History of the Patient

Biodata of the Patient

Name : Mr. Lalit

Age : 59 years
Gender : Male
IPD Number : 012790
Education : 10th pass
Occupation : Laborer
Marital Status : Married
Religion : Hindu
Address : Chugitti Bypass, Jalandhar.
Ward : Male Medical Ward
Date of Admission : 4.5.2021
Diagnose : COPD
Dr. Incharge : Dr. Moin
Hospital : Civil Hospital

 Chief Complaints:
Patient named Kishan Kumar 45 years old came to Civil Hospital, Jalandhar on 01.05.2021 with
the chief complaints of:
Breathlessness X 10 days
Cough with expectorants X 10 days
Fever X 5 days
Weakness X 3 days
Pain in chest X 3 days
  Present History:

 Present Medical History: Patient named Mr. Darshan 55 years old is admitted to Civil
Hospital, Jalandhar with present medical complaints of:
 Breathlessness
 Cough with expectorants
 Fever
 Pain in chest
 Weakness

 Present Surgical History: Patient had not undergone any surgery.

 Past History:

 Past Medical History: Patient is not having past medical history of TB, Diabetes, HIV,
Jaundice or any other disease.

 Past Surgical History: Patient had not undergone any kind of surgery in past.

 Family History:
There are total 4 members in patients family. Patient belongs to nuclear family.
Patient is the only source of income in his family.

 Family Tree:
Patient Patient’s Wife
55 years 52 years
Unhealthy Healthy

Patient’s Son Patient’s Daughter

26 years 22 years
Healthy Healthy
Keys:

= Female = Patient

= Male = Patient

= Dead Person

 Family Biodata:

Sr. Name Age/ Education Occupation Relation Remarks

No Gender with
. Patient

1. Mr. Lalit 59 Years 10th Pass Laborer Patient Unhealthy

2. Mrs. Sharda 52 Years 10th Pass Housewife Wife Healthy
3. Mr. Gautam 22 Years Graduate Student Son Healthy
4. Ms. Palvi 19 Years B.A.s 3rd Student Daughter Healthy
Year

 Personal History of the Patient:

 Dietary Pattern: Patient is vegetarian. Patient is taking Semi-solid Diet.

 Elimination Pattern: Patient is catheterized. Urine output is measured by urobag. Stool
is passed by patient.
 Sleeping Pattern: Sleeping pattern of patient is disturbed due to hospitalization and pain.
 Socio-economic Status: Patient is living in pucca house. There is proper lightening and
drainage facilities in patient’s home.
 Addiction: Patient is not addicted to any kind of addiction like drugs, alcohol, smoking,
tobacco etc.
 Vital Signs:
Sr. Vital Signs Normal Value Patient’s Value Remarks
No
.

1. Temperature 97-99ºF 101.4ºF Hyperpyrexia

2. Pulse 60-100 beats/min 118 beats/min Tachycardia
3. Respiration 16-24 breaths/ min 26 breaths/ min Tachypnea
4. Blood Pressure 110/70 – 140/90 mmHg 130/90 mmHg Normal

 Lab Investigations:

Sr. Name of Normal Value Patient’s Value Remarks

No. Investigations

Complete Blood
Count
1. Hemoglobin 12-14 gm/dl 10.5 gm/dl Mild anemic
2. Total Leukocyte Count 4000-11000/Cumm 18,200/ Cumm Leukocytopenia

3. Platelets 1.5-4.5 /uL 1.9 u/L Normal

4. Red Blood Cells 4.0-6.1/ uL 4.3 /uL Normal
5. Hematocrit 38.3-48.6 % 35 % Normal
6. Mean Corpuscle
Value 80-96 fL 80.8 fL Normal
7. Random Blood Sugar 110-140 mg/dl 125 mg/dl Normal

Renal Function Test

8. Serum Urea 14.3-17.8 mmol/L 38 mmol/L Hyperuremia
9. Serum Createnine 0.7-1.2 mg/dl 0.8 mg/dl Normal
10. Uric Acid 4.0-8.5 mg/dl 5.2 mg/dl Normal

Liver Function Test

11. Total Bilirubin Level 0-1.4 mg/dl 1.0 mg/dl Normal

12. HCV Reactive/Nonreactive Nonreactive ___

13. HbsAg Reactive/Nonreactive Nonreactive ___

Chest X-Ray: Chest X-ray shows inflamed lung parynchyma.

