Introduction

I have chosen knee and leg pain case , since it may affect many
patients ,therefore I want to know more information about it . And how to
offer an appropriate care to those patients having it , so the combination
between my practical training and theoretical study will give me a clear idea
regarding the case . Actually I feel I can make progress to help my patients
to become better .

THANK YOU MY TEACHER FOR EVERY THING

.YOU HAVE DONE FOR US

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 Bethlehem University
Faculty of Nursing and Health Sciences
Medical Surgical Nursing I , II
NURS 334-335 / Fall 2008

Data Collection Sheet

Student Name: Ahmad Amreih Date: October 3, 2008
Pt. Name: T.A.N Date Admitted: September 22, 2008
Sex: Male. Informant: Pt, family & pt File.
Age: 55 years Room No.:18-1
Martial Status: Married. Occupation: worker

Diagnosis:
- COPD due to chest infection.

Chief Compliant:
- Shortness of breathing, fever, and general weakness.

History of Present Illness:

- A-55 years old male pt admitted to M/W complain of
progressive SOB, productive cough, wheezing breath sounds, and general fatigue.

Past Medical History:

- The pt . had a Cardiac catheterization Surgery before two years . And a Recurrent
hospitalization due to COPD.

Family History:
- No family history of chronic diseases.

Nutritional History:
- Pt. accept hospital diet, and has no allergy to specific types
of foods. Patient limits his fats intake, but no other limitation in calories, caffeine,
etc.

Allergies:
- No allergies to any type of food or drug.

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General Appearance:
- Patient has good posture and balance, good coordination of movements, but he has a
bad tamper due to recurrent hospitalization, and he has hygiene deficit.
- Weight: 70 Kg.
- Height: 165 cm.
- BMI: 25.7 (Overweight).

Skin:
- has dark brown skin, with smooth and soft texture. warm
and dry ,has smooth nails, no clubbing, no skin rashes, but
patient has slight bad odor.

Lymphatic System:
- Nodes: no enlargement or tenderness of lymphatic nodes.

Head:
- He has a normal hair and normal distribution (with out alopecia or
balding), Hair is soft, but oily, and no present of nits. His scalp is pink and
with out any lesions . He has not any dandruff or limps or tenderness or
itching . All his hair are white result of his age.

Nails:
- Nails are convex, pink in color, and soft.

Face:
- He has a normal face, color is pink, symmetrical face . He has not any
ticks or asymmetry or bulging or sunken or edema on his face. Facial
muscles seem good and coordinative.

Neck:
- He has symmetrical shape of his neck . He has not any edema or masse
on his neck .Normal range of motion, no pain when extension, hyperextension or
flexion. Normal size and no enlargement. No neck vein distension. Normal tracheal
size and position, no enlargement of thyroid gland.

Eyes:
- Normal eye structure. Patient doesn't wear Glasses and visual acuity is good when
reading, normal extra ocular movements and react to light. Symmetrical and well
distributed eye brows, eyelids, and eyelashes. No edema.

Ears:

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 He has a normal auricle no deformed or lumps or lesions on it . No
present of dizziness by his ears. Hearing ; right and left is normal, he
dose not use hearing aid. His ears is pink. The ceriman on his ears has a
.gray color
Nose and Sinuses:
- External nose is patent, no nasal deviations. Moist internal nose, pink in color. No
tenderness when assessing maxillary and frontal sinuses.

Mouth and Throat:

His lips is pink , intact ,and moist (he has not any abnormal color on his
lips). his teeth is natural and he has four carries on his molar ,his gum is
pink ,moist and intact (he has not any abnormal color on his gum
(bleeding)). His buccal mucosa un palpable . His uvula is movable ,
pink , moist , and no edema . His hard and soft palate are pink , moist ,
intact , and no lesions. His tonsils are pink , moist (have not red color or
enlargement on it).His gag reflex is good .His pharynx and larynx have
. normal color. His tongue is smooth
Chest and Lungs:
- Chest color is normal, barrel shape. Respiratory rate is 36/min, with using of
accessory muscles, diminished breathing sounds, wheezing, no crackles, cough
aggravated by deep respiration.
Heart and Circulatory System:
- Heart sounds are normal, normal pulse patterns, pulse rate is 98 beat/min (RHR),
APEX does not palpable.
- Hypertension

Abdomen:
- His abdomen is soft , pink in color and intact . There is no distention on
his abdomen; his umbilicus was hidden on the tape. His bowel sound is
active . Femoral pulse is palpable. His abdomen sound is tympanic. No
melena is present. He has not hemorrhoids. He has not organomegaly or
rigidity.
Genitourinary System:
- Normal size, no redness or edema, no discharge, no lesions.
- the color of urine yellow, appearance is not turbid .no
congenital abnormalities.

