INTRODUCTION: Breathing is a basic human function that tend to be unconscious. Breathingis a physiologic function that is almost synonymous with being alive. Difficulty inbreathing as a threat to life itself. People with respiratory disorders are often veryanxious and fearful that they may die, perhaps agonizingly. Whether death is a realpossibility often has nothing to do with the fear. Respiratory problems are widespread. They may be acute (short term) orchronic( long term). Acute disorders range from minor inconveniences, such ascolds or flu, to more life-threatening problems, such as asthma some types ofpneumonia, and chest trauma Chronic respiratory problems are also widespread,and are the cause of significant disability. People who experience them often have to make radical life-style changes,often retiring from work earlier than they wish. Such disabling conditions includechronic obstructive pulmonary disease (COPD), now called chronic airflowlimitation, and certain restrictive lung diseases. Respiratory problems have many causes: allergies, occupational factors,genetic factors, smoking and tobacco use, infection, neuromuscular disorders, chestabnormalities, trauma, pleural conditions, and pulmonary vascular abnormalities.The most significant factor in chronic respiratory illness and lung cancer iscigarette smoking. Gas exchange is the primary function of the respiratory system. Therespiratory system takes oxygen from the atmosphere, transports it to the lungs,exchanges the oxygen for carbon dioxide in the alveoli, and returns carbon dioxideto the air.
OBJECTIVES: To collect baseline information from the client. To establish a good rapport with the client and his family. To provide a cost effective nursing care to the client. To promote positive attitude towards the treatment in the client. To identify the clinical significance and related nursing implications of the various tests and procedures used in the diagnostic evaluation. To assess the parameters appropriate for determining the status of COPD(chronic obstructive pulmonary disease) To use nursing process as a framework of care for clients with COPD. To study disease condition in practical. To reduce the complications. To educate the client and her relatives regarding the need for follow-up care after discharge and life style after the discharge.
CLIENT PROFILE:Name of client : Mrs. LakshmiAge : 62 yearsSex : FemaleI P No. : 3922Ward : 11Unit : III MuMarital Status : MarriedEducational Qualification : 10th stReligion : HinduOccupation : CoolyIncome : Rs.900/-Address :Admitted on : 26-5-11 at 11:05 a.mSource of data : PatientDiagnosis : COPD.
HISTORY COLLECTIONCHIEF COMPLAINTS: Patient had a history of fever for 3 days, cough with scanty mucoidsputum expectoration, breathlessness, wheezing for 5 years. No history ofvomiting, diarrhea, head ache, chest pain, abdominal pain.PRESENT HEALTH HISTORY: History of fever for 3 days, cough and scanty mucoid sputum expectoration,breathlessness, wheezing for 5 years.PAST HEALTH HISTORY: No child hood disease. Patient had wheezing for the past 5 years and tooktreatment in private hospital but not getting well. No history of any previoushistory of surgeries.FAMILY HISTORY: Mrs.Lakshmi husband died due to aging process. She had one son and twodaughters and son was married and had two childrenNo history of -> DM/IHD/ Allergies / no communicable disease.
FAMILY TREE: 70 yrs 62 yrs 40 yrs 35 yrs 32 yrs30 yrs 10 yrs 8 yrs MALE FEMALE DIED
FAMILY HEALTH HISTORY:ALLERGIES : NILChronic illness: Asthma : Absent Bronchiectasis : Present Cancer : Absent Cystic Fibrosis : Absent Emphysema : Absent Sarcoidosis : Absent TB : AbsentPERSONAL HISTORY:Alcohol drug abuse : NILPSYCOSOCIAL HISTOPRY:Occupation exposure : to dustHobbies : DustGeographic location : EnvironmentExercise : Not doing
SOCIO ECONOMIC CONDITION: Patient`s son is the only bread winner for the family. No other source ofsupport .Her family income of Rs 900/ month . Her son is a cooly. Her family iscomes under low socio economic group. She is living in a hut rented house, havingone window and one door. Her house is electrified. She is getting water frompublic pipe connection.SPIRITUAL HISTORY: Mrs.Lakshmi is Hindu. She visits temples once in a week. She celebratedDiwali and pongal festival.
