CASE PRESENTATION OF Pulmonary emphysema and basal pneumonia MISAMIS UNIVERSITY MEDICAL CENTER (MALE SURGICAL WARD) OZAMIZ

CITY February 15-19, 2010 PREPARED BY: Magbanua, Jessa Lou Marcolino, Alvin Matos, Carol Ezel Molina, Marjorie Monarca, Renjel Mugot, Bryll Pinote, Kristine Leonor Ponce, Lady Grace Quidet, Sarah Jean Rashid, Saida Rato, Christene Repolido, Anna Marie CLINICAL INSTRUCTOR: Mr. Elvin Gene B. Colcol, RN, MN, MAN

GENERAL OBJECTIVE:
At the end of our 1hour case presentatio, we will provide knowledge about the health assessment, we will also enhance and develop our skills in presenting the case that lastly, will also develop positive and well define attitude.

SPECIFIC OBJECTIVES:
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

At the end of 1 hour presentation, we will be able to; Present an introduction. Write a complete health assessment. Present and interpret laboratory results. Illustrate the pathophysiology. List 10 possible nursing diagnosis. Develop a nursing care plan. Formulate a health teaching plan. Summarize the entire assessment. Accept all constructive critism thrown to us positively. Achieve and met the general and specific objectives.

NURSING ASSESSMENT (ADULT)

Patient X Occupation: Wood canvasser Address: Purok Libertad Alto, Sinacaban (N/A) Age: 68 Sex: Male Religion: Philippine Independent Church Status: Married Chief complaints: Difficulty in breathing Date and Time Admitted: February 22, 2010 @ 1pm

PRESENT ILLNESS
The patients chief complaints was difficulty in breathing. A few months prior to admission he experienced productive cough, night sweats and back pain. It became worse since it first occurred. The pain felt sharp at the left upper quadrant of his back starting last January 2009 but it does not radiate to any part of his body. Pain scale of 8 /10. The cause of this problem was due to his habit of smoking cigarette with a maximum of 40 sticks a day and alcohol consumption. Upon assessment, he stated that whenever he is under stress, his back pain would most probably occur. The treatment that he used to relieve the pain was to placed Gabon on his back.

PREVIOUS ILLNESS
The patient experienced mumps, measles, and chicken pox during childhood. At 10, he fell from the horses back and got injured with his buttocks but he didnt decided to be hospitalized. He didnt have any immunizations when he was a child, no any allergies and no surgeries undergone.

REACTIONS AND EXPECTATIONS ABOUT HOSPITALIZATION

y

According to the patient, illness is an unhealthy condition and it requires an immediate attention, stressful, and is expensive especially with regards to medications. The effect of illness in his life interferes his daily living. He hopes and expect that the diagnostic procedures, therapies, and diet he have would alleviate his condition.

REACTIONS ABOUT TREATMENT AND

DIAGNOSTIC PROCEDURES

He would like to know if the therapies and treatment planned for his care would be effective. He would like to know if the results is normal or abnormal. He was very participative in any procedure helpful to his treatment. Exposure of his body parts during procedure is not a big deal to him for he trust his health care provider.

NursingHistory Normal Patterns of Functioning (Before Admission) The patient experience SOB upon walking at least 5 meters. The patient had an intermittent productive cough and interfere with rest. No sneeze. The reason of cough is smoking of 40 stick/ day since 16 years old- 50 yrs. Old. He didnt do breathing exercises.

Clinical Inspection Observation on First day of duty RR: 4PM-27 8PM-21 RHYTHM: Irregular Use of accessory muscles such as; trapezius and rales & wheezes upon inspiration with a yellowish color of sputum.

On-going Appraisal Observation on 2nd day of Duty

Other Sources Laboratory Exam Results

RR: 4PM-20 8PM-17 Noisy breathing. Funnel chest (pectos excavatum)type of chest wall configuration.

Chest PA FINDINGS: Haziness at both basis. Hyperlucent lung fields with depressed diaphragm Tracheal shadow is in midline. Bone and other chest structures are unremarkable. IMPRESSION: 1.Basal pneumonia 2. Pulmonary emphysema.

His BP is normal. The patient stated that he did not experience palpitation.

BP: 4PM130/70mmHg 8PM120/80mmHg PR: 4PM-88 bpm 8PM-88 bpm CAPILLARY REFILL: 2-3 seconds. TEMP: 4PM-36.4C 8PM-37.3C

BP: 4PM90/60mmHg 8PM100/80mmHg PR: 4PM-88 bpm Pulse Deficit-2 CAPILLARY REFILL: 2seconds TEMP: 4PM-36.3C No murmurs.

