UNIVERSITY OF BAGUIO

SCHOOL OF NURSING

CASE ANALYSIS:
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

CEZAR, ELEJAH
CHINANGLAS, SHAYANNAH
LUNA, SHERYLLE JEAN
RAGANIT, NICOLE ANNE
SINGH, ROXANNE

MR. DINDO A. DE GUZMAN, RN, USRN, DMD

SEPTEMBER 2020
A. IDENTIFY THE SPECIFIC DIAGNOSIS:
Case Diagnosis: Chronic Bronchitis r/t prolonged smoking as manifested by
complaints of chest cold and prolonged productive coughing.

B. PREPARE A COMPLETE MEDICAL HISTORY

Informant: Patient X 55/M

Chief Complaint: “Nahihirapan akong huminga, Parang barado ilong ko kung
minsan, tsaka mabilis ako mapagod lalo na kapag umuubo, eh madalas pa
naman, pakiramdam ko para akong nanghihina tapos kapag pa gusto kong idura
yung plema ko, ang hirap kasi nakakapagod talaga tapos mahirap lumabas”

History of Present Illness:

Patient X is a 55-year-old man with a previous diagnosis of Acute Bronchitis.
Patient stated that he was coughing for the past 2-3 months for which he did not
put attention to as though he stated thought was “normal” because he had
coughs before but disappeared after sometime. He is a long-term smoker for
about 25 years since he started at age 20 and consumes about a pack per day.

5 days prior to admission he had been feeling tired with body aches. He also felt
soreness in the chest and persistent productive cough that did not disappear as
he was supposedly expecting to for which reason he went for consultation in the
community clinic. However, he was only given pain relievers for his body aches
and was advised to go home to rest and increase his fluid intake.
1 day prior to admission, patient noted progression of symptoms and difficulty of
breathing with trouble in expectoration due to thick-like mucous and easy
fatiguability hence admission.

Current Medication: Acetaminophen (Tylenol) 500mg PRN for pain

Past History:
35 years of cigarette smoking, started at age 20 consuming about 1-2 cigarette
sticks per day, and increased per month until he was able to consume a
maximum of a pack (about 20 sticks) per day. Negative history of infectious
diseases and serious pulmonary diseases other than common childhood
illnesses were managed. He has complete vaccination until age 1.
Hospitalization record reveals 2017 initial diagnosis of Acute Bronchitis that was
not ruled out as follow up consultation was not done by patient after complying
with medication.

Patient History:
Patient X is single and lives alone.
He worked as a construction worker at age 17 up to age 48, at present he works
as a part time carpenter.
He is a habitual smoker started at age 20 and consumes a maximum of 1 pack
(20 cigarette sticks) per day; Patient is also an occasional drinker; and negative
in illegal drug consumption.
Familial History:
Patient lives alone. He was brought up by his grandfather; His father is an
alcoholic and is also a smoker who died of stroke and other health complications;
his mother was of DM and died with complications in health at age 35.

Head-To-Toe Assessment
A. Integumentary
Skin color is light brown in color in the lower and upper extremities, with an even
lighter facial and central body area color. Generalized dry skin is noted and is
cool to touch. No rashes noted. His hair is dry, whitish in color and is evenly
distributed on his head with no signs of lice infestations. He has a variable
amount of body hair evenly distributed around his body. The patient has
yellowish nails, with convex curve noted upon using Schamroth window test.
With a capillary refill of 2-3 seconds.

B. Head
Head is normo-cephalic and symmetrical. The face of the patient is lighter in
color compared to his body, his cheeks are swollen, skin is dry and wrinkled. No
nodules and/or tenderness were palpated.

C. Eyes
The client’s eyebrows are asymmetrical, evenly distributed and showed equal
movement when asked to raise and lower. Slightly droopy eyelids noted on
assessment and closes symmetrically with involuntary blinks approximately 8-10
times per minute, redness on patient’s sclera and periorbital puffiness noted.
Palpebral conjunctiva appears shiny and reddish. Iris is round flat and evenly
colored. Upon inspection with a penlight, both pupils react to light
accommodation. Patient is not wearing any corrective lenses. Screen visual
acuity is 20/20.