REVIEW OF SYSTEM PHYSICAL ASSESSMENTGENERAL HEALTHNourishment : Well nourishedBody built : Normally builtHealth : HealthyActivity : DullSkin condition:Color : PaleTexture : Warm Temperature : 1oo FHead and Face:Scalp : Hair black and whiteFace : PaleEyes:Eye brow : NormalEye lash : Normal in colorEye lid : No swellingEye ball : Normal
Conjunctiva and sclera : Not jaundicePupil : NormalLens :OpaqueVision : Dim blurred visionEars:External ear : No dischargeTympanic membrane : NormalHearing : NormalNose : No bleeding/ No obstructionMouth:Pharynx : No redness/ swelling/ No gum Bleeding/ No gingivitis.Teeth : Stained teeth/ No dental carries.Tongue : No ulcer / normalNeck :No lymph node enlargement/ NormalChest : Symmetry/wheezing present Tachyapnea/ cough present No hemoptysis
Heart : S1/S2 heardBreast/axilla : SymmetryAbdomen:Inspection :No lesion /No swellingPalpation :No tendernessPercussion :No mass/ No distended bladderAuscultation : Normal bowel soundGenitals : No ulcer/ pain / itching/discharge :No pain during urination/defecationRectum No hemorrhoids/No MelinaUpper extremities : Normal ROMLower extremities :Knee pain
SYSTEMIC ASSESSMENTRESPIRATORY SYSTEM:Chest movement : SymmetricalShape : NormalINSPECTIONChest wall Configuration : NormalSymmetry of Chest Wall : SymmetricalPresence of superficial veins : AbsentAngle of the Ribs : 45 DegreeIntercostals Space - Retraction : AbsentMuscles of Respiration : Use of accessory muscles: NoRespiration : 22/mtRate : TachypnoeaRhythm : NormalPattern : TachypnoealDepth : HyperphoeaSymmetry : SymmetricalAudiblity : Audible
DRUG CHART NURSESNAME OF DOSAG ROUT SIDE ACTION RESPONSIBILITHE DRUG E E EFFECTS TYInj 1 gm bd IV Broad Head ache Nephro toxicitycefatoxamie spect rum dizziness. watch for antibiotic Seizures increased BUN, inhibits heart failure urine output. bacterial syncope. Asses the signs of cell wall Nausea anaphylaxisis rash synthesis vomiting GI uticaria, purities, rendering bleeding chills watch for cell wall protein uria, over growth of osmotical nephrotoxici infection perineal ly ty renal itching , fever, austable failure malaise redness leading to leukcopenia painInj 500mg Bd cell death anaphylusismetromidazo Ivle Assess for Headache infection WBC dizziness corent, wound fatigue symptoms fever blurred assess vision by vision sore ophthalmic exam throat during cyter Anti nausea therapy maintain infective vomiting, I/o chart direct darkened acting urine, amibicide albunimuria tricho neuro monocide toxicity
Methylxanthine Mild CNS-irritability, Teach patients tocompound- bronchodilat restlessness, take at equalrelaxes muscle or, intervals insomnia,by maintenance throughout the seizures in toxic Therapy for day.increasing cyclic ranges bronchospasadenosine mono- To decrease GI m CV- palpitation,phosphate irritation, take tachycardia, with milk or hypotension crackers. GI- nausea, Monitor vomiting, Theophylline diarrhea blood level periodically as directed to ensure Oral Therapeutic range Maintenance and preventSympathomimeti therapy for Nervousness, toxicity.c (beta2- bronchospas tachycardia headadrenergic m, works ache, nausea,against) with within tremors. Observehighly selective 30min MDI, inhalation bybeta2 activity nebulized Continuous patient to be liquid rapid nebulization may certain that relief of cause correct technique bron- hypokalemia. is chospasm, dyspnea- Used. works within Caution patient 3-5min not to exceed prescribed dose. Adverse-effects often associated with excessive
use. Does notreduceinflammation.
DRUGS/ PHARMACOL INDICATIO ADVERSE NURSING OGIC NSADMINISTRAT EFFECTS CONSIDERATIO EFFECTSION NSCorticosteroids Patent anti- Acute CNS: Long term use Do inflammatory- exacerbation Depresion; not stop abruptlyHydrocortisone/p activity of asthma or euphoria, mood due to adrenalrednisone bronchitis changes suppression(DeItasone)(intravenous (l.V GI : gastric Take oral form preparation) irritation peptic with food.Injection, oral ulcerpreparation). Acute • Usually given as exacerbation Metabolic taper from higher or hypernatremia, dose to lowest maintenance hypokalemia, possible dose that theraphy hyperglycemia, achieves desired effect. (oral water preparation) retension, and It inhibiting weight gainCIPROFLOXACI bacterial DNAN and cause Respiratory Observe(250 bd) bacterial lysis tract, Urinary Nausea, head complication track, ENT, ache, vomiting, Bone and joint Diarrhoea, infection restlessness, It acts on CNS to abdominal produce analgesia pain, skin rashParacetamol and antipyretic Avoid lon-term Nausea, Epi(500mg tds) effect use, Pain and fever gastric distress, skin rash Observe complication
ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEMUpper AirwayStructureNasal Cavity The nose is formed from both bone and cartilage. A very small portion of thenose is bone; the nasal hone only forms the bridge of the nose. The remainder ofthe nose composed of cartilage and connective tissue. The nasal cartilages form theshape of the nose. The openings of the nose on the face are called nostrils or nares. Each nostrilleads to a cavity, called a vestibule. The vestibule is lined anteriorly with skin andhair (called vibrissae). The vibrissae filter foreign objects and prevent them frombeing inhaled. The posterior vestibule is lined with mucous membrane. Thismembrane is composed of columnar epithelial cells, which secrete mucus. Theportion of mucous membrane that is located at the top of the nasal cavity, justbeneath the cribriform plate of the ethmoid bone, is specialized epithelium, calledolfactory epithelium, which provides the sense of smell.The region is supplied bythe &factory nerve (cranial nerve I) which passes through holes in the cribriformplate. The olfactory epithelium does not lie along the usual path of air movement,so smell is enhanced by sniffing. Along the sides of the vestibUle are turbinates. The turbinates are mucousmembrane-covered projections. They contain a very rich blood supply (from theinternal and external carotid arteries), and they warm and humidify inspired air.Paranasal sinuses are open areas within the skull. They are named for the bones inwhich they lie—frontal, ethmoid, sphenoid, and maxillary. Passageways from theparanasal sinuses drain into the nasal cavities. The nasolacrimal ducts, which draintears from the surface of the eyes, also drain into the nasal cavity. The mouth is considered part of the upper airway, but only because themouth can be used to deliver air to the lungs. The mouth may be used for breathing
when the nose is obstructed or when high volumes of air are needed, such asduring exercise. The mouth does not perform the functions of the nose efficiently,especially warming, humidifying, and filtering air.PHARYNX: The pharynx is a funnel-shaped tube that extends from the nose to the larynx.It is used for digestion as well as for respiration. The pharynx is divided into threesections:(1) The nasopharynx, located above the margin of the soft palate;(2) The oropharynx, the part of. the pharynx that is visible when the tongue isdepressed with a tongue depressor;(3) The laryngopharynx, located below the base of the tongue. The nasopharynx is the upper Section and receives air from the nasal cavity.The nasopharynx is lined with ciliated columnar epithelium. From the ear, theeustachian tubes open into the nasopharynx. The pharyngeal tonsils are located onthe posterior wall of the nasopharynx. The tonsils are masses of lymphoid tissue;they serve as an additional defense mechanism against bacterial infection. Whenthe pharyngeal tonsils become enlarged following repeated infections or are at theirpoint of maximum growth during adolescence, they are called adenoids. The oropharynx serves both respiration and digestion. It receives air from thenasopharynx and food from the oral cavity. Palatine (facial) tonsils are locatedalong the sides of the posterior mouth, and the lingual tonsil are located at the baseof the tongue. The laryngopharynx (hypopharynx) is the most inferior portion of thepharynx. It connects to the larynx and serves both respiration and digestion.Larynx: The larynx is commonly called the voce box. It connects the upper (pharynx)and lower (trachea) airways. It is located anterior to the fourth and sixth cervicalvertebrae. The upper esophagus is just posterior to the larynx.
The larnyx is formed by nine cartilages: three paired and three singlecartilages. The three large unpaired cartilages are the epiglottis, thyroid, andcricoid; the three paired cartilage , which are smaller, are the arytenoid,corniculate, and cuneiform. The cartilages are held together and attached to thehyoid hone above the trachea and below the trachea by muscles aids ligaments.The larynx consists of the endolarynx and a surrounding triangle-shaped bone andcartilage. The endolarynx is formed by two pairs of folds of tissue, which formsthe false vocal cords and the true vocal coids. The slit between the vocal cords forms the glottis. The epiglottis, a leaf-shaped structure immediately posterior to the base of the tongue, lies above thelarynx. When food or liquids are swallowed, the epiglottis closes over the larynx,protecting the lower airways from aspiration. The thyroid cartilage protrudes infront of the larynx, forming the Adam’s apple. The cricoid cartilage lies just belowthe thyroid cartilage and is the anatomic site for an artificial opening into thetrachea (tracheostomy). These cartilages are all connected by ligaments thatprevent the larynx from collapse during inspiration and swallowing the internalportion of the larynx is composed of muscles that assist with swallowing, speaking,and respiration, and contribute to the pitch of the voice. The, blood supply to thelarynx is through the branches of the thyroid arteries. The nerve supply is throughthe recurrent laryngeal and superior laryngeal nerves.Function: Major functions of the upper airway are,(1) Air conduction to the lower airway for gas exchange;(2) Protection of the lower airway from foreign matter;(3) Warming, filtration, and humidification of inspired air. It is important for thenurse to appreciate the function of the upper airway. In various disorders and in the treatment of some disorders, this function islost or altered. For example, when a client has a cold, it is difficult to breathethrough the swollen nose, and mouth breathing is common. When the clientbreathes through the mouth, the normal functions of the nose (smell, taste,humidification, and filtering) are lost.