Medications:
Sr. Trade Name Pharmacological Dose Rout Frequency Action
No. Name e

1. Inj. Ceftrax Inj. Ceftriaxone 1000mg IV BD Antibiotic

2. Inj. Aciloc Inj. Rantidine 75 mg IV BD Antacid
Hydrochloride
3. Inj. Inj. Theophylline 50 mg IV BD Bronchodilator
Deriphylline and etophylline
4. Inj. Diclofenac 75 mg IM SOS Analgesic
Inj. Diclob Sodium
5. Tab. PCM Tab. Paracetamol 500 mg PO SOS Antipyretic
6. Inj. Efcorline Hydrocortisone 40 mg IV BD Corticosteroid

Physical Examination
General Appearance
Orientation : Patient is oriented to time, place and person
Consciousness : Conscious
Activity : Dull
Nourishment : Moderately nourished
Health : Unhealthy
Posture
Body curve : Normal
Movement : Normal
Skin
Color : Wheatish
Texture : Dry
Temperature : 101.6 ºF
Lesions : Absent
Head and Face
Shape of the skull : Normocephalic
Dandruff : Absent
Hair color : Dyed
Eyes
Eyebrows : Symmetrical
Eyelashes : Symmetrical
Conjunctiva : Pink
Sclera : White
Pupils : Normal
Vision : Normal
Ears
External ear : Normal
Cerumen : Present
Mouth
Lips : Brownish pink
Odour of mouth : Absent
Teeth : Normal
Tongue : Non-coated
Nose
Nasal septum : Mid-line
Discharge : Absent
Sense of smell : Normal
Throat and pharynx
Tonsils : Normal
Lymph nodes : Not-enlarged
Range of motion in Neck : Possible
Chest
Chest symmetry : Slightly barrel chest
Breath sounds : Wheezing sounds
Abdomen
Palpation : Soft
Bowel sounds : Present
Lesions : Absent
Pain : Present in chest
Extremities
Upper Extremities
Mobility : Movable
Alignment : Normal
Range of motion : Possible
Lower Extremities
Mobility : Movable
Alignment : Normal
Range of motion : Possible

Systemic Examination
 Respiratory System
Respiratory Rate : 26 breaths/ min
Dyspnea : Present
Breath sounds : Normal
 Neurological System
Orientation : Oriented to time, place and person
Consciousness : Conscious
Mental status : Healthy
 Cardiovascular System
Heart rate : 118 beats/min
Blood pressure : 130/90 mmHg
Heart sounds : S1 S2 normal
 Musculoskeletal System
Body symmetry : Symmetrical
Range of motion : Possible
Gait : Normal
Movement : Possible
 Gastrointestinal System
Appetite : Abnormal
Abdominal pain : Absent
Constipation : Absent
Bowel sounds : Present
Stool : Passed
 Genitourinary System
Voiding : Catheterized
Urine output : Normal

Anatomy and Physiology

 LUNGS

The lungs are a pair of spongy, air-filled organs located on either side of the chest (thorax). The
trachea (windpipe) conducts inhaled air into the lungs through its tubular branches, called
bronchi. The bronchi then divide into smaller and smaller branches (bronchioles), finally
becoming microscopic.

The bronchioles eventually end in clusters of microscopic air sacs called alveoli. In the alveoli,
oxygen from the air is absorbed into the blood. Carbon dioxide, a waste product of metabolism,
travels from the blood to the alveoli, where it can be exhaled. Between the alveoli is a thin layer
of cells called the interstitium, which contains blood vessels and cells that help support the
alveoli.

The lungs are covered by a thin tissue layer called the pleura. The same kind of thin tissue lines
the inside of the chest cavity also called pleura. A thin layer of fluid acts as a lubricant allowing
the lungs to slip smoothly as they expand and contract with each breath.

Alveoli: Alveoli are an important part of the respiratory system whose function it is to exchange
oxygen and carbon dioxide molecules to and from the bloodstream. These tiny, balloon-shaped
air sacs sit at the very end of the respiratory tree and are arranged clusters throughout the lungs.

Bronchi: Bronchi are the main passageway into the lungs. When someone takes a breath through
their nose or mouth, the air travels into the larynx. The next step is through the trachea, which
carries the air to the left and right bronchus.
Bronchioles: Bronchioles any of the minute branches into which a bronchus divides.

Trachea: Trachea, colloquially called the windpipe, is a cartilaginous tube that connects the
pharynx and larynx to the lungs, allowing the passage of air.

Pleura: Pleura each of a pair of serous membranes lining the thorax and enveloping the lungs in
humans.

