As a response of two main factors, which are ageing population and exposure to risk factors, the prevalence of chronic obstructive pulmonary disease (COPD) is rising worldwide. In fact, the disease is a challenge for public health and health care system because it demands high costs (Lisspers, Johansson, Jansson, Larsson, Stratelis, Hedegaard, & Stallberg, 2014). Besides, the American Lung Association (2013) reinforces that the COPD is the third leading cause of death in the United States. Data from 2007 showed that nearly 125,000 deaths nationwide occurred in response this disease, so it represents one COPD death approximately every four minutes. In addition, underlined in these numbers, many clients are not diagnosed or managed correctly, so the process to educate the client and the client knowledge are fundamental to eliminate risk factors and promote better quality of life for whom has been diagnosed with this pulmonary disease (Lisspers, et al., 2014). Throughout the course of this paper, some information will be described as the following: client’s information, description and clinical manifestation the client’s disease, the client’s prescription, and nursing diagnoses and intervention, which applies to this client.
Firstly, fundamental information about the client is necessary to be investigated and understood to proceed the diagnose and manage. Client’s history must provide knowledge to link present manifestations to past situations, and these will conduct to better management and promotion for future interventions. Patient Mrs. S., 82 years old, married, retired, catholic, and level of education restricted (not concluded high school). She was hospitalized as a result of pneumonia after being diagnosed with productive cough, which was with yellow secretion; and her temperature was 38.5oC. In her health history, she related that she was diagnosed with chronic obstructive pulmonary disease (COPD) although Mrs. S. could not specify the time when these diagnoses occurred. Mrs. S. was not alcoholic and smoking. She has related that at home, she uses medication (not specified) to relieve pain when it is necessary. In addition, she has related that she was not allergic and was responding well front the hospitalization.
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During her physical examination, she presented as following information: patient was LOC and verbalizing with difficulty because of gas exchange. She was using oxygen therapy by the spectacle-type nasal catheter with 2L/min; RR 32 and tachypnea; HR 81 bpm and normocardic; BP 130/70 mmHg and normotensive; temperature 38,5oC and febrile; and saturation SpO2 90%. Skin: dehydrated, normal colored, turgor characteristic of her age, hematoma in member superior left because of the catheter for serotherapy. In the moment, the catheter was salinized. The nervous reflex was preserved, full and firm pulse, rhythmic. Cranium: it was not present alterations and was hygienic. Pupils were isochoric and photo reactive. Thorax: plan, symmetric, thoracic expansion kept, symmetrical breasts characteristic of senescence. Lung: vesicular murmur and stridor presented in bilateral basis; pulmonary auscultation: normal sounds, regular rhythm in regular rhythm of two. Abdomen: it was plan, palpable in ascending loop, Blumberg/Cystic/McBurney negatives. Genito- urinary: paravaginal and perianal presented dermatitis. Eliminations: faeces twice by day with pasty aspect. Urine in grand quantity in diaper, dark yellow and characteristic smell, not related pain to urinate. Alimentation: hyposodic diet, oral, preserved appetite. Water ingest around one liter by day. Activity and sleeping: restrict movements and perambulation – with family help – difficulty to sleep. Security and protection: Braden’s scale with 16 points – low risk. Comfort: related pain – number six – in the right shoulder.
Secondly, understanding the Mrs. S’s history and results of the physical examination can provide an overview about the physiopathology because it must define connections among disease route. These connections are linked to the quality of life to know better about pneumonia and COPD. Pneumonia is an inflammation of the lung parenchyma caused by different microorganism agents (Hinkle & Cheever, 2010). In relation to Mrs. S. the according to the drugs prescribed the hypothesis is that the pneumonia is caused by a type of bacteria, which is inhaled by ambient air, where an upper airway bronchoaspiration occurred with colonization this bacteria, so this type of bacteria did a migration to lower airway and colonization in the bilateral inferior lobule region.
For instance, some risk factors can be applied for pneumonia. Two age groups at highest risk are infants/children and older people. These risk factors can be a chronic disease, for example, asthma, COPD, and heart disease; suppressed immune system, which can be developed by drug treatment and/or diseases (HIV/AIDS), and surgery; smoking; and client being placed on a ventilator during hospitalization. Still, some signal and symptoms presented because of pneumonia are fever, sweating, hypothermia (in older adults and people with weakened immune system), cough (can be productive or not), chest pain during cough and/or deep breathing, shortness of breath, fatigue, muscle aches, nausea and vomiting (most common for infants/children), and mental awareness (most common for seniors) (Hinkle & Cheever, 2010).
Another pathology presented in Mrs. S. was Chronic Obstructive Pulmonary Disease is characterized by Lewis, Dirksen, Heitkemper, Bucher & Camera (2014) as an airflow limitation, which is not reversible. This airflow limitation is progressive and related to an abnormal inflammatory response of the lungs to noxious particles or gases. COPD is composed of three different pathologic processes, which can possibly combine to develop the clinical case. They are: chronic bronchitis, emphysema, and asthma.