The upper airway is lined with mucous membranes to assist in warming andhumidifying inspired air. Regardless of the temperature of air inspired, by the timethe air reaches the lung (in about 0.25 seconds) the air has been warmed to 36° to37° C (96.8° to 98° F) and humidified to 70% to 80%. The mucus also helps trapforeign particles. The cilia of the membrane assist in moving the particles downinto the pharynx. The posterior part of the nasal cavity opens into the internal naresand the nasopharynx. The two nasal vestibules are divided by the septum. The nose also provides for the sense of smell and is an adjunct to taste. Thepart of the mucous membrane covering the cribriform plate is modified forolfaction. The nose provides a sneeze reflex, which is similar to the cough reflex.Irritation of the nasal passages causes receptors in the trigeminal nerve (cranialnerve V) to stimulate the respiratory centre in the medulla. The medulla stimulatesa blast f air through the nose that carries foreign matter out the nose and mouth.Sinuses lighten the weight of the skull and modify sound by acting as resonatingchambers.Lower Airway:Structure: The lower airway (trachea-bronchial tree) is composed of the,(1) trachea,(2) right and left mainstem bronchi,(3) segmental bronchi,(4) subsegmental bronchi,(5) terminal bronchioles. Smooth muscle, wound in overlapping clockwise and counterclockwisehelical bands, is found in all of these structures. This muscle is subject to spasm inmany airway disorders.Trachea:
The trachea (windpipe) extends from the larynx to the level of the sevenththoracic vertebrae where it divides into two main bronchi (also called primarybronchi). The point at which the trachea divides is called the carina. The trachearests anterior to the surface of the esophagus. The trachea is a flexible, muscular,long air passage with C-shaped cartilaginous rings. It is Iined with pseudostratifiedciliated columnar epithelium that contains numerous goblet (mucus-secreting)cells. Because the cilia beat upward, they tend to carry foreign particles andexcessive mucus away from the lungs to the pharynx. No cilia are present in thealveoli.Bronchi and Broncholes: The right main-stem bronchus is shorter and wider, and extends morevertically downward, than the left. Thus, foreign bodies are more likely to lodge inthe right main- stem bronchus than in the left main-stem bronchus. The segmental and sub-segmental bronchi are subdivisions of the mainbronchi and are spread in an inverted, treelike formation through each lung. Cartilage surrounds the airway in the bronchi. This structure contrastswith the bronchioles, the final pathway to the alveoli, which contain no cartilageand thus can collapse and trap air. The terminal bronchioles are the last airways ofthe conducting system. This area does not have gas exchange and is called theanatomical dead space. Inspired air that remains in the dead space is what allowsartificial respiration (mouth-to-mouth resuscitation).Function: The lower airways continue to warm, humidify, and filter inspired air that isen route to the lungs. In addition, they provide several defense mechanisms. The respiratory gas-exchanging membrane has a surface area that is almostthe size of a tennis court. The size of the membrane of the lungs and the dailyexposure of the lungs to atmospheric pollutants requires efficient protectivemechanisms. The elaborate defense mechanisms of the lungs fall into threecategories:(1) Clearance mechanisms,
(2) Immunologic responses in the lung, and(3) Pulmonary reaction to injury. An intact respiratory epithelium and mucociliarysystem are necessary for the efficient functioning of the lung defense mechanisms.Defense by the Respiratory:Epithelium: The predominant cell of the upper respiratory tract (trachea and bronchi) is aone-cell--layer thick squamous ciliated cell. The cilia are microscopic, hair-likeprojections that protect the airways with a rapid, coordinated, unidirectionalsweeping motion toward the mouth. The movement of the cilia propels a mucusblanket toward the mouth. This blanket is produced by goblet cells located on themucosal surface. The mucociliary system propels debris (pollutants and infectiousagents) to the mouth within 30 minutes for the large bronchi, 2.5 hours for most ofthe bronchial tree, and 5.6 hours for the peripheral airways. At the mouth, thedebris is removed from the airways by swallowing or coughing. Sputum is mucusexpelled by coughing. The alveolar lining is made up of flat, membranous pneumocytes (type Icells). Rounded granular cells (type II) are also found there. These type II cells areresistant to injury and cover most of the alveolar surface after exposure toinfectious agents. Alveolar macrophages, derived from blood monocytes thatmigrate into the lungs, are also found over the surface o the alveoli. Alveolarmacrophages are active phagocytes that remove deal cells and protein.Macrophages are also metabolically active cells that synthesize and secretesubstances that regulate the immune system. They leave the lung by either themucociliary system or the lymphatic system.Thorax, Diaphragm, and Pleura:Structure:Thorax and Diaphragm: The bony thorax provides protection for the lungs, heart, and great vessels.The outer shell of the thorax is made up of 12 pair of ribs. The ribs connectposteriorly to the transverse processes of the thoracic vertebrae of the spine.