Bronchial airways: In the bronchi there are incomplete tracheal rings of cartilage and smaller

plates of cartilage that keep them open. Bronchioles are too narrow to support cartilage and their
walls are of smooth muscle, and this is largely absent in the narrower respiratory
bronchioles which are mainly just of epithelium. The absence of cartilage in the terminal
bronchioles gives them an alternative name of membranous bronchiole.

Lung Conditions

• Chronic obstructive pulmonary disease (COPD): Damage to the lungs results in difficulty
blowing air out, causing shortness of breath. Smoking is by far the most common cause of
COPD.

• Emphysema: A form of COPD usually caused by smoking. The fragile walls between the lungs'
air sacs (alveoli) are damaged, trapping air in the lungs and making breathing difficult.

Disease Description
 Pneumonia

Introduction: 

Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs are made
up of small sacs called alveoli, which fill with air when a healthy person breathes. When an
individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing
painful and limits oxygen intake.

Definition:

An inflammatory process in lung parenchyma usually associated with a marked increase in

interstitial and alveolar fluid.

Etiology and Risk Factors:

In Book In Patient

Etiology:

 Bacteria, viruses, mycoplasmas, fungal agents & √

protozoa. 
 Aspiration of food, fluids, / vomitus.  X
 Inhalation of toxic/caustic chemicals, smoke, X
dusts/gases. 
 Influenza. X
Risk Factors:

o Advanced age.  X
o History of smoking.  X
o Upper respiratory infection.  X
o Tracheal intubation.  X
o Prolonged immobility.  X
o Immunosuppressive therapy.  X
X
o Nonfunctional immune system. 
X
o Malnutrition. 
X
o Dehydration.  X
o Chronic disease state.  X
o Cigarette smoking  X
o Recent viral respiratory infection (common cold,
laryngitis, influenza)  X
o Difficulty swallowing (due to stroke, dementia,
Parkinson's disease, or other neurological conditions)  X
o Chronic lung disease (COPD, bronchiectasis, cystic
fibrosis)  X
o Cerebral palsy  X
o Other serious illnesses, such as heart disease, liver
cirrhosis, /diabetes mellitus  X
o Exposure to air pollution.  X
o Altered consciousness (Alcoholism, Drug overdose,
General anesthesia, Seizure disorder).  X
o Inhalation of noxious substances.  X
o Residing in Institutional settings.  X
X
o Living in a nursing facility 
o Impaired consciousness (loss of brain function due to
X
dementia, stroke, or other neurologic conditions)  X
o Recent surgery or trauma 
o Immune system problem
Clinical Features:

In Book In Patient

o High Fever.  √
o Fever with Chills.  √
o Sweats.  √
o Pleuritic chest pain.  √
√
o Cough. 
√
o Sputum production.  √
o Hemoptysis.  √
o Dyspnea.  √
o Headache & fatigue. √
o Stabbing pleuritic chest pain.  √
o Malaise.  √
o Weakness.  √
o Elevated WBC count. 
√
o Tachypnea. 
√
o Crackles.
o Cyanosis.

Diagnostic Tests
In Book In Patient

o Chest auscultation.  √
o Sputum culture analysis & sensitivity/ serologic testing.  X
o Fiber optic bronchoscopy. X
X
o Transcutaneous needle aspiration/ biopsy. 
X
o Skin tests. 
X
o Blood cultures. X
o Urine cultures.  X
o ABG analysis.  √
o Chest X-ray.

Management

Medical management

In Book In Patient

o Smoking cessation √
o Bronchodilators √
o Corticosteroids √
o Antibiotics √
o Mucolytics √
o Antipyretics

Surgical Management

In Book In Patient

Lung volume reduction surgery: In this surgery, your

surgeon removes small wedges of damaged lung tissue. X
This creates extra space in your chest cavity so that the
remaining lung tissue and the diaphragm work more
efficiently. In some people, this surgery can improve
quality of life and prolong survival. 

Lung transplant: Lung transplantation may be an

option for certain people who meet specific criteria. X
 sTransplantation can improve your ability to breathe
and to be active, but it's a major operation that has
significant risks, such as organ rejection, and it
obligates you to take lifelong immune-suppressing
medications.

