettes at a time. Switch to a brand of cigarettes that you don't like.

3. list ways on how to improve appetite

General guidelines

Informal your doctor. discussion

Talk

to

Sometimes, poor appetite is due to depression, which can be treated. Your appetite is likely to improve after depression is treated.

Avoid non-nutritious beverages such as black coffee and tea. Try to eat more protein and fat, and less simple sugars. Eat small, frequent meals and snacks. Walk or participate in light activity appetite. to stimulate your

Keep food visible and within easy reach. Improve your circulation and help the body better use oxygen Improve your COPD symptoms Build energy levels so you can Informal do more activities without discussion becoming tired or short of

4. explain the benefits of doing exercise

breath

Strengthen

your

heart

and

cardiovascular system

Increase endurance Lower blood pressure Improve muscle tone and strength; improve balance and joint flexibility

Strengthen bones Help reduce body fat and help you reach a healthy weight Help reduce stress, tension, anxiety, and depression Boost self-image and self-

esteem; make you look fit and feel healthy

Improve sleep Make you feel more relaxed and rested

4. show positive response on exercising by knowing how often exercise should be done The frequency of an exercise program is how often you exercise. In general, to achieve maximum benefits, you should gradually work up to an exercise session lasting 20 to 30 minutes, at least three to four times a week. Exercising every other day will help you keep a regular exercise

Informal discussion

schedule. Pursed lip breathing is one of the 5. demonstrate ways on how to perform pursed lip breathing simplest ways to control shortness of breath. It provides a quick and easy way to slow your pace of breathing, making each breath more effective. Pursed lip breathing technique 1. Relax your neck and shoulder muscles. 2. Breathe in (inhale) slowly through your nose for two counts, keeping your mouth closed. Don't take a deep breath; a normal breath will do. It may help to count to yourself: inhale, one, two. 3. Pucker or "purse" your lips as if you were going to whistle or gently flicker the flame of a candle. 4. Breathe out (exhale) slowly and gently through your pursed lips while counting to four. It may help to count to yourself: exhale, one, two, three, four. Demonstr ation and return demonstra tion

2.6 SOAPIE Charting June 20, 2006

Name of Patient: Mr. Aviles, Teofilo Room/ Ward No.: MM1 Age: 75 y.o. Chief Complaint(s): dyspnea, cough SOAPIE # 1 S init bitaw ni siya. Gi hilantan man siya ganina sad as verbalized by significant other. O received patient, febrile, awake, conscious, coherent, cooperative with IV infusing well at left arm D5 .3%NaCl 1 liter at 10 drops/ minute. Patients skin is warm to touch, skin is flushed, poor skin turgor, with vital signs of BP: 180/80mmhg ; T: 37.7 ; P: 80 beats per minute ; RR: 28 breaths per minute. A Altered thermoregulation: hyperthermia related to upper respiratory tract infection P patient will be able to decrease body temperature from 37.7 to a normal range of 36.4-37.5 I monitored vital signs; noted shaking, chills or profuse diaphoresis; modified environment through turning off the ceiling fan; provided extra blanket ; advised to wear light clothing ; rendered tepid sponge bath; encouraged bed rest ; performed nebulization as prescribed and administered analgesic as prescribed. E patient manifested a decrease in body temperature from 37.7 to 37.2

June 21, 2006 Name of Patient: Mr. Aviles, Teofilo

Room/ Ward No.: MM1 Age: 75 y.o. Chief Complaint(s): dyspnea, cough SOAPIE # 2 S maglisud mana siya ug ginhawa, murag maghangak lang pirmi as verbalized by patients significant other. O - received patient, afebrile, awake, conscious, coherent, cooperative with IV infusing well at left arm D5 .3%NaCl 1 liter at 10 drops/ minute. Patient is experiencing a productive cough with thick, whitish phlegm. There is presence of crackles with slight wheezing heard upon auscultation. The patient also uses accessory muscle for breathing and has vital signs of BP: 140/80mmhg ; T: 37.3 ; P: 80 beats per minute ; RR: 30 breaths per minute. A Ineffective airway clearance: dyspnea related to increased production of tenacious secretions P patient will be able to have improved airway as evidences by a decrease of respiratory rate from 30 breaths per minute to a range within normal of 16-20 breaths per minute. I monitored vital signs ; taught client to maintain adequate hydration by drinking 8-10 glasses of fluid per day; taught effective coughing techniques; performed chest physiotherapy; performed nebulization as prescribed; due medications given. E the patient had a decrease in respiratory rate from 30 breaths per minute to 27 breaths per minute.