Anteriorly, the first seven pairs of ribs are attached to the sternum by cartilage. The8th , 9th, and 10th ribs (false ribs) are attached to each other by costal cartilage. The11th and 12th ribs (floating ribs) allow full chest expansion because they are notattached iii any way to the sternum. At the top of the thorax in the neck area are two accessory muscles ofinspiration—the scalene and sternocleidomastoid muscles. The scalene muscleselevate the first and second ribs during inspiration to enlarge the upper thorax andstabilize the chest wall. The sternocleidomastoid muscle elevates the sternum. Theparasternal, trapezius, and pectoralis muscles are also accessory inspiratorymuscles and are used during increased work of breathing. Between the ribs are the inter-costal muscles. The external intercostalmuscles pull the ribs upward and forward, thus increasing the transverse andanteroposterior diameter. The internal inter-costal muscles decrease theanteroposterior diameter of the chest wall. The diaphragm serves as the lowerboundary of the thorax. The diaphragm is dome shaped in the relax position, with central muscularattachments to the xiphoid process of the sternum and the lower ribs. Thediaphragm’s nerve supply (phrenic nerve) comes through the spinal cord at thelevel of the third cervical vertebra. Thus, C3 spinal injuries impair ventilation.Pleura: The pleura are serous membranes that enclose the lung in a double-walled sac.The visceral pleura covers the lung and the fissures between the lobes of the lung.Toe parietal pleura covers the inside of each hemithorax, the mediastinum, and thetop of the diaphragm. The parietal pleura joins the visceral pleura at the hilus (anotch in the. medial surface of the lung, where the main-stem bronchi, pulmonaryblood vessels, and nerves enter the lung). The pleural space is a potential space between the two layers of pleura.Normally, no space exists between the pleurae. A thin film (only a few milliliters)of serous fluid acts as a lubricant in the potential space. The fluid also causes themoist pleural membranes to adhere, creating a pulling force that helps to hold the
lungs in an expanded position. The action of pleura is analogous to coupling twosheets of glass by a thin film of water. It is extremely difficult to separate thesheets of glass at right angles to their surfaces, even though they readily slide pasteach other. Because of the nature of this coupling, the movement of the kingsclosely follows the movement of the thorax. If air or increased amounts of serousfluid, blood, or pus accumulates in the space, the lungs are compressed andrespiratory difficulties follow. These conditions are called pneumorhorax (air in thepleural space) or hemothorax (blood in the pleural space).Function: The function of the thorax and diaphragm is to alter pressures in the thoraxto move fresh air in and out. The movement of air depends on pressure differencesbetween the atmosphere and the air in the lungs. Air flows from regions of higherpressure lo regions of lower pressure. On inspiration, the dome of the diaphragm flattens and the rib cage lifts.This action increases the transverse diameter of the thorax, which increases thevolume of the thorax and the lungs. As volume increases, pressure decreases andair moves into the lungs. Airway resistance also affects air movement. Airway resistance it affected.by the viscosity of air length of the airways, and diameter of the airways. Doublingthe length of the airway doubles the resistance. You can experiment with thischange by trying to breathe through a straw and noting the increased effort that isrequired to move air. Decreasing the diameter by half creates a 16-fold increase inresistance. Thus, a decreased diameter of the airways due to bronchial musclecontraction or to secretions in the airways increases resistance and decreases therate of air flow. This is a common finding in obstructive airway diseases such asasthma. During quiet breathing, expiration is usually passive, that is, expiration doesnot require the use of muscles. The chest wall, in contrast to the lungs, has atendency to recoil outward. The opposing forces of lung and chest wall create asub-atmospheric (negative) force of about -5 cm H20 in the intrapleural space atthe end of quiet exhalation. Exhalation is also due to the elastic recoil of the lungs,which is discussed later in the chapter.