Nursing Assessment

1. Assess nursing history, family history and obtains a thorough smoking history of
the patient. 
2. Assess respirations: note quality, rate, pattern, depth, and breathing effort.
3. Assess lung sounds, noting areas of decreased ventilation & presence of
adventitious sounds. 
4. Inspects the chest to determine breathing rate & pattern and auscultates the chest
to determine depth of inspiration & to listen breath sounds. 
5. Assess skin color, temperature, capillary refill; note central versus peripheral
cyanosis. 
6. Assess for signs and symptoms of hypoxemia: tachycardia, restlessness,
diaphoresis, headache, lethargy, and confusion. 
7. Monitor ABGS & note changes. Increasing PaCO2, and decreasing PaO2, are
signs of respiratory failure. 
8. Use pulse oximetry to monitor oxygen saturation and pulse rate. Pulse oximetry
is a useful tool to detect changes in oxygenation. 
9. Assess patient's ability to cough effectively to clear secretions. Note quantity,
color, and consistency of sputum. 
10. Monitor for changes in orientation, increased restlessness, anxiety, and air
hunger. Restlessness is an early sign of hypoxia. 
11. Assess the ability of activities both before illness or condition now and also the use of aids
such as canes, wheel chairs and others. 
12. Ask the client's daily sleep habits, how long sleep, a nap. Often wake up during sleep caused
by pain, itching, urination, difficulty and others.

Nursing Diagnosis 

1. Ineffective airway clearance related to excessive secretions & weak cough as

evidenced by respiratory assessment of patient.

2. Ineffective breathing pattern related to tachypnea as evidenced by

respiratory assessment of patient.

3. Acute Pain in chest related to frequent coughing as evidenced by verbal

communication with the patient.

4. Impaired body temperature related to infection as evidenced by monitoring

vital signs of the patient.

5. Activity intolerance related to decreased oxygen levels for metabolic

demands as evidenced by Observation of the patient.

6. Deficient fluid volume related to fever, diaphoresis, & mouth breathing as

evidenced by monitoring intake/output chart of the patient.

7. Imbalanced nutrition less than body requirements related to dyspnea as

evidenced by monitoring intake/output chart.

8. Impaired oral mucous membrane related to mouth breathing & frequent

cough as evidenced by

Short Term Goals

 To improve the breathing pattern of the patient.
 To reduce the pain level of the patient.
 To reduce the temperature of the patient.
 To improve the nutritional pattern of the patient.
 To reduce the risk of infection.
Long Term Goals
 To rehabilitate the patient.
 To provide psychological support to the patient.
 To reduce the anxiety of the patient.
 To provide knowledge to patient regarding disease condition.

HEALTH EDUCATION

 MEDICATION: Instruct the patient to take her home medications

at the right time, right dose, and right route and also emphasized the
importance of taking them.

 EXERCISE: Encourage patient to do mild exercises such as

walking and have an adequate sleep and rest. Instruct the patient to
avoid strenuous activities, avoid straining, and lifting heavy object.
  TREATMENT: Encourage patient to do deep breathing exercise
Encourage patient to have adequate rest

 HEALTH: Instruct the patient to observe proper hygiene like

taking a bath every day, brushing teeth 3 times a day, and washing
hands before and after eating. Advise patient to maintain proper
environmental sanitation 

 OUTPATIENT: Instruct patient to attend his follow up checkup

for further evaluation of his condition

Day – 1
 Vital Signs:
Sr. Vital Signs Normal Value Patient’s Value Remarks
No
.

1. Temperature 97-99ºF 101.4ºF Hyperpyrexia

2. Pulse 60-100 beats/min 118 beats/min Tachycardia
3. Respiration 16-24 breaths/ min 26 breaths/ min Tachypnea
4. Blood Pressure 110/70 – 140/90 mmHg 130/90 mmHg Normal
  Lab Investigations:

Sr. Name of Normal Value Patient’s Value Remarks

No. Investigations

Complete Blood
Count
1. Hemoglobin 12-14 gm/dl 10.5 gm/dl Mild anemic
2. Total Leukocyte Count 4000-11000/Cumm 18,200/ Cumm Leukocytopenia

3. Platelets 1.5-4.5 /uL 1.9 u/L Normal

4. Red Blood Cells 4.0-6.1/ uL 4.3 /uL Normal
5. Hematocrit 38.3-48.6 % 35 % Normal
6. Mean Corpuscle
Value 80-96 fL 80.8 fL Normal
7. Random Blood Sugar 110-140 mg/dl 125 mg/dl Normal

Renal Function Test

8. Serum Urea 14.3-17.8 mmol/L 38 mmol/L Hyperuremia
9. Serum Createnine 0.7-1.2 mg/dl 0.8 mg/dl Normal
10. Uric Acid 4.0-8.5 mg/dl 5.2 mg/dl Normal

Liver Function Test

11. Total Bilirubin Level 0-1.4 mg/dl 1.0 mg/dl Normal

12. HCV Reactive/Nonreactive Nonreactive ___

13. HbsAg Reactive/Nonreactive Nonreactive ___

Medications:
Sr. Trade Name Pharmacological Dose Rout Frequency Action
No. Name e

