PURBANCHAL UNIVERSITY
EVEREST COLLEGE OF NURSING
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A
CASE STUDY
ON
Cerebrovascular Accident
Submitted By Submitted To
Susmita K C Miss Sonam Limbu
Roll no:38 Miss Alisa Risal
Miss Anjali Shrestha
Date
of submission:2073/10/
S.N CONTENTS
PAGE
NO
1
Acknowledgement
2 Background
3 Selection of Case
4 Objectives(General +Specific)
5 Bio-data of patient
6 chief complain
7 History of past illness
8 Personal history
9 Family history/Family Tree
10 Physical Examination
11 Summary of history taking &
physical examination
12 Growth & Development
13 Cerebralvascular accident
14 Etiology
15 Patho-physiology
16 Clinic features
17 Diagnostic procedure
18 Management & Treatment
19 Drug Bank
20 Nursing Management
21 Application of nursing theory
22 Nursing Care Plan
23 Stress Management & Diversional Therapy
24 Discharge Planning & Teaching
26 Learning experience from case study
27 Summary
28 Bibliography
ACKNOWLEDGEMENT
This case study report on
Cerebralvascular accident has been prepared
based
on the patient work-up during the eight weeks clinical posting at Helping hand Hospital,Chabehil,
kathmandu. This report has been prepared as a partial fulfillment for the post Basic
Basic Bachelor in nursing curriculum of Purbanchal University under practicum
of Medical Surgical Nursing. I realized that is requirement to complete a case
study has been an important opportunity for us to gain new experience and
knowledge.
I
could have never completed this case study without the help of some
intellectual giants and wellwisher.I want to express my heartfelt gratitude and
appreciation to all those people whose voluntary efforts continued to defy the
received wisdom.
Specially,
I would like to express all my gratitude to Co-ordinator Sonam Limbu,
Instructor Anjali Shrestha and Alisha Rijal, for providing continuous
monitoring, supervision, guidance and encouragement throughout the entire
period of clinical practicum.
I would like to express my
gratitude to the campus chief, tutors, administration, and library staffs for
providing me the opportunity to have case study and making availability of all the
necessary materials. I would like to remember my seniors and colleagues for
their valuable suggestions and support.
Here I can’t forget to
express thanks to Director, Matron, all Incharge of Helping hand Hospital for granting me the
permission to conduct the case study.Furthermore I would like to thank all the
concerned staffs for their help and co-operation. Without their help the case
study would not have been completed.
At last but not least,
my genuine gratitude is offered to the patient and her family
for providing me the
valuable information, time co-operation that help me for a successful completion
case study.
Susmita kc
PBBN 1st year
Everest College Of
Nursing
Tinkune,Kathmandu.
Background
of the study:
As a partial
fulfillment of Post Basic Bachelor Nursing Curriculum Of Purbanchal University
under practicum of
Medical Surgical Nursing,we are required to do 8 weeks practical at
Helping hand
Hospital,Chabahil,Kathmandu.
During this practicum
period,we had posting in different wards, where we individually
were supposed to do
detail case study of the patient. So,I choosed case from Medical ward where
the patient was
diagnosed as Cerebrovascular Accident” for the case study.
Selection
of the case study on Cerebrovascular Accident:
I have chosen the case
of CVA
which is a major health problem that effect cardiovascular system
showing effect in neurological disorder
So, learning about this
problem deeply it’s all parts, we can educate patient’s family and
other people about this
problem and its prevention.
Objective
of the case study on Cerebrovascular Accident:
General
Objectives
To gain depth knowledge
about "CVA" by comprehensive assessment, proper nursing
diagnosis, planning
appropriate care, implementing care according to need and evaluate the
outcome.
Specific
Objectives
· To
provide holistic nursing care to the patient by applying nursing process
according to
the nursing theory.
· To
apply knowledge from the basic science and nursing theories in planning the
comprehensive care to
patient.
· To
gain the knowledge about specific condition.
· To
maintain good interpersonal relationship with the patient and family members
and
provide care according
to their need.
· To
provide health teaching and psychological support to the patient along with the
visitors to promote and
maintain the health status of the patient.
· To
provide information and knowledge about the disease process to the patient and
family.
· To
prevent from further complications.
Bio-Demographic Data of the Patient
Name Uma
Devi Ghimire
Age 68 years
Sex Female
Religion Hindu
Marital Status married
Economic status middle class family
Educational status Illiterate
Occupation housewife
Ward Medical ward
Bed no 05
Inpatient number
Date of admission 2073/9/10
Diagnosis Cerebrovascular
Accident
Attending
doctor Dr.Niraj
Residence Kapan,Kathmandu
Informants Patient
self, her daughter and documents.
Chief
complains:
Productive
cough,fatigue since 3-4 days
Breathlessness since
1day
Restless, chest
tightness since night
History
of present illness:
This patient is the
known case of copd under regular medication ,who states that she was in
her usual state of
health until 3-4days prior to admission, when she experienced productive
cough with excessive
mucoid to purulent sputum usually worse in morning with worsening
dyspnea doing simple
activities 1day back that increases on supine position. Since night she
became restless and had
chest tightness then, she was brought to Madhyapur Hospital
,Emergency department.
So she was admitted in medical ward for further management.
History
of past illness: She
doesn't have any history of surgery and other
genetic or hereditary
history.
History
of allergies/injuries/previous hospitalization:
No history of major injuries
till now. Patient was hospitalized 1 year back due to COPD and
gives history of
cold,dust allergies as characterized by cough .
Personal
Habit:
Smoking: chronic
smoker(for 15-20)years but now stopped since 1year.
Drinking habit: No such
history.
Drugs:Under regular
medication as per prescription=Tab Doxobid OD HS,R/C Foracort400mcg
BD,R/C TIOVA 18mcg
OD,tab.lasilactone 1 tab P/O morning.
Dietary Habit:She had
regular dietary habit and is a non-vegetarian
No.of meal taken :
heavy meal morning and night ,morning breakfast and lunch at day time.
Food allergy:none
Recreation:enjoys
watching TV, listening bhajans
Elimination
habit:normal bowel and bladder habit
Rest and sleep habit:
She used to sleep 6-8 hours at night and 1 hour day nap
Immunization: not known
Birth History:Place of
delivery=Home delivery
Mode of delivery=normal
Birth weight=not known
Birth complications=not
known
Bathing-1to 2 times a
week
Socio
economic status:
She is from middle
class family.They use gas for cooking now but used to have woodfire
6-7years back.
No.of rooms in home=10
Separate kitchen
room=yes
Source of drinking
water=Jar water after boiling
Type of toilet=water
seal latrine
Type of drainage
system=closed
Type of refuse
disposal=taken by municipality van
Psychological
History:
She has not any
psychiatric illness till now.
Health
related beliefs and practices:
She has faith on modern
medicines and also beliefs on traditional healer in some extent.
Occupational
History:
She is a house wife
takes care of her home and family.
Family
History:
Type of family=joint
family
They have 5 children- 2
sons and 3 daughters who all are maried. She is now living with her
husband, two sons
,daughters in law and elder son have 1 boy.Her husband have diabetes and
hypertension under
medication.No known disease on her children.
Family
tree:
Indicator:
EXPIRED MALE FEMALE
EXPIRED FEMALE PATIENT
MALE
PHYSICAL
EXAMINATION:
A physical examination
is the evaluation of a body to determine its state of health. A
complete health
assessment also includes gathering information about a person’s medical history
and lifestyle,
conducting laboratory tests, and screening for disease. These elements
constitute
the data on which a
diagnosis is made and a plan of treatment is developed.
I also performed the
physical examination of Mrs.Uma Devi Ghimire to determine her health
status. The techniques
used for physical examination are inspection, palpation, percussion,
auscultation,
measurement and smelling.
Baseline
data/measurement:
· Height:
5ft 2inches
· Weight:
62kg
· Temperature:
97.00F
· Pulse:
100/min
· Respiration:
36/min
· Blood
pressure: 110/80mm of Hg
· SPO2:78%
with out O2, 92%with 02
General
appearance
· Consciousness
level-She is conscious and oriented to time, place and person.