ECG Result: Atrial Fibrillation: I. Heart Rate 111 II. Heart Rate 130 III.Heart Rate 90 V4. Heart Rate 116 V5. Heart Rate 120 V6. Heart Rate 112 aVR. Heart Rate 138 aVL. Heart Rate 120 aVF. Heart Rate153 V1. Heart Rate150 V2.Heart Rate125 V3. Heart Rate 122 FEBRUARY 24, 2010 RBC=4.27 Hemoglobin=14.0 Hematocrit=0.42 WBC=27.0 Lymphocyte=0.05 Eosinophil=0.01 Platelets= Normal Segmenters=0.93

FEBRUARY 22, 2010 RBC=5.09 HEMOGLOBIN=10.3 HEMATOCRIT=0.15 WBC=46.7 LYMPOCYTE=0.03 PLATELETS=Normal PLATELET COUNTS=399 SEGMENTERS=0.93 MONOCYTE=0.04

FOOD AND FLUID INTAKE He eats 3x/day with a snack sometimes. He admitted that he forgot to eat his meals sometimes due to his several works. Meal usually consists of 2-3 cups of rice and 1 medium size fish,ginamos and bulad as appetizer and serves as a viand if there is no other viand. Eats vegetables at least 3x/week. Eats meat occasionally. He drinks coffee 1cup/day, 2 glasses of tuba. They use edible oil in cooking and uses ginisa mix sometimes if they cooked meat

1ST DAY DUTY Weight: 57kg Height: 55 Body Build: Ectomorph Skin: No active lesions

2ND DAY DUTY Diet: DAT Parenteral: PNSS 1L @ 20gtts/min. Intake 3-11: 500 cc Output 3-11: 760cc Parenteral: 260 cc pH=6.0

LAB. RESULT URINALYSIS: Macroscopic Color: yellow Transparency: SL hazy pH:6.0 Sp Gr:1.030 Microscopic WBC:0-4/hpf RBC:0-3/hpf Epithelial cells: few Mucus Threads: Plenty Bacteria: Moderate CHEMICAL: Protein: Negative Glucose: Negative Glucose Fasting: 123.7mg/dL Na:131.0meq/L K:3.40meq/L Creatinine: 1.01mg/dL

ELIMINATION

1ST DAY DUTY

2ND DAY DUTY He urinated 760cc, with its lightly yellow appearance. There was no passage of feces in the entire 8 hour duty.

LAB. RESULT

He defecates once The urine is a day usually in yellow as the morning and described. stools are usually colored brown and formed. Urinates at least 5x during the day and once at night before going to sleep.

REST AND SLEEP He usually sleep 9hours a day. He often goes to sleep at 7pm and wakes up at around 4am in the morning. Noise and his cough sometimes interrupt his sleep. He sometimes take a nap during noon time or when feeling exhausted from work.

1ST DAY DUTY wala jud koy tarong tulog kay saba ang palibot as verbalized. The patient was observed spitting his secretions in an empty bottle.

2ND DAY DUTY Sige jud ko og mata mata kay saba ang palibot. According to him, he just slept for more or less 2 hours in our entire duty.

LAB. RESULT

EXERCISE He worked as wood canvasser for the past 12 years until the age of 68. It usually involves heavy lifting. He is right handed. He cannot performed some of the daily activities. He can only perform some of the daily activities if there is assistance. He is observed in fowlers position. Performed range of motion. Can performed ADLs like toileting, eating without assistance.

PAIN/DISCOMORT Prior to admission, he experience SOB, cough which prompt him to seek medical advice. He has complaints of difficulty of breathing.

1ST DAY DUTY He felt pain at the cage of his ribs when coughing sometimes. With a pain scale of 10/10. He was observed to be avoidance in smoke because he was easily to get worst when he inhaled it, as complained.

2ND DAY DUTY A pain scale of 7/10. . The pain felt sharp at the left upper quadrant of his back starting last January 2009 but it does not radiate to any part of his body. Pain scale of 8 /10. The cause of this problem was due to his habit of smoking cigarette with a maximum of 40 sticks a day and 2 bottle of alcohol consumption/day.

LAB. RESULT

REGULATORY MECHANISM He is able to tolerate in a warm environment and his body usually perspire profusely when placed longer in warm area

1ST DAY DUTY

2ND DAY DUTY

LAB. RESULT

TEMP: temp: 4PM4pm-36.3c 6PM6pm-36.8c 8PM8pm-36.5c He has a dry skin due to aging He is responsive, aware to the person who care for him, but not time and medication oriented.

Personal hygiene he take a bath after waking up in the morning He brush his teeth twice a day after breakfast and dinner He stayed 10minutes for taking a bath He shaves his mustache after taking a bath

1st day duty His skin is dry due to aging, nails are poorly trim, scalp are dry due to aging, and mouth isnt smell good

2nd day duty He still needs an assistance and the need for teaching about the importance of hygiene, but our patient this time is done with bedside care through TSB.

Lab. result

COMMUNICATION 1ST DAY AND SPECIAL DUTY SENSES He can speak, hear, understand but he cant speak english but can understand little bit. He uses cellular phones in keep touch to his family, he went on to the house of his friend for visit but to his work he goes it personally. He is responsive, communicate also copatients,not oriented about the medication given and time and amount he was micturate and deficate and amount of the output.

2ND DAY DUTY

LAB. RESULT

Low tone of voice upon talking, use eye glasses when necessary, no contact lenses, no use of hearing aid device, no speech defect

Results of sights used eyeglasses occasionally. Hearing test result, ear is functioning well

COPING WITH STRESS He will find ways to solve the problem even if how it is hard it for him. Advices taken from his wife If his wife will get angry, he will just leave his wife alone to avoid quarrelsome

1ST DAY DUTY He uses calmness when approaching everyone. He is not easily get angry.