The pathophysiology involves gradual destruction of alveolar septum and destruction of the lung parenchyma, which increase the incapacity to provide gas exchange among alveolus and blood. The definitions of the three possible pathology are: a) chronic bronchitis: it describes as an excessive production of mucus in the bronchial tree, and it has chronic productive cough or recurrent during unless three months by year, which is two years consecutive; b) emphysema: it is understood how an anatomic alteration, which is characterized with abnormal alteration in the air spaces distal to the terminal bronchioles, and it is accomplished with destructives alterations in the alveolar walls; c) asthma: it is a chronic inflammatory disease, which is characterized with lower airway hyper responsiveness and variable limitation in the air flux. It can be spontaneously reversible or with treatment. Asthma has clinical manifestation by recurrent episodes of wheezing, breathlessness, chest tightness, and coughing (Hinkle & Cheever, 2010).
Furthermore, according to Hinkle & Cheever (2010) some risk factors are related to COPD can be: first, cigarette smoking, which is considered the major risk factor. Second, occupational chemicals and dusts, which involve two main factors – air pollution and infection – air pollution is a problem for urban people although a comparison among cigarette smokers and air pollution, the first has a high level of influence. Thrid, heredity, which is a deficit in the α1 –Antitrypsin (AAT) deficiency autosomal recessive disorder), but it is only 1% – 2% in the United States. Last one, aging: where some degree of emphysema is common in older adults, even non-smokers. Also, some signals and symptoms must be present in the client, who has COPD. These signals and symptoms can be shortness of breath, wheezing, chest tightness, chronic cough, which produces excess mucus, respiratory infection, lack of energy, cyanosis, and weight loss, which must be in the chronic stage. These symptoms and signals must varies person to person, and they can be present on worse stage in some parts of the day.
After all, a connection is applied between COPD and pneumonia. Both diseases have a rouge link. First, COPD provides to people, who have this pulmonary disease, a facility to contract pneumonia and difficult to diagnose pneumonia because of similar signals and symptoms. Also, COPD does a difficulty treat pneumonia because the patient has a restriction in his/her immune system, so the antibodies cannot provide the adequate defense. Another situation is inflammation and irritation present in the lungs of COPD, so pneumonia increases these both factors and restricts more the breathing and oxygen exchange. In relation to the diagnoses, if pneumonia is diagnosed early, the recovery can be more satisfactory although COPD restricts it. In fact, management with antibiotics to promote better recovery and care needs to be applied, and prevention must be considered by the client and health professional, so vaccine must be used a method of prevention (Lewis et al, 2014).
Thirdly, the physician provided prescriptions to the client. Mrs. S’s. physician provided a medical prescription based on her diagnosed (COPD and pneumonia) to provide adequate management and recovery. The physician requested lung X-ray, which showed the presence of opacity in the lower thirds as a result of pneumonia. The medications were: 1- Dipyrone 2ml + 10 ml of distilled water (IV), every 6 hours if pain or fever; 2- Omeprazole 20mg (oral) on an empty stomach, in the morning; 3- Rocephin 1g + 100ml (IV) of saline 0.9%, every 12 hours; 4- Levofloxacin 500mg (IV), every 24 hours; 5- Bamifylline 300 mg (oral), 8 a.m. and p.m; 6- Nebulization therapy with saline 0.9% 5ml + Atrovent 35 drops + Berotec 5 drops (inhalation), every 6 hours; and 8- Oxygen therapy by spectacle-type nasal catheter with 2L/min if saturation ≤ 90%.
Consequently, some interventions can be understood by this prescription. The medication aspects understand that Mrs. S. was doing management of the presented and the subsequent disease. Medication for pain helps to relieve the discomfort caused by the difficult to breathe and the intercostal muscles, and bronchodilator drugs help to facilitate the air passage, so the air volume in the upper and low airway and gas exchange in the alveolus will increase, and it helps in the chronic disease keeping a bronchodilation the airway (promotion of the health conditions). Antibiotic medication works to eliminate the pathologic agent, which provided pneumonia. The drug referent to proton pump inhibitors is utilized to prevent stomach injuries because of antibiotic therapy (Deglin & Vallerand, 2013). Nebulization helps to humidify airway. Oxygen therapy provides a supplement of oxygen to increase the available quantity in the alveolus (Potter & Perry, 2009).
Likewise, chest x-ray was asked to clarify and provide adequate diagnostic for Mrs. S., and it confirmed what part and the expansion of the lungs had pneumonia (presence of opacity in the lower thirds). Another factor to ask for this exam is because of the COPD, so it helps the physician to evaluate shortness of breath, support the diagnosis, and analyzes for advanced emphysema (Kee, 2010).
Furthermore, pharmacology should have attention to Mrs. S. because she had a variety of medications during hospitalization, so nurses must know medication information such as main effect and nursing care for this client. The according with Deglin & Vallerand (2013) Mrs. S’ medications are described as follows:
- Dipyrone – 2ml + 10 ml of distilled water (IV), every 6 hours if pain or fever.