· Nutritional
status- looks weak,thin
· Appearance-
she is anxious and ill looking.
· Posture/gait-balanced
· Hygiene
and grooming- poorly groomed.
· Behaviour-
appropriate reaction to the situation.
· Mood-no
mood swings. Appropriate to situation.
· Speech-.
Language easily understandable.
· Integumentary:
· Skin
colour- black brown
· Texture-dry,wrinkled
skin
· Cyanosis-absent
· Turgor-
intact
· Oedema-
nil
· Erythema-not
seen
· Hair-thining
and graying of hair
· Nails-no
clubbing, capillary refill normal
· Head:
· Normocephalic
· No any
mass, nodules or scar
· No
depressed swelling or injury.
· Scalp
clear, no dandruff, lice
· Eyes:
· Eyebrows-equally
distributed hair, symmetrical, equal movement of eyebrows.
· Eyelid-no
exopthalmus, no ectropion and no entropion, symmetrical closing, no
swelling, redness, no
drooping.
· Bulbar
conjunctiva-transparent and white in colour.
· Palpebral
conjunctiva-slightly pinkish in colour, no discharge.
· Sclera-white
in colour.
· Cornea-transparent,
no abrasions, no opacity.
· Lens-equal,
light reflex is equal, clear, no opacities. Pupils-symmetrical, round
constricts on light and
well accommodated. PERRLA-pupils equal, round, reacting to
light and well
accommodated, prompt response to light. No sluggishness or absent of
reactivity.
· Ocular
movement-smooth, symmetrical, bilateral equal movement, no divergence in
any positions/no squint
present.
· Conjunctival
hemorrhage-not present.
D)
Ears:
· Location-normal,
the margins of the pinna, outer canthus of the eye meets at occipital
protuberance.
· Pinna-no
lesion, lump, smooth rounded counter and B/L symmetrical.
· External
ear canal-no redness, discharge, mass or foreign body. Wax present.
· Lymph
nodes and mastoid area-not palpable, no swelling and tenderness
· No
discharge or drainage from the ear.Hearing normal.
E)
Nose:
· Location-centrally
located on face.
· Nostrils-uniform,
no nasal flaring and discharge.
· Nasal
septum-normal, no deviation, no extra growth.
· Nasal
canal-pinkish mucosa, no extra growth.
· Smelling-good.
· Sinuses-no
tenderness and pain when palpating maxillary and frontal sinuses.
F)
Face:
· Symmetrical
– symmetrical in terms of palpebral fissure, nasolabial folds. No facial
palsy.
· Sensation-
Able to feel normally. Has touch sensation.
· Temporal
pulse – Present
· Movement
– Symmetrical up on voluntary movement, smile, puff out cheeks, shows
teeth.
G)
Mouth and throat:
· Lips-brown
in colour but dry, no injury.
· Teeth-yellowish
in colour, dental caries present and no missing teeth.
· Mucosa-moist
and pink in colour.
· Gums-no
ulcer or inflammation. No gum bleeding.
· Tongue-cyanosed
without oxygen, no ulcer, can move freely.
· Palate-soft
palate(pink in colour), hard palate(white in colour)
· Tonsils-present,
no swelling.
· Pharynx-pink,
smooth oropharynx.
· Uvula-free
hanging, single, pear shaped projection.
· Gag
reflex-present.
H)
Neck:
· Range
of motion-normally flexed, no stiffness normal extension.
· Thyroid
gland-no enlargement, no swelling, no lump on the neck.
· Jugular
vein-slightly distended
· Lymph
nodes-no tenderness.
· Carotid
pulse-bilateral equal and strong.
I)
Chest (thorax and lungs)
· Inspection
· Barrel
shaped(AP diameter increased than transverse diameter) prolonged expiration
· Palpation:
- No any lump, tenderness,
depression along the ribs.
· Percussion:
- High resonance on
percussion
· Auscultation:
expiratory wheeze, decreased breath sound,
.
J)
Heart:
· Auscultation:-
- Normal lub-dub sound
heard on the valves.
- Apex beat-regular in
rate and rhythm, 100/min, compatible with radial pulse.
K)
Back:
· Spine-centrally
located, ’s’ shaped, concave on cervical region, convex on thoracic
region, concave lumbar
region and convex on sacral region.
· Slightly
leaned forward.
· Spinous
process-vertically aligned, non-tender, muscle mass equal, no any lesions.
· Breathe
sounds-wheeze present.
· Range
of motion-full(with difficulty)
L)
Abdomen
- No scars
- No visible blood
vessels.
- Abdominal distention
presentation and abdominal pain.
- Liver and spleen are
not palpable.
- Gurgling bowel sound
present.
M)
Anus and Female genitalia
- Normal
- No abnormal
discharges.
- No history of
bleeding during defecation.
N)
Extremities:
· Upper
extremities/arms
· Skin-slightly
dark
· Nails-hard,
pink in colour, no clubbing of nail or thickening.
· Symmetry-symmetrical
in shape and size.
· Range
of motion-full in all joints, bilaterally equal.
· Joints-no
tenderness, no swelling.
· Temperature-
normal
· Reflexes-biceps
and triceps reflex are present.
· Muscular
strength present.
· Lower
extremities/legs
· Skin-slightly
dark, No pallor and cyanosis.
· Temperature-normal
· Nails-hard,
no clubbing
· Symmetrical-symmetrical
in shape and size.
· Range
of motion full in all joints, bilaterally equal.
· Joints-no
tenderness, no swelling.
· Pulses-dorsalispedis,
posterior tibials and popliteal pulses are present.
· Reflexes-planter
reflexes are present.
· Posture
and gait-normal.
O)
Nervous system:
- Muscle strength-equal
strength in all limbs.
- Sensation-good
- Co-ordination and
movement-well co-ordinated.
P)
Reflexes:
· Motor
and sensory reflex-good
· Corneal
reflex-positive
· Biceps
reflex-positive
· Triceps
reflex-present
· Brachio-radial
reflex-both forearm flex
· Knee-jerk
reflex-present
· Planter
reflex-present
· Ankle reflex-present.
Summary
of History Taking and Physical Examination
History taking and
physical examination helps to reveal information about the patient.
They are the tool in
obtaining subjective and objective data and thus help to assemble
information about
patient.
About 80% of the
information in the assessment is obtained by history taking. It is
therefore essential to
take history in systematic manner. About 15% of the information is
revealed by physical
examination. It helps to identify the health status of the patient. Physical
examination is
performed to gather objective data and to correlate them with subjective data.
It
also reveals additional
problems that the patient has not recognized. When doing physical
examination,
cephalocaudal approach is followed, that is head to toe approach.
After performing
history taking and physical examination following things were found:
· Patient
was anxious, ill looking.
· Patient
belonged to middle class family.
· Used
to smoke but now stopped since 1 year.
· Dental
carries present
· Patient
is dirty and poorly groomed.
· Respiration
rate 36breaths per minute
· Nutritional
status-muscle wasting
· Appetite-slightly
decreased.
· Dry
lips, dry wrinkled skin
· Chest:expiratory
wheeze, barrel shaped, hyper resonance
DEVELOPMENTAL
TASKS:
My patient’s age is
68years, falls under late adulthood. WHO divides the later maturity in 3
segments:Elderly(65-75),The
old(76-90),Very old>90 years.Resolving the crisis of integrity
versus
despair. This is Erikson’s eighth and final developmental stage,which
individuals
experience during late
adulthood.In the later year of life, we look and evaluate what have done
with our lives. Through
many different routes, the older person may have developed a positive
outlook in most of all
of the previous stages of development.If so,the retrospective glances will
reveal a picture of a
life well spent, and the person will feel a sense of satisfaction-integrity
will
be achieved. If the
older aduli resolved many of yhe earlier satages, negatively, the retrospective
glances likely will
yield doubt or gloom- the despair Rrikson talks about.
According
to the Book
In My
Patient
Disengage for paid
works As she was a house wife she was never
engaged in paid works.