Sex and Reproduction:

- Patient has 6 sons and daughters.

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Neurological System:
- Patient alert and conscious. Full movement coordination and body balance. Normal
reflexes. No history of trauma, and drinking.

Musculo-Skeletal System:
- He has a good strength and tone. He has not tenderness or resistance. He
has atrophy limbs. His joints is normal no swelling or hot & tender or
crepitation. His extremities is normal without any deformed or nodules
and swelling. On his bone no change in contour and their are symmetry.
He has not full R.O.M. on his joints.

Social Environment:
- Patient is married, lives with his wife and his 6 sons. Good relationships with his
family and friends.

Life Style:
- Smoking for 20 years about 5 cigarettes/day. No drug or alcohol addiction. Normal
sleep patterns 8 hrs/day.

Diagnostic Procedures::
- ABGs, Chest X-Ray, Blood tests, Cultures, ECG.

Lab. Data:
- Blood tests.
- X-Ray.

- Blood tests.

*Blood CBC

The CBC is used as a broad screening test to check for such disorders as anemia, infection, and many
other diseases. It is actually a panel of tests that examines different parts of the blood.

Lab Investigation Patient' s value Normal value Comments

3/10/2008
WBC 20.7 K/UL 4.5-13.9 Infection
RBC ×10^12 5.16 m/µL 4.3-5.3 Normal
HGb 16.0 g/dL 14-18 Normal
HCT 47.4% 39-50% Normal

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 Neutrophils 90.8% 40-80% Bacterial infection
PLT ×109 264 150-400 Normal
MCH 31.0 pg 26-34 pg Normal
RDW 16.3% 12.8%–14.6% Iron deficiency

* Blood culture : No results yet

*ABGs

The arterial blood gas test measures the dissolved oxygen and carbon dioxide in the arterial blood and
reveals the acid-base state and how well the oxygen is being carried to the body.

Lab Investigation Patient' s value Normal value Comments

3/10/2008
PH 7.41 7.35-7.45 Normal
PaCo2 39 35-45 mmHg Normal
PaO2 49 80-100 mmHg Hypoxemia
O2 Saturation 85% 95-100%
HCo3 24 22-28 mEq/L Normal

*ESR

The erythrocyte sedimentation rate (ESR) is the most widely used lab test to monitor the course of
inflammatory disease, as well as infections. The ESR is a reflection of acute-phase reaction in
inflammation and infection.

Lab Investigation Patient' s value Normal value Comments

4/10/2008
ESR 31 0-20 Inflammation

*Troponin I

Confirmation of acute myocardial infarction.

Lab Investigation Patient' s value Normal value Comments

4/10/2008
Troponin I Negative Negative Normal

ECG : (September 22,2008) Normal results .

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- X-Rays
Chest X-Ray

A chest x-ray is a radiology test that involves exposing the chest briefly to radiation to produce an
image of the chest and the internal organs of the chest. A chest x-ray can be used to define
abnormalities of the lungs, heart, and bones.

Test results: Hyper inflated Lungs.

Pathophysiology:

COPD, or chronic obstructive pulmonary disease, is a progressive inflammatory

disease connecting the airways, lung parenchyma, and vasculature. It causes the damage
and remodeling of the airways and lung tissue. Proper functioning of lungs is rejected
continuously by COPD. Over a period of time, these changes result in more severe
conditions such as pulmonary hypertension and right heart failure. The precise
pathophysiology of COPD is unidentified.

The inflammatory process is a driving aspect in the pathophysiology of COPD.

Recent verification suggests that the inflammatory response results in a number of
effects, including an arrival of inflammatory cells such as macrophages, neutrophils and
lymphocytes. Thickened airways and structural changes such as increased smooth muscle
and fibrosis may also be manifested. Cigarette smoking causes an inflammatory response
in the lungs. This response does not cease with the removal of the stimulus, but
progresses for an unlimited period of time. COPD is a subset of obstructive lung diseases
that includes cystic fibrosis, bronchiectasis and asthma. Degeneration and destruction of
the lung and supporting tissue are characteristic of COPD. These processes result in
emphysema, chronic bronchitis, or both. Emphysema begins with a small airway disease
and progresses to alveolar destruction, with a predominance of small airway narrowing
and mucous gland hyperplasia.

The pathophysiology of COPD is not entirely understood. Chronic inflammation

of the cells lining the bronchial tree plays a major role. Smoking and, seldom, other
inhaled irritants, perpetuates an ongoing inflammatory response that results in airway
narrowing and hyperactivity. Airways become edematous, excessive mucus production
occurs and cilia function weakly. Patients face increasing difficulty clearing secretions

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with disease progression. Accordingly, they develop a chronic productive cough,
wheezing and dyspnea.