Forced expiration and coughing bring the internal intercostal muscles and theabdominal muscles into play. The abdominal muscles force the diaphragm upwardto its dome-shaped position. The intercostals muscles contract, pulling the ribsinward.The Lungs and Alveoli:Structure:Lungs: The lungs lie within the thoracic cavity on either side of the heart. The lungsare cone shaped, with the apex above the first rib and the base resting on thediaphragm. Each lung is divided into superior and inferior lobes by an obliquefissure. The right lung is further divided by a horizontal fissure, which bounds amiddle lobe. The right lung, therefore, has three lobes, whereas the left lobe hasonly two. In addition to these five lobes, which are visible externally, each lungcan be subdivided into about 10 smaller units called bronchopulmonary segments.Each bronchopulmonary segment represents the portion of the lung that is suppliedby a specific tertiary bronchus. These segments are important surgically, because adiseased segment can be resected without having to remove the entire lobe or lung.The two lungs are separated by a space called the mediastinum. The heart, aorta,vena cava, pulmonary vessels, esophagus, part of the trachea and bronchi, and thethymus gland are located in the mediastinum.Alveoli: The lung parenchyma is the working area of the lung tissue. Theparenchyma consisting of millions of alveolar units. It is estimated that 24 millionalveoli are present in humans at birth. By age 8 years, the number of alveoli hasincreased to the adult number of 300 million. The total working alveolar surfacearea is approximately 750 to 860 ft2. The large number of alveoli and the largesurface area are necessary to meet both resting and exercise oxygen requirements.Each alveolar unit is supplied with 9 to 11 pre-pulmonary and pulmonarycapillaries. The blood supply for these capillaries comes from the right ventricle ofthe heart. The major function of the alveolar unit is the exchange of oxygen andcarbon dioxide between pulmonary capillaries and alveoli. Because of the
extensiveness of the capillary system, the flow of blood in the alveolar wall hasbeen described as a “sheet” of flowing blood. The entire alveolar unit (respiratory zone) is made up of respiratorybronchioles, alveolar ducts, and alveolar sacs, This is the region where gasexchange takes place. The respiratory zone consists of the respiratory bronchioles,the alveolar ducts, and alveolar sacs. Alveoli, small air sacs at the end of therespiratory bronchioles, permit exchange of the oxygen and carbon dioxide. Thealveolar walls are extremely thin, and within them is an almost solid network ofinterconnecting capillaries. Oxygen and carbon dioxide are exchanged through a respiratory membranethat is about 0.2 m thick.The average diameter of the pulmonary capillary is onlyabout 5x10-6m, which means that a red blood cell must squeeze through it.Therefore the red blood, cell actually touches the capillary wall, so that oxygen andcarbon dioxide need not pass through significant amounts of plasma as theydiffuse. The thickness of the respiratory membrane occasionally increases (e.g.,with pulmonary edema or fibrosis), Increases in thickness of the membraneinterfere with normal exchange of gases. The alveolus is comprised of two cell types: type I and II pneumocytes.Type I pneumocytes are thin and incapable of reproduction. They line the alveolus.Type II pneumocytes are cuboidal and do not exchange oxygen and carbon dioxidewell. These cells produce surfactant and differentiate into type I cells. These cellsare important in lung injury and repair. When lung tissue has been damaged, typeII cells are produced, which eventually: differentiate into type 1 cells. During thetransition, oxygenation is impaired due to the thickness of the cells.Function: The function of the lungs is to deliver oxygen to the mitochondria toliberate energy stored in molecular bonds of adenosine triphosphate (ATP) andremove carbon dioxide. Cellular processes for life require ATP. Ventilation, gasexchange, the relationship of ventilation and perfusion, and oxygen transport arediscussed in the following text.Gas Exchange:
Oxygen Transport After oxygen diffuses into the pulmonary capillaries, it is transportedthroughout the body by the circulatory system. The oxygen is dissolved in theplasma (3%) or bound with hemoglobin (97%) in ferrous ion. The combination offerrous iron and oxygen forms oxy-hemoglobin, which releases oxygen to tissuesthat have a low partial pressure of oxygen. Tissues take up oxygen at varying rates.The most metabolically active tissues receive it first. Methemoglobin, carbonmonoxide, and other chemicals impair the uptake of oxygen by tissues. The oxy-hemoglobin dissociation curve represents the relationshipbetween Pa02 and the saturation of hemoglobin. This saturation reflects theamount of oxygen available to the tissues. In plotting the normal curve, it isassumed that the client’s temperature’ is 37° C, p1-I is 7.40, and Pa02 is 40 mmHg. This relationship is represen2ed in Figure 38—13 as an S-shaped curve.Changes in the Pao2 at the flattened top portion of the curve result in smallchanges in oxygen saturation. The opposite is true as the slope of the curvesteepens. At the steepest portion the curve, with the Pao2 below 60 mm Hg, smallchanges in the Pao2 result in large drops in ‘oxygen saw- ration. The oxy-hemoglobin curve is affected by a number of factors, includingtemperature, pH, Pco2, enzymes in the red blood cell (2, 3-diphosphoglycerate[2,3,-DPGJ), presence of carbon monoxide, and abnormal hemoglobin. Changes inaffinity of oxygen for hemoglobin cause the oxy-hemoglobin to move from itsnormal contour, or shift. A shift to the left of the oxy-hemoglobin dissociation curve increases theaffinity of the hemoglobin molecule for oxygen. It is easier for oxygen to bind tohemoglobin, but it is not easily released at the tissues. Thus, at any P02 level,oxygen saturation is greater than normal, but tissue hypoxia is present. Clinicalsituations that cause decreased affinity include alkalosis, hypocapnia, hypothermia,decreased 2, 3-DPG, and carbon monoxide poisoning. A shift of the curve to the right indicates an easier release of oxygen at thetissue level. It is more difficult for oxygen to bind in the lungs, but it releaseseasily at the cells. This shift protects the body by allowing oxygen attached tohemoglobin to be released in the tissues in an attempt to maintain adequate tissue
oxygenation. Clinical situations that cause decreased affinity include acidosis,hypercapnia, hyperthermia, hyperthyroidism (which increases 2, 3-DPG), anemiaand chronic hypoxia. Carbon Dioxide Transport Carbon dioxide is the waste product of tissue metabolism. It is carried bythe blood in the three following ways:(1) In plasma:(2) Coupled with hemoglobin;(3) Combined with water as carbonic acid. Most carbon dioxide is carried by redblood cells as carbonic acid. It rapidly breaks down into hydrogen ions andbicarbonate ions. As venous blood enters the lungs for gas exchange, thesechemicals form carbon dioxide, which is exhaled from the lungs.Regulation of Acid-Base Balance: The lungs, through gas exchange, have a key role in regulating the acid-basebalance of the body. Pulmonary disorders that change the carbon dioxide level inthe blood cause either respiratory acidemia or respiratory alkalemia. Hypercapnia(retention of excessive amounts of carbon dioxide) causes respiratory acidemia,and hypocapnia (low amounts of carbon dioxide in the blood) results in respiratoryalkalemia. The effectiveness of ventilation is best measured by the partial pressure ofcarbon dioxide in the arterial blood (Paco2). Because the respiratory system isnormally set to maintain a PaC02 between 35 and 45 mm Hg at sea level, a PaC02above this range represents hypoventilation. Anesthetic agents, sedatives, andnarcotics all tend to increase the resting Paco2.