Reassess for finances
Thinks medical costs as a financial burden
Be concern with
personal health care She is not maintaining maximum level of
health due
weakness,doesn’t eat adeequately
Maintain interest in
people outside the family
and in social ,civic
and political responsibilities
She is not interested
in social, civil , and
political
responsibilities
Adjust to a single
state Her husband is alive
Continue a supportive,
warm relationship with
the spouse,including a
satisfying relationship
She has good,
supportive and warm
relationship with her
husband
Find a satisfactory
home or living arrangement
and establish a safe,
comfortable household
routine to fit health.
She has good living
arrangements but has
limited activity at
home due to fatigue.
Be reconciled to death
She has adjusted the dealth of her parents
Recognize and adjust to
the aging process She accepts her ageing process and decreasing
physical strength and
health.
Anatomy
and Physiology of the Lung
The lungs are the
primary organs of the respiratory system. The main function of the human
respiratory system is
to transport oxygen from the atmosphere into the blood, and to expel carbon
dioxide from the body.
Healthy levels of oxygen are absolutely crucial for the human body, as
oxygen gives our cells
energy and helps them regenerate.
The
Anatomy of the Lung
Each lung is divided
into lobes. The right lung, which has three lobes, is slightly larger than the
left, which has two.
The lungs are housed in the chest cavity, or thoracic cavity, and covered by a
protective membrane
called the pleura. The diaphragm, the primary muscle involved in
respiration, separates
the lungs from the abdominal cavity.
The pulmonary arteries
carry de-oxygenated blood from the right ventricle of the heart to the
lungs. The pulmonary
veins, on the other hand, carry oxygenated blood from the lungs to the
heart,so it can be
pumped to the rest of the body.
The lungs expand upon
inhalation, or inspiration, and fill with air. They then return to their
resting volume and push
air out upon exhalation, or expiration. These two movements make up
the process of
breathing, or respiration.
The respiratory system
contains several structures. When you breathe, the lungs facilitate this
process:
· Air
comes in through the mouth and/or nose, and travels down through the trachea,
or
"windpipe."
This air travels down the trachea into two bronchi, one leading to each lung.
The bronchi then
subdivide into smaller tubes called bronchioles. The air finally fills the
alveoli, which are the
small air sacs at the ends of the bronchioles.
· In the
alveoli, the lungs facilitate the exchange of oxygen and carbon dioxide to and
from
the blood. Adult lungs
have hundreds of alveoli, which increase the lungs' surface area
and speed this process.
Oxygen travels across the membranes of the alveoli and into the
blood in the tiny
capillaries surrounding them.
· Oxygen
molecules bind to hemoglobin in the blood and are carried throughout the body.
This oxygenated blood
can then be pumped to the body by the heart.
· The
blood also carries the waste product carbon dioxide back to the lungs, where it
is
transferred into the
alveoli in the lungs to be expelled through exhalation.
Lung
Volume And Lung Capacity
Terms Symbols
Description Normal
Value
Significance
Lung
Volume
Tidal volume
VT or TV
The volume of air inhaled
and exhaled with each
breath.
500mLor
5≈10mL∕Kg
The tidal volume may
not
vary,even with severe
disease.
Inspiratory
reserve volume
IRV The maximum volume
of
air that can be inhaled
after a normal
inhalation.
3000mL
Expiratory
reserve volume
ERV The maximum volume
of
air that can be exhaled
forcible after a normal
exhalation
1100Ml Expiratory
reserve volume is
decreased with
restrictive
conditions,such as
obesity,ascites,pregnancy.
Residual
volume
RV The voume of the air
remaining in the lungs
after maximum
exhalation
1200ml Residual volume
may be
increased with
obstructive
disease
Lung
capacity
Vital capacity
VC
The maximum volume of
air exhaled from the
point
of maximum inspiration
VC=TV+IRV+ERV
4600ML
A decrease in
vitalcpacity may
be found in neromuscular
disease,generalized
fatigue,atelectasis,pulmonary
edema,COPD &
obesity.
Inspiratory
capacity
IC The maximum volume
of
air inhaled after
normal
expiration.
IC=TV+IRV
3500 ML A decrease in
insppiratory
capacity may indicate
rstrictive disease.May
also be
decreased in obesity.
Functional
residual
capacity
FRC The volume of air
remaining in th lung
after
a normal expiration
FRV=ERV+RV
2300 ML Functional
residual capacity
may be increased with
COPD
and decreased in ARDS
and
obesity.
Total lung
capacity
TLC The volume of air
in the
lung after a maximum
inspiration .
TLC=TV+IRV+ERV+RV
5800ML Total ling
capacity may be
decreased with
restrictive
disease(atelectasis,pneumonia)
& increased in COPD
CHRONIC
OBSTUCTIVE PULMONARY DISEASE
The Global Initiative
for Chronic Obstructive lung Disease(GOLD)has defined chronic
obstructive
pulmonary disease (COPD) as"a preventable and treatable disease with some
significant
extrapulmonary effects that may contribute to the severity in individual
patients.Its pulmonary
component is characterized by airflow limitation that is not fully
reversible.The airflow
limitation is usually progressive and associated with an abnormal
inflammatory response
of the lung to noxious particles or gases."(GOLD,2008)
COPD inlcudes
emphysema, an anatomically defined condition characterised by destruction
and enlargement of the
lungs alevoli; chronic bronchitis,a clinically defined condition with
chronic cough and
phlegm; and small airways disease, a condition in which bronchioles are
narrowed.
COPD is present only if
chronic airflow obstruction occurs.
The altenative name of
COPD :
COCD- Chronic
obstruction lung disease
COAD- Chronic
obstruction airway disease
CORD- Chronic
obstruction rspiratory disease
· ETIOLOGY
According to Book In
Patient
-Cigarette Smoking
Present
-Airway Responsiveness
& COPD Present
-Respiration Infection
Absent
-Occupation Exposures
-Air Pollution
-Antitrypsin Deficiency
-genetic
INCIDENCE
AND PREVALENCE OF COPD
According to WHO
estimates, 65millon people have moderate to severe COPD.At one time,it
was more common in men,
but because of increased tobacco use among women in high-income
countries and the
higher risk of exposure to indoor air pollution (such as biomass fuel used for
cooking and heating) in
low-income countries, the disease now affects men and women almost
equally.
Total dealths from COPD
are projected to increase by more than 30% in the next 10 years unless
urgent action is taken
to reduce the underlying risk factors ,especially tobacco use. Estimates
show that COPD in 2030
the third leading cause of dealth worldwide.
· PATHOPHYISOLOGY
Persistent reduction in
forced expiratory flow rates is the most typical finding COPD.
Increase in the
residual volumme and the residual volume/total ling capacity ratio , nonuniform
distributioon of
ventillation, and the ventillation-perfusion mismatching also ocurs.
-
AIRFLOW OBSTRUCTION
Airflow limitation,
also known as airflow obstruction, is typically determined by spirometry.
Patients with airflow
obstruction related to COPD have a chronically reduced ration of FEV1
/FVC.
In contrast to asthma,
the reduced FEV1 in COPD seldom shows large responses to inhaled
bronchodilators,
although improvements up to 15% are common.
-
HYPERINFLATION
COPD there is often
"air trapping"(increased residual volume and increased ratio of
residuak
volume to total lung
capacity) and progressive hyperinflation(increased total lung capacity) late
in the disease.
- GAS EXCHANGE
The PaO2 usually
remains normal until the FEV1 is decreased to 50% of
prediction.
An elevation of the
arterial level of carbon dioxide(PaCO2) is
not expected until the FEV1 is
<25% of predicted.
Pulmonary hypertension
severe enough to caus cor pulmonale and right ventricular failure due to
COPD typically occurs
in individuals who have marked decreased in FEV1 (<25%
of predicted)
and chronic hypoxemia
(PaO2<55 mm of Hg).
· PATHOLOGY
Cigarette smoke
exposure may affect the large airways, small airways(less or equal to 2mm
diameter), and alveoli.
Changes in large
airways cause cough and sputum, while changes in small airways and alveoli
are responsible for
physiologic alterations.