2ND DAY DUTY He is still maintaining his positive attitude towards stressful situation like his case

LAB. RESULT

RELIGIOUS LIFE He attend to church mass minimally atleast twice in every month He is active if there are activities done in church No personal devotions

1ST DAY DUTY No medal worns Belief not o eat blood of dressed animals Believe for blood transfuse

2ND DAY DUTY He pray to GOD before taking his meals and go to bed

LAB. RESULT No need for counselling

SOCIAL/ 1ST DAY OCCUPATIOPNAL DUTY LIFE he is a wood canvasser, at the same time carpenter Uses 9-11 hours of work He is a father, husband They are 8 in all but 2 only remain, he and his wife only all there siblings separate from them after there childrens got married His friends also visits to him He wants especially to see all of his siblings He uses cultural He warmly welcome his visitors, communicate well his room mates He follow all the instructions came from the staff nurses He heartily receives his disease

2ND DAY DUTY

LAB. RESULT

He said malipay jud ko ug naay mobisita nako and malingaw siya kung naa ang mga student nurses kay mabibo napod ang kwarto as stated by the patient.

RECREATION/ DIVERSIONAL ACTIVITIES He went to his neighbors for fun He stay in there house only and got rest when he feel ill. He want to go to the place of his children but have no time and no budget for fare Sometimes, he went to his neighbor to drunk with his friends

1ST DAY DUTY

2ND DAY DUTY

LAB. RESULT

He communicate his co-patient but still he feel boredom upon staying in the hospital

His boerdom was minimize because he was care well by the nursing student and he can talk with

HEALTH SUPERVISION He followed it for a short time, when he feel well he stop following the prescription of the doctor for his health. It is his condition sends him to bed the dx of basal pneumonia and pulmonary emphysema He stay out of work for the treatment of his illness He consult doctor for curement of his condition

1ST DAY OF DUTY It need for teaching regarding self-medication, health supervision use of community facility so that he can stick with the doctors prescriptions for his health also the treatment plan

2ND DAY OF DUTY Use of culture medicine for alternative treatment and to save money for foods.

LAB. RESULT

 He keep appointed to his health in there center 2 weeks before he send to the MUMC  X-ray examination last 2007 at S.I.L Clinic, Oz.City  His wife will give care to him after hospital discharge

10 POSSIBLE NURSING DIAGNOSIS

1.

IMPAIRED GAS EXCHANGE RELATED TO VENTILATION PERFUSSION IN BALANCE INEFFECTIVE BREATHING PATTERN RELATED TO SHORTNESS OF BREATH IMBALANCE NUTRITION LESS THAN BODY REQUIREMENTS RELATED TO INABILITY TO TAKE FOOD REQUIREMENTS IMPAIRED BREATHING RELATED TO BRONCHOSPASM HYPERTHERMIA RELATED TO INFECTIOUS PROCESSES RISK FOR INFECTION RELATED TO INADEQUATE SECONDARY DEFENSES RISK FOR FLUID VOLUME DEFICIT RELATED TO FEVER AND RAPID RESPIRATION. DIFFICIENT DIVERSIONAL ACTIVITY RELATED TO PHYSICAL LIMITATION. AVTIVITY INTOLERANCE RELATED TO IMBALANCED BETWEEN OXYGEN SUPPLY AND DEMAND. SELF CARE DEFICIT RELATED TO FATIGUE.

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INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible. This newest definition COPD, provided by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), is a broad description that better explains this disorder and its signs and symptoms (GOLD, World Health Organization [WHO] & National Heart, Lung and Blood Institute [NHLBI], 2004). Although previous definitions have include emphysema and chronic bronchitis under the umbrella classification of COPD, this was often confusing because most patient with COPD present with over lapping signs and symptoms of these two distinct disease processes. COPD may include diseases that cause airflow obstruction (e.g., Emphysema, chronic bronchitis) or any combination of these disorders. Other diseases as cystic fibrosis, bronchiectasis, and asthma that were previously classified as types of chronic obstructive lung disease are now classified as chronic pulmonary disorders. However, asthma is now considered as a separate disorder and is classified as an abnormal airway condition characterized primarily by reversible inflammation. COPD can co-exist with asthma. Both of these diseases have the same major symptoms; however, symptoms are generally more variable in asthma than in COPD.

Currently, COPD is the fourth leading cause of mortality and the 12th leading cause of disability. However, by the year 2020 it is estimated that COPD will be the third leading cause of death and the firth leading cause of disability (Sin, McAlister, Man. Et al., 2003). People with COPD commonly become symptomatic during the middle adult years, and the incidence of the disease increases with age.

ANATOMY AND PHYSIOLOGY: The respiratory system consists of all the organs involved in breathing. These include the nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important things: it brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes wrong with part of the respiratory system, such as an infection like pneumonia, chronic obstructive pulmonary diseases, it makes it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide. Common respiratory symptoms include breathlessness, cough, and chest pain.