V. Evaluation and Recommendation

Prognosis The prognosis for people with mild COPD is favorable, little worse than the prognosis for smokers without COPD; continued smoking, however, virtually assures that symptoms will worsen. With moderate and severe airway obstruction, the prognosis becomes progressively worse. People with an FEV1 between 35% and 50% of normal are still only slightly more likely to die within 10 years than a normal person. However, about 30% of people with more severe airway obstruction die in 1 year; 95% die in 10 years. Death may result from respiratory failure, pneumonia, pneumothorax, heart rhythm abnormalities (arrhythmias), or blockage of the arteries leading to the lungs (pulmonary embolism). People with COPD have a risk of lung cancer beyond that due to their use of cigarettes. The patient has quit smoking for more than 2 years now and is sticking to his treatment program. His symptoms have improved considering he is on an oxygen therapy. With regards to his nutrition, he is still on a struggle since he only eats atleast 2 3 tablespoons of the food served. Considering also his old age, it makes his prognosis poor. Prognosis The goals of COPD treatment are to prevent further deterioration in lung function, to alleviate symptoms, to improve performance of daily activities and quality of life.Below are listed recommendations for the patient : 1) Quit cigarette smoking Set a date for quitting. If possible, plan to have a friend quit smoking with you. Notice when and why you smoke. Try to find the things in your daily life that you often do while smoking (such as drinking your morning cup of coffee or driving a car).

Change your smoking routines: Keep your cigarettes in a different place. Smoke with your other hand. Don't do anything else when you are smoking. Think about how you feel when you smoke.

Smoke only in certain places, such as outdoors. When you want a cigarette, wait a few minutes. Try to think of something to do instead of smoking. For example, you might chew gum or drink a glass of water. Buy one pack of cigarettes at a time. Switch to a brand of cigarettes that you don't like.

2) Taking medications to dilate airways (bronchodilators) and decrease airway inflammation 3) Vaccinating against influenza and pneumonia 4) Regular oxygen supplementation

VI. Evaluation and Implication of this Case Study to: NURSING PRACTICE This case study of a patient with Chronic obstructive pulmonary disease will enable the student nurse to accomplish a well prepared Nursing Care Plan to patients with such disease. With its outcome, it may serve as a guide or reference in providing care to patients with the said disease. This will help in the development of nursing measures in the clinical setting. NURSING EDUCATION This case study will serve as a reference guide to students who are interested in the diseases of the lungs and who, later on when they become nurses. This will enable them to increase their knowledge, attitude and skills in giving care to patients with Chronic obstructive pulmonary disease. NURSING RESEARCH There have been several researches with regards to nursing that might not have gotten the support that it needs for justification. Hopefully, this will be another one of the most reliable sources as remedy to the support of the researchers study. This will also serve as a difficult but nevertheless an interesting topic for research and studies.

BIBLIOGRAPHY Brunner and Suddarth; Medical Surgical Nursing; 10th edition; Lippincott Williams and Wilkins; copyright 2004 Black and Hawks; Medical Surgical Nursing; 6th edition; W.B Saunders Company; copyright 2001 Long, Phipps, Woods; Medical Surgical Nursing Concepts and Clinical Practice; 2nd edition; The C.V Mosby Company; copyright 1983 Patrick, Woods; Medical Surgical Nursing; 2nd edition; J.B Lippincott Company copyright 1991 Potter and Perry; Fundamentals of Nursing; 5th edition; The C.V Mosby Company; copyright 2001 Robbins; by Pathologic basis of disease; 5th edition; Rodale Press; copyright 1994 www.google .com www.medlineplus.com www.medicinenet.com