Emphysema and small
airway pathology are both present in most persons with COPD.
- LARGE AIRWAYS
Cigarette smoking often
results in mucous glaand enlargement and goblet cell hyperplasia
leading to cough and
mucous production that define chronic bronchitis.
Goblet cell not only
increase in number but in extent through the bronchial tree.
- SMALL AIRWAYS
The major site of
increased resistance is most individuals with COPD in airways lesss than 2mm
diameter.
Characteristics
cellular changes includes goblet cell metaplasia with these mucus-secreting
cells
replacing
surfactant-secreting Clara cells.
Infiltration of
momonuclear phagocytes is also prominent.
Smooth-muscle
hypertrophy may br present.
These abnormalities may
cause luminal narrowing by fibrosis, excess mucus, edema, and cellular
infiltration.
Reduced surfactant may
increase surface tension at the air-tissue interface,predisposing to airway
narrowing or collapse.
Because small airway
patency is maintained by the surrounding lung parenchyma that provides
radial on bronchioles
at point of attachment to alveolar septa, loss of bronchiolar attachments as
a result of
extracellular matrix destruction may cause airway distortion and narrowing in
COPD.
- LUNG PARENCHYMA
Emphysema is
characterised by destruction of gas-exchanging air spaces, i.e.,the respiratory
bronchioles, alveolar ducts,
and alveoli.
Their walls become
perforated and latter obliterated with coalescence of small distinct air spaces
into abnormal and much
larger air spaces.
· PATHOGENESIS
Airflow limitation the
major physiologic change in COPD, can result from both small airway
obstruction and
emphysema.
The dominant paradigm
of the pathogenesis of COPD comprises four interrelated events :
(1) Chronic exposure to
cigarette smoke may lead to inflammatory cell recruitment within the
terminal air paces of
the lung.
(2) These inflammatory
cell release elastolytic proteinases that damage the extracellular matrix
of the lung.
(3) Structural cell
death resukts from oxidant stress and loss of matrix-cell attachment.
(4) Ineffective repair
of elastin and other extracellular matrix components result in the air space
enlargement that
defines pulmonary emphysema.
STAGES
OF COPD
Stages of COPD
classified on basis of spirometry result.In the spirometry lung function FEV1
is
a test that shows slow
fast the client can breathe air out of the lung.FEV1 stands for forced
expiratory volume in 1
second.It can be measured by machine called spirometers.
There are various stage
of COPD on the basis of spirometry result:
1.AT
RISK COPD-STAGE -O:In this stage breathing test is normal but there is a possibility
of
developing COPD.Mild
symptoms of the condition include a chronic cough and sputum
production.
2.STAGE
I MILD COPD:The breathing test shows mild airflow limitation,symptoms may
include a chronic cough
and sputum production.Lungs functions FEV1 of 80% of normal or
higher.
3.MODERATE
COPD STAGE 2:In this stage, the breathing test shows a worsening of airflow
limitation, usually the
symptoms have increased. Lung function FEV1 of 50%to 70%.
4.SEVERE
III STAGE:Lung function FEV1 30-49%.
5.STAGE
IV VERY SEVERE COPD:Life threatening COPD flare ups with cyanosis,chronic
cough with lots of
mucus,weight loss and severe shortness of breath.
Clinical
Features:
ACCORDING TO BOOK IN MY
PATIENT
Productive cough
Excessive present mucoid to purulent
Shortness of breath
Present when exertion also on rest
Wheezing Expiratory
wheeze sound heard on auscultation
Chest tightness present
Tachypnea
RR32-38breaths/min
Barrel chest AP
diameter greater than transverse diameter
Clubbing of fingers of
toes absent
Distended neck veins
present
Fatigue Present on
walking short distance,climbing
upstairs.
Hoover’s sign absent
Hypoxaemia
hypercapnia
Diagnosis
of pneumonia:
ACCORDING TO BOOK IN MY
PATIENT
History taking,physical
examination Done
Chest X-ray done
Arterial blood gas
analysis Not done
ECG done
Pulmonary function test
by spirometer Not done
TIME test
Sputum G/S,C/S
Blood for renal
function, CBC
Pulse oximetry
monitoring
Alpha 1 antitrypsin
deficiency test Not done
Laboratory
finding comparison:
SN
Examination Normal value Patient report
1. Hematology test:
Total leucocytes
Differential counts
Neutrophils
Lymphocytes
Eosinophils
Monocytes
Basophils
RBC counts
Haemoglobin
PCV
Mcv
MCH
MCHC
Platelets
BIOCHEMICAL TESTS
Blood glucose(R)
Urea
Creatinine
NA
K
4000-11000/mm3
40-75%
20-50%
1-6%
2-10%
0-1%
4.5-6.5million/mm3
2.
3. Neutrophils 50-70%
67
4. Lymphocytes 25-30%
27
5. Monocytes 4-6% 06
Management
of copd:
· Medical management of COPD
i. Maintaining patient airway and effective gas exchange
through.
a. Suctioning and liquefying secretions
fluids,humidification of air.
b. Chest physiotherapy and deep breathing and coughing
excersice.
c. HIgh fowler's position (promotes good lung expansion.
· Pharmacological management
i. For improve ventillation
a. Bronchodilator via inhalation,oral,intravenous.
b. Beta2
adrenergic which increased
mucus clearance and dilatation of bronchus.
c. Anticholinergics-bronchodilators-beta2 against blocks the
cholinergic receptors in large
airways resulting bronchodilation.(Ipravent)
d. Methylxanthines-theophylines,aminophylineshas
bronchidilatory property,which
enhance mucus ciliary clearance and stimulates respiratory
center.
e. Corticosteriod-decrease inflammation and
edema,bronchodilatory effects.
f. Oxygen therapy-low flow/concentration of O2 1-3 lit via canula.
g. Antibiotics-if infection or severe form of COPD or an
exacerbation.
· For removal of bronchial
secretion
i. Nebulization with bronchodilators and positive pressure
airway flow.
ii. Postural drainage and chest physiotherapy,deep
breathing and coughing excersice.
· For promoting excercise
i. Aerobics excercise improves the lungs function but
strengthen respiratory muscles.
ii. Breathing excercise may be prescribed,to encourage
diaphragmatic breathing
discourage,rapid,shallow,panic breathing.Encourage purse
lip breathing too which
enhanced CO2
flushing.
CONTROL COMPLICATIONS:
Edema and corpulmonale are treated with diuretics and
digitalis.
· Improve general health/change
life style.
-Stop smoking, avoid exposure to allergy and avoid high
altitudes
-Adequate nutrition-frequent meals and provide more
calorie diet
· Surgical management in COPD
Sometimes surgery is helpful for COPD in selected cases
-Bullectomy:surgical removal of a bulla large air filled
space more in lungs
-Lung volume reduction surgery is similar, relatively good
lung and work better
-Lung transplantation is sometime performed for severe
COPD, particularly in
younger adults.
· Other management
-Influence vaccine:patient should be given annually to
prevent influenza and
infection.
-Benzodiazepines is used in low to reduce anxiety
-In advanced critical care illness decision for CPR are
addressed.
Treatment
used in my patient:
· Oxygen
inhalation.
· Pharmacotherapy
· Inj
taxim 125 mg IV TDS
· Inj
Genta 7.5 mg IV BD
· Inj
Dexona 0.5mg IV TDS
· Inj
Aciloc 3 mg IV TDS
· Inj
10% dextrose 180 mg over 24 hours.
On
discharge:
· Syp.
Sporidex 0.5ml PO TDS for 5 days.
Oxygen
therapy:
Oxygen
therapy – is the administration of oxygen as a therapeutic modality. It is
prescribed by
the physician, who
specifies the concentration, method of delivery, and liter flow per minute.
Benefits
of Oxygen Therapy:
Additional
Benefits of Oxygen Therapy:
· Increased
clarity
· Relieves
nausea
· Can
prevent heart failure in people with severe lung disease
· Allows
the bodies organs to carry out normal functions
Long-Term
Benefits of Oxygen Therapy:
· Prolongs
life by reducing heart strain
· Decreases
shortness of breath
· Makes
exercise more tolerable
· Results
in fewer days of hospitalization
Oxygen
Delivery Systems
1.