- Main effect: it is an analgesic and antipyretic.
- Nursing care:
- Teaching the client about the side effects related to use this medication. Side effects that are more common are allergy and/or breathing discomfort; if it is present, the nurse immediately communicates the physician.
- This medication must be administrated if the patient refers pain or fever, so the nurse is responsible to verify vital signs and pain scale.
- Omeprazole – 20mg (oral), an empty stomach, in the morning.
- Main effect: it provides protection for the gastric wall because of the high quantity of medicaments administrated.
- Nursing care:
- The nurse asks the patient about allergy.
- Nurse administrates one hour before breakfast (according to the physician’s prescription).
- Rocephin – 1g + 100ml (IV) of saline 0.9%, every 12 hours.
- Main effect: it is an antimicrobial to act in gram negatives.
- Nursing care:
- Medicament reconstruction must be in saline 0.9%.
- The administration needs to be slow (minimum 30 minutes).
- Levofloxacin 500mg (IV), every 24 hours.
- Main effect: it is an antimicrobial. It is used for the treatment of pneumonia.
- Nursing care:
- The nurse must administrate the medication slowly.
- The nurse should orient the client about side effects such as nauseas and vomiting.
- The nurse must not administrate other antimicrobial drug in the same time.
- Bamifylline 300 mg (oral), 8 a.m. and p.m.
- Main effect: it is a bronchodilator.
- Nursing care:
- The nurse should monitor for drug hypersensitivity.
- The nurse should assess for low bone density and periodically during therapy.
- Nebulization therapy with saline 0.9% 5ml + Atrovent 35 drops + Berotec 5 drops (inhalation).
- Main effect: Atrovent acts as a bronchodilator (parasympathetic nervous system), and Berotec acts as a bronchodilator (sympathetic nervous system).
- Nursing care:
- Nebulization needs to be done according to the physician’s prescription.
- The nurse should monitor for side effect such as tachycardia.
Nursing Diagnoses and Interventions
Finally, Wilkinson & Ahern (2009) emphasize that nurses provide their actions using the Nursing Care Systematization, which consists in to analyze the affected client’s conditions and to implement actions to restore his/her normal conditions of daily life. Indeed, Mrs. S’ nursing diagnoses and interventions could be applied, so these actions are described as a follower:
- Ineffective Breathing Pattern: inspiration and expiration that do not provide adequate ventilation, which is characterized by increased restlessness, oxygen saturation decreased, and using accessory muscles for breathing. Thus, the goal is to provide adequate ventilation pattern.
- Keeping superior airway clear, so it can be done using a suction catheter where necessary.
- The position of the patient where he/she feels a relieve in dyspnea. The client has a frequent stimulating change of position in bed, keeping elevation in the headboard, and stimulating deep breathing and cough.
- If necessary, the client can use oxygen therapy, which is conform physician’s prescription. It can be offered by spectacle-type nasal catheter. This catheter must be changed every 24 hours if the presence of secretion. The nurse should monitor humidification the oxygen for oxygen therapy.
2- Ineffective Airway Clearance: client’s inability to clear secretions or obstructions from the respiratory tract to keep a clear airway when it is presented, which is characterized by adventitious breath sounds, changes in the respiratory rate and rhythm, cyanosis, dyspnea, and absent cough. As a result, the goal is to keep or perform a clear airway.
i. Teaching the client how to provide adequate coughing. It can use specific techniques to perform such as tapotement.
ii. Encouraging ambulation, so it helps the client to eliminate lung’s secretion and facilitate breathing.
iii. Encouraging the client does a deeply breathing, coughing, and teaching him/her the importance to do this.
iv. Checking for client’s hydration, it must be adequate because dehydration difficult to breath and eliminate airway secretion.
3- Risk for Infection: it is related to increased environmental and pathogens exposition, invasive procedures, and a deficit in knowledge to avoid pathogen’s exposition. Therefore, the goal is to prevent hospital infection or sepsis.
i. The nurse should monitor and check for local and systemic signs and symptoms of infection.
ii. Providing adequate hydric and nutritional ingest. The nurse can stimulate the client to keep adequate alimentary ingest, orient the client and his/her family about the necessity of adequately ingest of fibers, vitamins, proteins, and water.
iii. The nurse must teach the client and his/her family about signs and symptoms of infection, so they can go to a health professional, who will evaluate it.
The discharge plan and education about health habits must be presented and constructed during the hospitalization with the client and his/her family, so it will provide adequate management and quality of the life for the client (Ackley & Ladwig, 2014).
In brief, in the following paper was described Mrs. S’s historical and physical examination, her physiopathology, her exams and medicaments, and nursing diagnoses and interventions about COPD and pneumonia once both diseases were presented by Mrs. S. Besides these processes, nurses provide their diagnoses and interventions in the heath plan to care and provide promotion and prevention for the client, who was diagnosed with pulmonary disease. Nurses must continue to implement their nursing diagnoses and interventions with doing research because it is fundamental for the health care system to improve quality of recovery and life for clients and their family.
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