D. Ears
The auricles have no deformity, lumps or lesions. They are lighter in color than
facial skin and symmetrically aligned with outer canthus of the eye, mobile firm
and not tender. Bits of impacted cerumen were noted at the sides of the ear
canal. Patient was able to hear 1 out of 2 words stated using whisper test
(sweet=swim; pen=pen); for about 1-2 feet away, patient was able to hear and
understand what 2 student nurses tried to converse about. No tingling and
ringing in ears noted as stated by client. Patients’ voice is at normal range and
not shouting.

E. Nose
Nose appeared large, uniform in color. Minimal discharges noted upon
inspection, however alar flaring was noted from time to time during assessment.
During the CN-I test, patient was able to smell and identify 2 out of 4 scents such
as strawberry and melon scents, and was not able to identify coffee and orange
scents.
 F. Mouth
The client’s lips were uniformly dark red in color with slight cyanosis noted,
symmetric with a dry texture. The client is able to purse his lips when asked to
whistle. The enamels were yellowish in color with presence of cavities noted, the
patient has 18/32 teeth. Darkening of the gingiva were noted. The buccal mucosa
appeared moist, soft and with yellowish color. The tongue was centrally
positioned and a presence of black-tinged coating was noted on the top of the
tongue. The patient was not able to differentiate some tastes such as sour
(orange), salty (potato fries), but were able to determine sweet (candy), and bitter
(powdered black coffee) tastes.

G. Neck
The neck muscles were equal in size and showed coordinated, smooth head
movement with no discomfort. The lymph nodes of the patient were not palpable.
The trachea is placed in the midline of the neck. No jugular vein distention noted.

H. Thorax, Lungs
Rhonchi noted upon auscultation at the left lung while diminished breath sounds
were noted at the right lung, upon percussion on the posterior chest stony
dullness is noted. Patient has shallow and fast breathing with a respiratory rate
ranging from 25-30 bpm and O2 saturation ranging from 80-88% when on supine
position. Productive cough with yellowish-colored phlegm upon expectoration
noted. Decreased tactile fremitus noted.

I. Abdomen
Skin of abdomen is uniformly light in color. Enlargement of the abdomen noted.
Soft clicks and gurgles heard at a rate of 7-10 per minute. Flank dullness upon
percussion and decreased vocal resonance noted.

J. Extremities
Undetermined pain rated 4/10 noted upon movement. The patient has limited
activity because of easy fatiguability. Positive asterixis noted with tar stained
fingers. Able to ambulate with no needed assistance. Pitting edema 1+ noted on
upper extremities, and pitting edema +3 noted on lower extremities, no nodules
noted.

C. PREPARE DIFFERENT NURSING DIAGNOSES AND PRIORITIZE

List of Identified Problems
1. Ineffective Airway Clearance

2. Impaired Gas Exchange

3. Ineffective Breathing Pattern

 4. Activity Intolerance
5. Imbalanced Nutrition: Less than body requirements
Prioritization & Justification
Prioritization
1. Ineffective Airway Clearance
2. Ineffective Breathing Pattern
3. Impaired Gas Exchange
4. Activity Intolerance
5. Imbalanced Nutrition: Less than
body requirements
Justification
The equipment theory for respiratory care states that
the first problem to overcome with regards to
respiratory distress is airway clearance because
breathing is the top priority in patients with respiratory
problems in order for oxygenation to happen.
According to equipment theory of respiratory care the
inadequate inspiration and respiration may not
provide adequate ventilation, this in turn will not allow
the alveoli’s to properly expand which will increase
the risk of atelectasis that may therefore impair gas
exchange.
Equipment theory of respiratory care states that
impaired gas exchange will be the third priority after
therapeutic management is done on airway clearance
and breathing pattern. This emphasizes on the
exchange of oxygen and carbon dioxide, it's
elimination, and the altered oxygen supply.
Because of the predisposing factors of respiratory
distress, activity intolerance will be one of the many
constituents. due to the lack of circulation of
oxygenation, activity will be lessened.
According to Maslow’s Hierarchy of needs,
Physiologic needs such as food for nutrition if not
satisfied, the human body cannot function optimally.
Maslow considered physiological needs the most
important as all the other needs become secondary
until these needs are met.
 C. PREPARE AN NCP BASED ON THE PRIORITIZED NURSING DIAGNOSES