Nasal Cannula
· Also
called nasal prongs.
· Is the
most common inexpensive device used to administer oxygen.
· It is
easy to apply and does not interfere with the client’s ability to eat or talk.
· It
delivers a relatively low concentration of oxygen which is 24% to 45% at flow
rates of
2 to 6 liters per
minute.
2.
Face Mask
· It
covers the client’s nose and mouth may be used for oxygen inhalation.
· Exhalation
ports on the sides of the mask allow exhaled carbon dioxide to escape.
Types
of Face Masks:
· Simple
Face Mask - Delivers oxygen concentrations from 40% to 60% at liter
flows of 5 to 8 liters
per minute, respectively.
· Partial
Rebreather Mask – Delivers oxygen concentration of 60% to 90% at
liter flows of 6 to 10
liters per minute, respectively.
· Non
Rebreather Mask – Delivers the highest oxygen concentration possible
95% to 100% – by means
other than intubation or mechanical ventilation, at liter
flows of 10 to 15
liters per minute.
· Venturi
Mask – Delivers oxygen concentrations varying from 24% to 40% or
50% at liter flows of 4
to 10 liters per minute.
3.
Face Tent
· It can
replace oxygen masks when masks are poorly tolerated by clients.
· It
provide varying concentrations of oxygen such as 30% to 50% concentration of
oxygen
at 4 to 8 liters per
minute.
4 .
Transtracheal Oxygen Delivery
· It may
be used for oxygen-dependent clients.
· The
client requires less oxygen (0.5 to 2 liters per minute) because all of the low
delivered enters the
lungs.
Oxygen
Therapy Safety Precautions:
· For
home oxygen use or when the facility permits smoking, teach family members and
roommates to smoke only
outside or in provided smoking rooms away from the client.
· Place
cautionary signs reading “No Smoking: Oxygen in use” on the clients door, at
the
foot or head of the
bed, and on the oxygen equipment.
· Instruct
the client and visitors about the hazard of smoking with oxygen use.
· Make
sure that electric devices (such as razors, hearing aids, radios, televisions, and
hearing pads) are in
good working order to prevent the occurrence of short-circuit sparks.
· Avoids
materials that generate static electricity, such as woolen blankets and
synthetic
fabrics. Cotton
blankets should be used , and client and caregivers should be advised to
wear cotton fabrics.
· Avoid
the use of volatile, flammable materials such as oils, greases, alcohol, ether,
and
acetone(e.g. nail
polish remover), near clients receiving oxygen.
· Ground
electric monitoring equipment, suction machines and portable diagnostic
machines.
· Make
known the location of the fire extinguishers, and make sure personnel are
trained in
their use.
Drugs
profile:
Cefotaxim
Action: inhibits
bacterial cell wall synthesis, rendering cell wall osmotically unstable leading
to
cell death.
Uses:
· Gram
negative organisms- haemopilus influenza, haemophilus parainfluenzae, E.coli,
enterococcus faecals,
neisseria gonorrhea, neisseria meningitis.
· Gram
positive organisms- streptococcus pneumonias, streptococcus pyogenes,
staphylococcus aureus.
· Serious
lower respiratory tract, urinary tract, skin, bone, gonococcal infections.
· Bacteremia,
septicemia, meningitis, skin infection, CNS infection.
Dosage
and route;
· Adult:
IM/IV 1-2 gram 12 hourly.
· Child:
1 month-12 years. IM/IV 50 – 180 mg/kg/day in 4-6 divided doses.
· Severe
infection
· Adult-
IM/IV 2 gm 4 hoursly, not to exceed 12gm/day
· Child
1 month to 12 years, IM/IV 50-180mg/kg/day in 4 to 6 divided dose.
Side
effect:
· CNS-
headache, dizziness, weakness, paresthesia, fever, chills, seizures.
· GI-
nausea, vomiting, diarrhoea, anorexia, abdominal pain, cholestasis.
· Integumentary;
rash, urticaria, dermatitis.
· Respiratory-
dyspnoea.
Contraindication-
hypersensitivity to cephalosprins.
Nursing
consideration:
· Assess
the sensitivity to penicillin, other cephalosporins.
· Assess
electrolytes (potassium, sodium, calcium) monthly if patient is on long term
therapy.
· Assess
for bowel pattern daily, if severe diarrhoea occurs, product should be
discontinue.
· Assess
for anaphylaxis such as rash, urticaria, prurits, chills, fever, joint pain.
· Assess
for I/V site, change cannula if swelling present.
Gentamycin:
· Functional
class: anti infective
· Chemical
class: aminoglycoside
Action:
interfere with protin synthesis is bacterial cell by blinding to ribosomal
subunit, causing
misresding of genetic
load. Inaccurate peptide sequence forms in protein chain, causing bacterial
death.
Indication:
Severe systemic
infection of CNS, respiratory, GI, urinary tract, bone, skin, soft tissue
caused by susceptible
steains of pseudomonas aeruginosa, proteus, klebsiella, serratia, E.coli,
enetrobacter.
Contraindication:
hypersensitivity to this or other amino-glycosides,
fungal/viral/myocabetrial
infection.
Dosage
and route:
· severe
systemic infection
· Adult:
I/V 3 – 6 mg /kg/day in divided doses 8 hourly.
· Child:
IM/IV 2-2.5mg/kg 8 hourly
· Neonate
and infant: IM/IV 2.5mg/kg 8-13 hourly.
· Neonate<1
week: I/V 2.5mg/kg 12-24 hourly.
Side
effects:
· CNS: confusion,
depression, numbness, tremors, seizures, muscle twisting, neurotoxicity,
dizziness, vertigo
· Cardiovascular:
hypo/hypertension, palpitation, oedema
· EENT:
ototoxicity, deafness, visual disturbance.
· GI:
nausea, vomiting, anorexia.
· Genitor-urinary-
oliguria, hematuria, renal damage, azotemia, renal failure.
Nursing
consideration:
· Weight
before treatment, calculation of dosage is usually based on ideal body weight
but
may be calculated on
actual body weight.
· Assess
Intake and output, report sudden changes in urine output.
· Assess
for vital signs during infusion, watch for hypoternsion, change in pulse.
· Assess
IV site for thrombophlebitis including pain, redness, swelling, change side if
needed.
· Assess
dehydration, high specific gravity, decrease in skin turgor, dry mucous,
membranes, and dark
urine.
· Assess
for overgrowth of infection including fever, malaise, redness, pain, and
swelling.
Dexona:
· Functional
class: corticosteroid, synthetic.
· Chemical
class: glucocorticoids long acting
Action:
decreased inflammation by suppression of migration of
polymorphonuclear leukocytes,
fibroblasts, reversal
of increased capillary permeability and lyosomal stabilization.
Uses:
· Inflammation
· Allergies
· neoplasms
· cerebral
oedema
· septic
shock
· collagen
disorder
Dosage
and routes:
· inflammation:
· Adult:
PO 0.75-9mg/day in divided doses 6-12 hourly or phosphate IM
0.5-9mg/day divided
6-12 hourly or acetate IM 4-16mg 1-3 weeks.
· Child-
PO 0.024-0.34mg/kg/day in divided doses, q 6-12 hourly.
· ARDS
(acute respiratory distress syndrome)
· Adult
IM/IV (dexomethasone sodium phosphate) 0.5-9mg/day in 2-4 divided
doses.
· Child:
IM/IV (dexomethasone sodium phosphate) 0.06-0.3mg/kg/day or
1.2-10mg/m² in divided
doses q6-12 hourly.
Available form:
· Dexomethasone
tablets 0.25mg, 0.5mg, 0.75mg, 1mg, 1.5mg, 2mg, 4mg, 6mg
· Oral
solution 0.5mg/5ml, 1mg/1ml
· Injection:
acetate 8mg/ml, 16mg/ml, phosphate 4mg/ml, 10mg/ml, 20mg/ml, 24mg/ml.