Chronic Obstructive Pulmonary DiseaseDEFINITION:Chronic obstructive pulmonary disease (COPD), also called chronic obstructivelung disease (COLD), refers to several disorders that affect movement of air inand out of the lungs. The most important of these disorders are obstructive bronchitis,emphysema, and asthma. Although bronchitis, emphysema, and asthma mayoccur in a “pure form,” they most commonly coexist, and clinicalmanifestations overlap the term COPD is commonly used COPD may occur as a result of increased airway resistance secondaryto bronchial mucosal edema or smooth muscle contraction. It may also be aresult of decreased elastic recoil, as seen in emphysema. Elastic recoil, like therecoil of a stretched rubber band, is the force used to passively deflate the lung.Decreased elastic recoil results in a decreased driving force to empty the lung. COPD is a widespread disorder, affecting I in every 10 Americans,Most COPD clients are men over the age of 45. With the increase in smokingamong females, however, the incidence of COPD among women is steadilyrising.
Etiology and Risk Factors: The specific causes of COPD are not clearly understood. However, the effects of numerous irritants found in cigarette smoke (i.e., stimulation of excess mucus production and coughing. destruction of ciliary function and inflammation and damage of bronchiolar and alveolar walls) make smoking the leading risk factor for the development of the disorder. Chronic respiratory infections, including sinusitis, contribute to the development of COPD, as does the aging process. In addition, heredity and genietic predisposition appear to have a role.Pathophysiology: COPD is a combination of chronic obstructive bronchitis, emophysema, and asthma. The pathophysiology of bronchitis and emphysema is : • Chronic Obstructive Bronchitis Chronic obstructive bronchitis is inflammation of the bronchi. This causes increased mucus production and chronic cough. In contrast to acute bronchitis, the clinical manifestations of chronic bronchitis continue for at least 3 months of the year for 2 consecutive years. Additionally, if the client has a decreased FEV, /FVC ratio of less than 75% and chronic bronchitis, then the client is said to have chronic obstructive bronchitis. This term implies that the client has obstructive lung disease combined with chronic cough. Clients with chronic bronchitis have (1) an increase in the size and number of sub mucous glands in the large bronchi, which increases mucus production (2) An increased number of goblet cells, which also Secrete mucus; (3) Impaired ciliary function, which reduces mucus clearance. Therefore, the lung’s mucociliary defenses are impaired, and there is increased susceptibility to infection. When infection occurs, mucus production
is even greater, and the bronchial walls become inflamed and thickened.Chronic bronchitis initially affects only the larger bronchi, but eventually allairways are involved. The thick mucus and inflamed bronchi obstruct airways, especiallyduring expiration. The airways collapse and air is trapped in the distal portionof the lung. This obstruction leads to reduced alveolar ventilation. An abnormalV/Q (ventilation-perfusion) ratio develops, with a corresponding fall in Pa02,Impaired ventilation may also result in increased levels of Paco2. As compensation for the hypoxemia, polycythemia overproduction oferythrocytes) occurs.EmphysemaEmphysema is a disorder in which the alveolar walls are destroyed. This leadsto permanent over distention. Air passages are obstructed as a result of thesechanges, rather than from mucus production, as in chronic bronchitis. Althoughthe precise cause of emphysema is unknown. Research has shown that theenzymes protease elastase can attack and destroy the connective tissue of thelungs . Emphysema may_resuIt from a breakdown in the lung’s normal defensemechanisms(alpha antitrypsin or AAT), against these enzymes. Difficultexpiration emphysema is the result of destruction of the walls (septa) betweenthe alveoli, partial airway collapse, and loss of elastic recoil. As the alveoli andsepta collapse, pockets of air form between the alveolar spaces (blebs) andwithin the lung parenchyma (bullae). This process leads to increasedventilatory dead space, areas that do not participate in gas or blood exchange.The work of breathing is increased because there is less functional lung tissue toexchange oxygen and carbon dioxide. Emphysema also causes destruction ofthe pulmonary capillaries, further decreasing oxygen perfusion arid ventilation.There are three types of emphysema).Centrilobular emphysema, the mostcommon type, produces destruction in the bronchioles, usually in the upper lungregion. Inflammation develops in the bronchioles, but usually the alveolar sacremains intact. Panlobular emphysema affects both the bronchioles and alveoliand most comnonly involves the lower lung. These form of emphysema occurmost often in smokers. Paraseptal (or panacinar) emphysema destroys the