The basic pathophysiologic process in COPD consists of increased resistance to

airflow, loss of elastic recoil and decreased expiratory flow rate. The alveolar walls
frequently break because of the increased resistance of air flows. The hyper inflated lungs
flatten the curvature of the diaphragm and enlarge the rib cage. The altered configuration
of the chest cavity places the respiratory muscles, including the diaphragm, at a
mechanical disadvantage and impairs their force-generating capacity. Consequently, the
metabolic work of breathing increases, and the sensation of dyspnea heightens.

Medications:

Drug Name Uses Rational Contra- Side effects

indications &
drug
interactions
Aspirin® 100 mg Aspirin is used to decrease enhance - Aspirin should not - Aspirin can cause
PO treat mild to moderate to MI and Angina. be given to a child or stomach pain,
(Acetylsalicylic Acid) pain, and also to teenager. heartburn, nausea,
reduce fever or vomiting, and
inflammation. It is - Drug Interaction ulceration,
sometimes used to when using NSAIDs perforation, and gross
treat or prevent heart and other OTC drugs. GI bleeding.
attacks, strokes, and Aspirin is
angina because it act contraindicated in - Aspirin may also
as Anticoagulant . patients with known cause hyperglycemia
Aspirin should be allergy to NSAIDs or hypoglycemia in
used for and in patients with children.
cardiovascular asthma, rhinitis, and
conditions only under nasal polyps. It may
the supervision of a cause anaphylaxis,
doctor. laryngeal edema,
severe urticaria,
angioedema, or
bronchospasm
(asthma).

- Patient should avoid

drinking alcohol
because it increases
the chance for
stomach bleeding.

Mepral® 20 mg - Omeprazole is used - Mepral® is given to - Allergy and - Diarrhea, headache,

PO to treat symptoms of this patient to prevent hypersensitivity to dizzeness, blured
(Omeprazole) gastroesophageal stomach disorders Omeprazole. vision, insomnia
reflux disease caused by excessive
(GERD) and other drugs intake. - Avoided but not - anorexia, irritable
conditions caused by contraindicated in colon, allergic
excess stomach acid. patients with hepatic reaction.
- Omeprazole is also diseases or have

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 used to promote history of Hepatic
healing of erosive diseases.
esophagitis (damage
to your esophagus
caused by stomach
acid).
- Omeprazole may
also be given together
with antibiotics to
treat gastric ulcer
caused by infection
with helicobacter
pylori (H. pylori).

Tavanic® 50 Is Antibiotic used for: - Used to treat - in patients - Diarrhoea

PO - Acute bacterial infection in hypersensitive to
(levofloxacin) sinusitis. respiratory system. levofloxacin or other - Nausea
- Acute bacterial quinolones or any of
exacerbations of the excipients, - Hepatic enzyme
chronic bronchitis. - increased (ALT/AST,
Community acquired - in patients with alkaline phosphatase,
pneumonia epilepsy, GGT).
Complicated urinary
tract infections - in patients with
including history of tendon
pyelonephritis disorders related to
Chronic bacterial fluoroquinolone
prostatitis. Skin and administration,
soft tissue infections.
- in children or
growing adolescents,

- during pregnancy,

- in breast-feeding
women.

Apovent® 1ml Apovent® is - relief of - Ipratropium bromide - tachycardia,

Inhalation indicated as a bronchospasm in is contraindicated in palpitations, eye pain,
(Ipratropium) bronchodilator for acute COPD known or suspected urinary retention,
maintenance exacerbation cases of urinary tract infection
treatment of hypersensitivity to and urticaria.
bronchospasm Ipratropium bromide,
associated with or to atropine and its - Headache, mouth
chronic obstructive derivatives. dryness and
pulmonary disease, aggravation of COPD
including chronic symptoms are more
bronchitis and common when the
emphysema. total daily dose of
Ipratropium bromide
equals or exceeds
2,000 mcg.

- Allergic-type
reactions such as skin
rash, angioedema of
tongue, lips and face.

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Symbicort® - Budesonide is a - Symbicort® used to - allergic or sensitive - cough.
Inhalation steroid that reduces improve breathing to or have had a
(Budesonide & inflammation in the and to reduce reaction to - headaches.
formoterol) body. inflammation caused budesonide or
by COPD. formoterol. - hoarse voice.
- Formoterol is a
long-acting - have adrenal or - infection of the
bronchodilator that pituitary gland mouth and throat.
relaxes muscles in the problems.
airways to improve - irritation in the
breathing. - have adrenal or throat.
pituitary gland
- The combination of problems. - dizzeness.
budesonide and
formoterol is used to - have heart problems
prevent
bronchospasm in - have high blood
people with asthma or pressure
chronic obstructive - have kidney
pulmonary disease problems.
(COPD).
- have liver problems.