Side
effects:
· CNS-
depression, flushing, sweating, headache, mood changes, euphoria, seizure,
insomnia.
· CV-
hypertension, tachycardia, edema, cardiomyopathy.
· EENT-
fungal infection, increase intraocular pressure, blurred vision, cataracts,
glaucoma.
· GI-
diarrhoea, nausea, abdominal distention
Contraindication:
children <2 years, psychosis, hypersensitivity to corticosteroid or
benylalcohol,
idiopathic thrombocytopenia, acute glomerulonepharits, fungal infection, AIDS,
TB, glaucoma.
Nursing
consideration:
Assess:
· Potassium,
blood, urine glucose while long term therapy, hypokalemia and
hyperglycemia.
· Weight
daily: notify prescriber of weekly gain >9 lb.
· Intake
and output ration, be alert for decreasing urinary output, increasing oedema.
· Infection-
fever, WBC even after withdrawal of medication.
· Mental
status, affect, mood, behavioral changes, aggression.
Aciloc
(ranitidine bisthmuth citrate)
· Functional
class: H₂ Histamine receptor antagonist.
Action:
inhibits histamine at H₂ receptor site in parietal cells, which inhibit gastric acid
secretion.
Uses:
· Duodenal
ulcer.
· Gastric
ulcer
· Hypersecretry
condition
· Gastro
esophageal reflux disease.
· Stress,
ulcer, active ulcers with helicobacter pylori in combination with clari
thromycin.
· Heart
burn.
· Unlabeled
uses: prevention of aspiration pneumonitis, upper GI bleeding, NSAID
induced ulcer
prophylaxis.
Available
forms: ranitidine tablet 75mg, 150mg, 300mg, solution of injection
25mg/ml,
Side
effects:
· CNS-
headache, sleepness, dizziness, confusion, agitation, depression, hallucination
(geriatric patient)
· CV-
tachycardia, bradychardia
· GI-
constipation, abdominal pain, diarrhoea, nausea, vomiting.
Contraindication:
hypersensitivity.
Nursing
consideration:
Assess:
· Gastric
Ph (>5 should be maintained)
· Intake
and output ration, BUN, creatinine.
· Mental
status: confusion, dizziness, depression, anxiety, weakness, tremors, report
immediately.
· In GI,
nausea, vomiting, diarrhoea.
Niko
paediatric drops
· Functional
class- non opoid analgesic antipyretic.
· Chemical
class- non salicylate, paraaminophenol derivative.
Action:
may block pain impulses peripherally that occur in responses to
inhibition of
prostaglandin
synthesis, does not possess anti inflammatory properties; antipyretic action
results
from inhibition of
prostaglandins in the CNS (hypothalamic heat- regulation center)
Uses: mild
to moderate pain or fever, arthralgia, dental pain, dysmenorrhoea, headache.
Doses
and routes:
· Adult
and child: >12 years PO/RECTUM 325-650mg q4-6 hourly, Prn. 4g/day.
· Child
1-12 years, PO 10-15 mg/kg q4-6 hourly, maxes 5 doses/24v hours.
· Neonate:
rectum 10-15mg/kg/dose q6-8 hours.
Available
form: tablet, injection, syrup, suspension.
Side
effects:
· CNS:
stimulation, drowsiness.
· GI:
nausea, vomiting, abdominal pain, GI bleeding.
· Genito
urinary: renal failure, (high prolonged doses)
· Integumentry:
rashes, urticaria
· Toxicity:
cyanosis, anaemia, neutropenia, jaundice, seizure.
Nursing
consideration:
Assess
· Hepatic
studies: AST, ALT, billirubin, creatinine, prior to therapy, if long term therapy
is
anticipated may cause
hepatic toxicity.
· Renal
studies- BUN, urine creatinine, occult blood, albumin, if patient is not long
term
therapy; presence of
blood or albumin indicate hepatitis.
· Intake
and output ratio, decreasing output may indicate renal failure.
· For
fever and pain- type of pain, location, intensity, duration.
· Provide
medicine with food or milk to decreased gastric symptoms if needed.
· Shake
well for suspension before a
Cefalexin
(INN)
It is a
first-generation cephalosporin antibiotic. It is an orally administered
agent with a
similar antimicrobial
spectrum to the intravenous agents cefalotin and cefazolin.
Action:
Active against strep.
Pneumoniae, nesseria meningitidits, N.gonorrhoeae and
staphylococci, strep.
Viridans. Less active against penicillianse producing staphylococci.
It works by interfering
with the bacteria's cell wall formation, causing it to rupture, and killing
the bacteria
Dosage
and route:
Oral: Treatment of
susceptible infections including skin, urinary and respiratory tract
infections:
Adult: 1-2 g daily in
divided doses at 6-8, 12 hour intervals, increased to 6 g in deep seated
infections.
Child: 25-100mg/kg body
weight daily in divided doses. Max dose: child 4g daily
Uses: Cefalexin
is used to treat a number of infections including:
· otitis
media,
· streptococcal
Pharyngitis,
· bone
and joint infections,
· pneumonia, cellulites
· urinary
tract infections
· It may
be used to prevent bacterial endocarditits.
Contraindication:
hypersensitivity to cephalosporines.
Special
precaution: hypersensitivity to penicillins, pseudomembranous colitis,
pregnancy, and
lactation.
Adverse
effects
· Diarrhea,
dizziness, headache.
· headache,
· indigestion,
· joint
pain,
· Stomach
pain (usually mild) and tiredness.
Nursing
consideration:
· Assess
the eyes, skin color because it can also cause yellowing of the eyes
· Assess
the color of skin because it can cause red, blistered, swollen or peeling
skin
· Monitor
intake and output: decreased urination;.
· Observe
for anaphylaxis reaction. Symptoms of an allergic reaction include rash,
itching, swelling, or
trouble breathing.
· Shack
well before administering the medicine.
Nursing
management:
· General
management:
· Make
the child lie on the side position to facilitate the drainage of the nasal
secretion.
· Keep
the child comfortably warm.
· Keep
him in a well ventilated room and avoid overcrowding near the child.
· Give
him plenty of fluid to drink.
· Administer
O₂ as needed. Nasal catheter and cannula is the best method to
administer O₂
· Specific
treatment:
It consist of treating
the causative organism by appropriate antibiotics, the commonly uses
antibiotics are
amoxicillin, cotrimoxazole, ampicilline, penicillin.
· Symptomatic
management:
· Suctioning
should be done as needed to remove secretion and infected form
oropharynx and
nasopharynx and to facilitate breathing.
· Steam
and benzene inhalation should be given twice a day or more frequently as
needed to broken out
the secretion and to facilitate coughing out.
· Paracetamole
is given to fever.
· Preventive
management:
· Promote
breast feeding and keep warm.
· Immunize
the child against infectious disease
· Keep
the child away from indoor smoke and dust.
· Keep
the child in well ventilated and less crowed areas.
· Encourage
mother to frequent/regular antenatal check up and teach mother about
infection.
Complications
of COPD
-Corpulmonale with
congestive heart failure and acute respiratory failure
-Spontaneous
pneumothorax due to rupture of bulla
-Peptic ulcer hyper
secretion of gastric acid due to decrease 02 and increase CO2
-
Prevention
Prevention includes
vaccination, environmental measures, and appropriately treating other
diseases.
Vaccination
Vaccination is
effective for preventing certain bacterial and viral pneumonias in both
children
and adults. Influenza
vaccines are modestly effective against influenza A and B. The Center
for
Disease Control and
Prevention (CDC) recommends that everyone 6 months and older get yearly
vaccination. When an
influenza outbreak is occurring, medications such as amantadine,
rimantadine, zanamivir, and oseltamivir
can help prevent influenza.
Vaccinations against Haemophilus
influenzae and Streptococcus pneumoniae in the first
year of life have
greatly reduced the role these bacteria play in causing pneumonia in children.
Vaccinating children
against Streptococcus pneumoniae has also led to a decreased incidence
of
these infections in
adults, because many adults acquire infections from children. Hib
vaccine is
now widely used around
the globe. A vaccine against Streptococcus pneumoniae is
also available
for adults, and has
been found to decrease the risk of invasive pneumococcal disease.