Assessment Explanation of Goals and Intervention Rationale Evaluation

The Problem Objectives
S: “Nahihirapan The patient STO: After 8 Dx STO: After 8
akong huminga, started smoking hours of nursing -Auscultate breath -Some degree of hours of
Parang barado at a young age, intervention, sounds. Note bronchospasm is present nursing
ilong ko kung and is frequently patient will: adventitious breath with obstructions in airway intervention,
minsan, tsaka exposed to dust sounds such as and may or may not be patient
mabilis ako and smoke - Express signs wheezes, crackles, or manifested in adventitious verbalizes
mapagod lalo na because of his of relief and rhonchi breath sounds, such as, relief and ease
kapag umuubo, occupation as a ease of scattered, moist crackles; in breathing
eh madalas pa construction breathing faint sounds with expiratory
naman, worker. Due to wheezes; or absent breath
pakiramdam ko the prolonged sounds
para akong exposure to
nanghihina tapos respiratory LTO: After 3 -Assess and monitor -Tachypnea is usually
kapag pa gusto irritants, the days of nursing respiratory rate. Note present to some degree and LTO: After 3
kong idura yung patient developed intervention, inspiratory-to- may be pronounced on days of nursing
plema ko, ang COPD. Thus, patient will: expiratory ratio admission, during stress, or intervention,
hirap kasi causing an during concurrent acute patient still
nakakapagod inflammation in - Maintain infections. Respirations may does not have
talaga tapos his bronchial Airway Patency be shallow and rapid, with airway patency
mahirap airways together with breath prolonged expiration in and could not
lumabas” with an increase sounds clearing comparison to inspiration properly
O: Smoking; in production of demonstrate
Construction sputum, causing - Demonstrate -Assist client to -Elevation of the head of the behaviors to
worker; (+) difficulty in behaviors to maintain a bed facilitates respiratory improve airway
Rhonchi; breathing. The improve airway comfortable position function and expectoration clearance
Diminished increase in the clearance preferably in a High using gravity; however, client
breath sounds; production of Fowler’s position or in severe distress will seek
productive cough secretions leaning forward the position that most eases
with yellowish coupled with position to facilitate breathing
sputum; fast narrowing and breathing and
breathing; RR= inflammation of expectoration. Done
25-30bpm; alar the airways plus by elevating the head
the easy of the bed, leaning on
flaring fatiguability lead or over bed table, or
to a nursing sitting on the edge of
diagnosis of the bed.
ineffective airway
Nursing Dx: clearance.
Ineffective Tx
Airway Schematic -Beta-agonists, such -to aid in airway dilation and
Clearance Smoking as and salmeterol. relieve acute symptoms.
related to  salbutamol
inability to Chronic irritation
expectorate  -Bronchodilators, -to have longer duration of
secretions sec Hypertrophy / such as action with less toxicity
to easy Hyperplasia anticholinergic potential, whereas still
fatiguability  agents; Salmeterol providing the effective relief
Hypersecretion of ipratropium of the beta-antagonists
mucin (small and
large airways) -Assist with - To facilitate breathing
 respiratory exercises help enhance
Decrease airway treatments, such as diffusion and expectoration
diameter spirometry and chest
 physiotherapy as
Airway narrowing ordered 1 hr. before
 and 2hrs. after meals
Obstruction

Edx
Ineffective airway
-Teach and assist -Provides client with some
clearance
with abdominal or means to cope up with and
pursed lip breathing control dyspnea and reduce
exercises air-trapping