- have or have had

tuberculosis.

- have
phaeochromocytoma.

- have risk factors for

osteoporosis.

Calcimore® 600 mg - This medicine is - given to prevent - hypercalcemia. - chalky taste,

PO used as an antacid in stomach disorders Constipation, dryness
(Calcium Carbonate) cases of hyperacidity caused by excessive - sarcoidosis of the mouth,
and heartburn drugs intake. increased thirst, lack
- sensitivity to any of of
- as a calcium drug contents appetite, difficult
supplement in cases (Calcium Carbonate, urination, headache,
of Mannitol, Sodium nausea or vomiting.
deficiency or as Saccharin, Sugar,
dietary additive. Magnesium Stearate,
Talc, Spearmint
Flavour, Peppermint
Flavour)

- sensitive to any type

of food or medicine,
especially calcium
containing.

Solu Medrol® 40 mg - for disorders need - used as anti- - systemic fungal - Fluid and
IV strong inflammatory for infections. Electrolyte
(methylprednisolone intiinflammatory COPD. - hypersensitivity. Disturbances.
sodium succinate) action.
- Muscle weakness.
- Endocrine
Disorders. - Ulcerative

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 esophagitis and peptic
- Rheumatic ulcer.
Disorders.
- Convulsions.
- Collagen Diseases.
- Increased intraocular
- Dermatologic pressure.
Diseases.

- Allergic States.

- Respiratory
Diseases.

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Nursing Care plan

Patient Problems Nursing Action Rational Evaluation

Impaired gas exchange - encourage fluid intake. - increasing fluid - Patient reported more
related to chest infection, intake moistens the comfortable breathing.-
bronchoconstruction and secretions and
high mucous production facilitates its - breathing rate
as manifested by removing. decreased to 30
tachypnea (36 breaths/min.
breaths/min), PaO2= - teach patient
49mm Hg, fatigue, diaphragmatic - this reduces the - patient know more
productive cough, barrel breathing. respiratory rate, about smoking
chest, diminished lung increases alveolar dangers.
sounds. ventilation.

Goal: improving gas - administer antibiotics

exchange as ordered - to treat infection

- Promoting s
moking cessation.
- Because smoking
has such a
detrimental effect on
the lungs.
- administer O2 therapy
as ordered.
- provide O2 to
correct hypoxemia.

Ineffective Breathing - Teach patient - to decrease - breathing rate

Patterns related to diaphragmatic breathing breathing rate and decreased to 30
History of smoking and deep breathing make removing breaths/min.
secondary to COPD as technique. secretions easy.
manifested by
tachycardia 36 - patient know more
breaths/min, restlessness, - Promote smoking - because smoking about smoking
using accessory muscles, cessation. irritates the airway. dangers.
productive cough, and
fatigue.

- Maintained patient on - This position helps

moderate high back rest. maximize lung
expansion.

Goal: Improvement in
breathing pattern (lessens
breathing patterns).

Self-care deficits related - teach patient deep and - to lessens and avoid - patient is clean and
to fatigue secondary to diaphragmatic breathing more fatigue while tidy.
insufficient oxygenation with activity. doing activities.
as manifested by hygiene - patient can do bathing
deficit, bad body odor, and walk

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 and oily hair. - encourage patient to do - to improve independency.
bathing, walk and daily independency.
Goal: Independence in activities.
self-care

impaired Urinary - encourage fluid intake. - Increased fluid - Goal not met till now.
Elimination related to intake dilutes urine
idiopathic reason as and decrease burning
manifested by urgency, and pain.
burning, and pain when - encourage cranberry
urinate, and abnormal juice intake. - preventing bacteria
urination patterns from sticking to the
(over10 times a day). walls of the bladder,
and Cranberry juice
Goal: lessens pain when acts like a natural
urination antibiotic to the
urinary system

Conclusion
Thought my working and researching in this case study , I got good
results out of this experience , and now am able to deal with those patient
with COBD , furthermore my knowledge has been enriched , beside i
recognize the importance of communication between nurse and patient , and
his/her professional and social role in health care improvement .

References

Bruner and suddarth’s. (1996). Medical -Surgical Nursing. -1

.(8th ed).Lipincott: Philadelphian

Richard A. Lehne. (2001). Pharmacology for Nursing care. -2

.(4th ed). Philadelphia: Pennsylvania

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chart -3

.patient. And their family -4

http://ezinearticles.com/?Pathophysiology-of- -5
COPD&id=408861

The End

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