Environmental: Reducing
indoor air pollution is recommended as is smoking
cessation.
Other:
Appropriately treating underlying illnesses (such as AIDS) can
decrease a person's risk
of pneumonia.
There are several ways
to prevent pneumonia in newborn infants.
Testing pregnant
women for Group B
Streptococcus and Chlamydia trachomatis, and giving antibiotic
treatment,
if needed, reduces
pneumonia in infants. Suctioning the mouth and throat of infants with
meconium-stained
amniotic fluid decreases the rate of aspiration
pneumonia.
Prognosis:
COPD usually gets
gradually worse overtime and can ultimately result in dealth.It is estimated
that3%of all disability
is related to COPD.The proportion of disability from COPD globally has
decraesd from 1990 to
2010 due to improved indoor air quality primarily in Asia.The overall
no.of years lived with
disability from COPD,however,has increased.
The rate at which COPD
worsens varies with the presence of factors thay predict a poor
outcome,including
severe airflow obstruction, little ability to exercise,SOB,significantly
underweight or
overweight,congestive heart failure,continued smoking,and frequent
exacerbations. Long
term outcomes in COPD can be estimated using BODE index which gives a
score of zero to ten
depending on FEV1, body mass index,the distance walked in six minutes,
and the modified MRC
dypnea scale. Significant weight loss is a bad sign. Results of spirometry
are also a good
predictor of the future progress of the disease but not as good as the BODE
index.
Nursing
Interventions
o Improving airway
clearance
-eliminate pulmonary
irritant
-cessation of smoking
-administer
bronchodilators
-mobilize patient when
stable
-keep secretion
liquids, liquefy
o Improving breathing
patterns
-Teach about breathing
resraining exercise to improve dyspnea
-Teach diaphragmatic,
lower coastal, abdominal breathing
-Use of pursed lip
breathing
-Keep the patient head
in high position
NURSING
MANAGEMENT IN MY PATIENT:
Nursing management was
done by applying nursing theory of Virginia Henderson through the
nursing process which
is described as follows:
NURSING
THEORY APPLIED IN MY PATIENT:
The role and functions
of professional nurses vary with the situation. Although there is
always a role for
family and the patient, the pie wedges for team members vary in size according
to
· The
problem of the patient.
· The patient’s
self help ability
· The
help resources.
Central to nursing that
seeks to help patients toward independence is empathetic,
understanding and
unlimited knowledge. The patient is an individual who requires help toward
independence. The nurse
assists the individual whether ill or not, to perform activities that will
contribute to health,
recovery or peaceful death, activities that the individual who had necessary
strength, will or
knowledge would perform unaided. That’s why, I used this theory” Virginia
Henderson Theory”.
INTRODUCTION TO VIRGINIA
HENDERSON’STHEORY:
The Henderson theory of
nursing was developed by Virginia Henderson. She did not believe
that she was setting
out a theory, and preferred it to be thought of as a definition. Whether it is
considered a definition
or a theory, it has had a wide influence on concept and practice of
nursing.
Virginia Henderson was
born on November 30, 1897, in Kansas City, Missouri. She began her
nursing education in
the U.S. Army School of Nursing during World War I, from which she
graduated in 1921. She
died March 19, 1996, when she was 98 years old. The definition of
nursing is the
fundamental part of Henderson's theory of nursing.
Henderson defined nursing
as doing things for patients that they would do for
themselves if they
could, that is if they were physically able or had the required knowledge.
Nursing helps the
patient become healthy or die peacefully, and also helps people work toward
independence, so that
they can begin to perform the relevant activities for themselves as quickly
as possible. Rather
than focus on a particular task, Henderson focused on the patient. She saw
how nursing could focus
on the patient, and how it was possible to focus on developing a good
nurse-patient
relationship. This deeply affected her and she believed strongly that
patient-focused
nursing was the most
beneficial kind of nursing for the patient.
Henderson also
enumerated the 14 functions she believed to be part of basic nursing care. The
nurse should help the
patient to perform the following functions
Henderson’s 14 basic needs:
CONCEPT
USED BY HENDERSON:
· Human
being: The patient as an individual who requires assistance to achieve
health and
independence or peaceful
death. The mind and body are inseparable. The patient and his
family are viewed as a
unit.
· Health: The
quality of health rather than life itself, that margin of mental physical vigor
that allows a person to
work most effectively and to reach his highest potential of
satisfaction in life.
· Environment:
She used Webster Dictionary, which defines environment as “the
aggregate of all the
external conditions and influences affecting the life and development
of an organism.”
· Nursing:
“The unique function of the nurse is assist the individual, sick
or well, in the
performance of those
activities contributing to health or its recovery (or to peaceful
death) that he would
perform unaided is he had the necessary strength, will or knowledge.
And to do this, in such
a way as to help him gain independence as rapidly as possible.
APPLICATION
OF NURSING THEORY
NEEDS
NURSING CARE
· Breathe
Normally · Maintain semi fowler’s position
· Administration
of Oxygen by nasal cannula.
· Check
SPO2 saturation routinely.
· Nebulization
given as prescribed.
· Eat,
drink adequately · Encourage the patient’s mother
to feed the baby
adequate breast milk.
· Elimination
of bodily waste · Record of urine output and
stool properly.
· Desirable
movement and
position
· Explain
the mother and patient party to minimize
handling the baby that
need extra oxygen and
prone to infection.
· Sleep
and rest. · Assess for sleep pattern.
· Change
the wet napkin of the baby.
· Minimize
the sound while baby is sleeping.
· Suitable
Clothing · Encourage the mother to wrap the baby in clean
cloth.
·
· Maintain
body temperature. · Take temperature 4 hourly to
assess the patient
body temperature.
· Open
the windows to maintain proper ventilation
and room temperature
since it’s a hot climate.
· Keep
patient clean and well
groomed.
· Encourage
mother and visitors to remain clean
and tidy.
· Assist
to make bedside clean.
· Frequently
change the wet napkin.
· Avoid
danger environment. · Maintain cross ventilation.
· Make
the floor dry after cleaning by opening
window and by
controlling visitors.
· Keep
the oxygen cylinder in wall side and bed
locker properly in safe
side.
· Keep
the side rail on baby’s bed.
· Communication.
· Maintain good IPR with the mother and patient
party.
· Give
enough time to express feeling and listen
carefully them.
· Worship
according to patient
party in their own
faith.
· Baby’s
mother want to worship by sacrificing
black goat in
Manakamana after being recovered
from her disease but
did not interrupted in it.
· Work
sense
accomplishments.
My patient is neonate.
· Learn,
discover and satisfy
curiosity.
· Patient’s
mother was satisfied with my care and
hospital staff, so she
always used to wait me to
tell her curiosity and
any problem or
improvements related to
her child.
NURSING
PROCESS AND NURSING CARE PLANS
The nursing process is
often defined as the application of critical thinking to client care
activities.
The nursing process is
a method of organizing and delivering nursing care. To understand its
functions, components
and interactions, the nurse should have a working knowledge of the
nature of the process.
A process is a series of steps or components leading to a goal, which
includes the following;
· Assessment
· Diagnosis
· Planning
· Implementation
· Evaluation
ASSESSMENT:
As for assessment I did
a thorough history taking and physical assessment and also gathered
information through the
current charts. Hence, I collected subjective and objective data and
made assessment of
patient’s needs and problems (current and potential).
NURSING
DIAGNOSIS:
· Ineffective
breathing pattern related to presence of tracheo-bronchial secretions and nasal
secretions as evidence
by increasing respiration rate, nasal flaring and shortness of breath.
· Impaired
gas exchange r/t collection of secretions affecting oxygen exchange across
alveolar membrane as
evidence by dyspnea, tachycardia
· Risk
for infection (spread) related to inadequate secondary defenses(decrease
hemoglobin, hematocrit
and immunosuppression
· Altered
in body temperature (fever) related to related to presence of infection as
evidence
by Flushed skin, skin
warm to touch, with body temperature of 38.4ºC
Knowledge deficit
regarding home care and preventive health measures
S.N Assessment Nursing
Diagnosis
Nursing
Goal
Plan
Action
Nursing
Intervention
Rationale Evaluation
1. Subjective
data
Patient
says,’’I have
difficulty in
breathing.’’