1. Inj. Ceftrax Inj. Ceftriaxone 1000mg IV BD Antibiotic

2. Inj. Aciloc Inj. Rantidine 75 mg IV BD Antacid
Hydrochloride
3. Inj. Inj. Theophylline 50 mg IV BD Bronchodilator
Deriphylline and etophylline
4. Inj. Diclofenac 75 mg IM SOS Analgesic
Inj. Diclob Sodium
5. Tab. PCM Tab. Paracetamol 500 mg PO SOS Antipyretic
6. Inj. Efcorline Hydrocortisone 40 mg IV BD Corticosteroid
 HEALTH EDUCATION

 MEDICATION: Instruct the patient to take her home medications at the

right time, right dose, and right route and also emphasized the importance of
taking them.

 EXERCISE: Encourage patient to do mild exercises such as walking and

have an adequate sleep and rest. Instruct the patient to avoid strenuous
activities, avoid straining, and lifting heavy object.

 TREATMENT: Encourage patient to do deep breathing exercise Encourage

patient to have adequate rest

 HEALTH: Instruct the patient to observe proper hygiene like taking a bath
every day, brushing teeth 3 times a day, and washing hands before and after
eating. Advise patient to maintain proper environmental sanitation 

 OUTPATIENT: Instruct patient to attend his follow up checkup for further

evaluation of his condition

Day – 2
 Vital Signs:
Sr. Vital Signs Normal Value Patient’s Value Remarks
No
.

1. Temperature 97-99ºF 101.4ºF Hyperpyrexia

2. Pulse 60-100 beats/min 118 beats/min Tachycardia
3. Respiration 16-24 breaths/ min 26 breaths/ min Tachypnea
4. Blood Pressure 110/70 – 140/90 mmHg 130/90 mmHg Normal
  Lab Investigations:

Sr. Name of Normal Value Patient’s Value Remarks

No. Investigations

Complete Blood
Count
1. Hemoglobin 12-14 gm/dl 10.5 gm/dl Mild anemic
2. Total Leukocyte Count 4000-11000/Cumm 18,200/ Cumm Leukocytopenia

3. Platelets 1.5-4.5 /uL 1.9 u/L Normal

4. Red Blood Cells 4.0-6.1/ uL 4.3 /uL Normal
5. Hematocrit 38.3-48.6 % 35 % Normal
6. Mean Corpuscle
Value 80-96 fL 80.8 fL Normal
7. Random Blood Sugar 110-140 mg/dl 125 mg/dl Normal

Renal Function Test

8. Serum Urea 14.3-17.8 mmol/L 38 mmol/L Hyperuremia
9. Serum Createnine 0.7-1.2 mg/dl 0.8 mg/dl Normal
10. Uric Acid 4.0-8.5 mg/dl 5.2 mg/dl Normal

Liver Function Test

11. Total Bilirubin Level 0-1.4 mg/dl 1.0 mg/dl Normal

12. HCV Reactive/Nonreactive Nonreactive ___

13. HbsAg Reactive/Nonreactive Nonreactive ___

Medications:
Sr. Trade Name Pharmacological Dose Rout Frequency Action
No. Name e

1. Inj. Ceftrax Inj. Ceftriaxone 1000mg IV BD Antibiotic

2. Inj. Aciloc Inj. Rantidine 75 mg IV BD Antacid
Hydrochloride
3. Inj. Inj. Theophylline 50 mg IV BD Bronchodilator
Deriphylline and etophylline
4. Inj. Diclofenac 75 mg IM SOS Analgesic
Inj. Diclob Sodium
5. Tab. PCM Tab. Paracetamol 500 mg PO SOS Antipyretic
6. Inj. Efcorline Hydrocortisone 40 mg IV BD Corticosteroid
 HEALTH EDUCATION

 MEDICATION: Instruct the patient to take her home medications at the

right time, right dose, and right route and also emphasized the importance of
taking them.

 EXERCISE: Encourage patient to do mild exercises such as walking and

have an adequate sleep and rest. Instruct the patient to avoid strenuous
activities, avoid straining, and lifting heavy object.

 TREATMENT: Encourage patient to do deep breathing exercise Encourage

patient to have adequate rest

 HEALTH: Instruct the patient to observe proper hygiene like taking a bath
every day, brushing teeth 3 times a day, and washing hands before and after
eating. Advise patient to maintain proper environmental sanitation 

 OUTPATIENT: Instruct patient to attend his follow up checkup for further

evaluation of his condition