Objective data
Wheeze on
auscultation,
tachypneac,
cough.
Ineffective
airway
clearance
related to
excessive
secretions
as
evidenced
by
difficulty in
breathing
and
ineffective
cough
The patient
Will
maintain a
patent
airway after
nursing
intervention
In my duty
hour
Assess
patient
condition
Maintain
proper
position
Provide
02 therapy
Teach
proper use
Assessed for
breathing
pattern,rate,
abnormal
sound
,forceful
respiration.
Patient was
placed on
semi-fowlers
Position
Humidified 02
via nasal
prong @2-3
litres per min
provided
Patient was
taught for
It will help
To obtain
baseline
data for the
further
management
It facilitates
respiration
by
maximum
air exchange
and lungs
expansion
It will
correct
hypoxaemia
It improves
ventilation
Goal was
partially met
as she
demonstrates
diaphragmatic
breathing,
shows signs
of decreased
respiratory
efforts
of
incentive
spirometry
and deep
breathing
and
coughing
exercise
Provide
broncho
dilators
Encourage
for
hydration
unless
contraindi
cated.
Avoid
bronchial
irritants
maximum use
of incentive
spirometry
and deep
breathing and
coughing
exercises
A:I:NS
nebulization
1:1:2 as per
prescription
provided for
10-15 mins.
Patient was
encouraged to
drink fluids
(hot)
Patient was
suggested to
avoid
exposure to
cold,
smoke,dust,
extreme
temperatures.
by opening
airways to
facilitate
clearing the
airways of
sputum. Gas
exchange is
improved
and fatigue
is
minimized.
It decreases
airway
resistance
secondary to
broncho
constriction
It helps to
keep the
secretion
moist and
easy to
expectorateI
As it causes
bronchial
Constriction
and
increases
mucus
production
S.N Assessment Nursing
Diagnosis
Nursing
Goal
Plan
Action
Nursing
Intervention
Rational Evaluation
S.N Assessment Nursing
Diagnosis
Nursing
Goal
Plan
Action
Nursing
Intervention
Rational Evaluation
S.N Assessment Nursing
Diagnosis
Nursing
Goal
Plan
Action
Nursing
Intervention
Rational Evaluation
S.N Assessment Nursing
Diagnosis
Nursing
Goal
Plan
Action
Nursing
Intervention
Rational Evaluation
Daily
progress note:
2068/0
2068/03/20
2068/03/21
Today is his third day
of hospitalization. His general condition is improved the day before. His
vital signs are also
established. No fever and no difficulty in breathing. Morning care given in
the morning and ordered
medication also given timely. Bladder and bowel were also regular. On
morning round, patient
was discharge. Discharge teaching was given.
Discharge
planning and teaching:
The patient needs
nursing care not only during hospitalization but also after discharge from the
hospital too. So one of
the important part of nursing care is discharge teaching. I gave following
instruction or teaching
while discharging patient:-
· Medication
to take:
Instruct and explain
the patient’s mother than the medication is very important to
continue depending on
the duration that the doctor ordered for total recovery of the
patient.
· Exercise:
Instruct the mother to
let her child play but it should be limited to a period of time
only to prevent the
occurrence of shortness of berthing.
· Treatment:
Advice the mother to
keep her baby relaxes in order to recover in his present
condition. Instruct the
mother to minimize the patient from exposure to open
environment such as
dusty and smoke area, which airborne microorganism are
present that can be a
high risk factor that may cause severity of his condition.
· Health
education:
Encourage and explain
to the patient’s mother that it is important to maintain proper
hygiene to prevent
further infection. Instruct the patient’s mother to bath her baby
every day and explain
that bathing in the morning is not a factor cause of having
pneumonia. Instruct to
increase fluid intake of the patient.
· Outpatient
follow up:
Regular consolation to
the physician can be factor for recovery and to asses and
monitor patient’s
condition.
· Diet:
Diet as tolerated,
meaning, the patient can eat everything until he can. Diet play a
big role in fast
recovery so that, instruct the mother to give nutritious foods intended for
respiratory problems.
Follow-up
care and home visit:
Follow-up care is
important for continuity of care of patient after discharge. From follow-up
care, we came to know
the prognosis of disease. The main objectives of follow-up care are:
· To
assess the health status of the patient.
· To
find out the prognosis of disease.
· To
help the patient and family to manage their problems related to health.
· To
find out if there is another health problem.
· To
evaluate the knowledge, that is learning in hospital.
· To
prevent from further complication.
· To
provide health education for promotion of and maintenance of the health of the
patient
and family.The patient
has no further problem related to health. The family of the patient is
more conscious to
prevent the etiological factors for COPD.
Action
to minimize the stress of illness and hospitalization
Hospital is a very
threatening and stressful to everybody. Being a nurse, it is our duty and
responsibility to help
and support them coping with the disease condition and such terrible
situation.So I took
following action to minimize stress of patient party, built a good rapport with
patient and family.
· Gave
complete orientation of ward, staffs, ward routine, hospital’s rules and
regulation to the
patient party.
· Gave
clear information on disease process, diagnostic procedures to the
mother and patient
party.
· Patient
and visitors were allowed to express feelings, fears and concerns
about disease.
· One
visitor was allowed to stay with her to explore problems, and maintain
homely environment.
· Each
procedure performed was fully explained to her and her family.
· Taught
her about relaxation technique.
· Allow
to follow their traditional and cultural belief during treatment .
Learning
from the case study:
Case study is the
effective method of learning about the related disease in depth and practice.
Case study gives the
comprehensive study of one selected patient and comparison with book in a
real situation.
During my case study of
COPD, I collected information from different sources such as library,
internet and consulted
with doctors, seniors of ward, teachers and with my friends. I learned
many things from the
case study which are as follows:-
· About
patient: During case study, I was completely involved and attached with my
patient
and his family members.
I came to know the emotional status and medical reaction of the
patient’s family’s
members about treatment and disease process.
· About
family and environment: I also got an opportunity to learn general attitude of
family
and their environment.
I also got a chance to know socio cultural, educational and religious
and economic status of
patient.
· About
nursing care: I got opportunity to learn application of nursing theory while
caring the
patient and use of
nursing process. It enhances the scientific method of caring the patient.
· About
diversional therapy and stress management: During case study, I got chance to
detect
the stressful factors
and different therapy to overcome these stress. I got chance to use
diversional therapy in
practical.
· About
documentation: During case study I also developed further skills in
documentation in
a more revised manner.
· About
hospital policy: During case study, I was involved in many sectors of
activities like
reporting, recording,
admission, discharge procedure, investigation. So I got a lot of
knowledge about
hospital policy.
Finally, I think the
case study is one of the ways to develop individual
knowledge and attitude.
Conclusion:
Case study is one of
the most important parts of nursing practice. It is a best method of learning.
Case study is concerned
with the individualized care which helps to provide holistic nursing care
including
physiological, psychological social and cultural traditional beliefs.
According to the
curriculum of PBBN, I had taken a case of COPD of Uma Devi
Ghimire, for case
study. I collected essential health history from patient and her family during
the case study. Then
thorough physical examination was done and recorded. I revised the normal
development process of
late adulthood. I reviewed the collected health history, investigations
report, and outcome of
physical examination and formulated nursing diagnosis. I applied the
nursing theory of
Virginia Henderson for the nursing management of the patient. Complete
nursing care was
provided to the patient by applying nursing process. During the case study, I
also studied about
disease, its etiology, pathophysiology, its sign and symptoms, diagnostic
procedure, therapeutic
as well as nursing management from different books.
Patient was admitted on
2073/1/17 with complain of cough,shortness of breath and was
treated with I\V
antibiotics, Vitals were taken regularly. Patient’s general condition improved
gradually. She was
hospitalized for 4 days and was discharged on 2073/1/20.
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