alveoli in the lower lobes of the lungs resulting in isolated blebs along the lungperiphery. Paraseptal emphysema is believed to be the likely cause spontaneouspneumothorax, Paraseptal emphysema occurs in the elderly and in clients withan inherited deficiency of AAT. CLINICAL MANIFESTATIONBOOK PICTURE PATIENTPICTURE• Cough Cough• Dyspnea Dyspnea• Sputum production Sputum production• Weight loss Weight loss• Barrel chest (emphysema) _____________• Hemoptysis _____________• Exertional dyspnea ______________• Clubbing of fingers ______________• Malaise______________• Wheezes Wheezes• Crackles______________• Anemia______________
Triglyceride : < 150 normal < 160Total Lymphocyte count : 1500 - 1800 cells/mm3 1600 cells/mm3Albumin : 3.5 – 5.0 gm/dl 4 gm/dlGlucose : 85 – 125 mg/dl 80 mg/dlCreatinine : 0.6 – 1.2 mg % 0.9mg% TIME PLAN DATE TIME WORK PLAN 7.30 am to Selected the patient for my care 9.30 am Established a good rapport between the16-05-2011 patient and her relatives.. 10.30 a.m to Bed making done
7.00 p.m Vital signs checked Collected baseline Informations 7.30 am to Bed making done 9.30 am Vital signs checked Blood samples taken for routine investigations Collected and sent to laboratory17-05-2011 Physical examination done 4.00 pm to Her doubt regarding the disease, clarified. 7.00 pm Medicines given (Tab Ciprofloxcin 5oo mg bd Tab Derriphylline 1 tds) 7.00 am to Bed making done 10.00 am Vital signs checked Morning dose medicine given18-05-2011 Accompanied him to X-ray department 5.00 pm to Health education given regarding 7.00 pm nutritious diet. Bed making done 7.00 am to Vital parameters checked 9.00 am Accompanied the client’s relatives to collect19-05-2011 the result of the investigations 4.00 pm to 7.00 pm Clarified the client’s doubts regarding the results 7.00 am to20-05-2011 9.00 am Bed making done 11.00 am to12.00 Vital parameters checked noon Medicine given Administered nebulization to the patient 7.00 am to10.30 am Advised regarding personal hygiene Bed making done21-05-2011 4 pm to 7 pm Vital parameters checked Collected all the investigations reports Nebulization given. Administered medication.
DATE TIME WORK PLAN 11.00 am to Bed making done 1.00 pm Nebulization given23-05-2011 Medicine given Physical assessment done 4.00 pm to Educated about deep breathing and coughing 7.00 pm exercize Vital parameters checked 7.00 am to10 am Bed making done Provided contusive environment Vital parameters checked24-05-2011 11 00 pm to Nebulization given 1.00 pm Medicine given Drug chart maintained 7.30 am to Bed making done 9.30 am Vital parameters checked Personal hygeine care given Physical assessment done Tab ciprofloxacin 500mg is given.25-05-2011 4.00 pm to Nebulization given 7.00 pm Educated about the importance of drug and nutricious diet. 7.30 am to Bed making done - 9.00am Vital parameters checked Tab ciprofloxacin 500 mg given orally Advised to do breathing exercize26-05-2011 4.00 pm to Nebulization given 7.00 pm Bed making done 10.00 am to Provided a comfortable bed 11.00 am Encouraged the patient to do deep breathing and coughing exercize
27-05-2011 4.00 pm to Vital parameters checked 7.00 pm Physical assessment done DATE TIME WORK PLAN 8.00 am to Bed making done 10.00 am Morning dose of medicine given28-05-2011 Vital parameters checked 1.00 pm to Nebulization given 2.30 pm Physical assessment done 5.00 pm to Evening dose of medicine given 8.00 pm Vital parameters checked Health education given regarding dietary30-05-2011 Habit 7:30 am to 9.00 am Bedmaking done Vital parameters checked31-05-2011 4.00 pm to Nebulization given 7.00 pm Health education given regarding follow up care. 7.30 am to 9.30 am Prepared the client for discharge Explained them about the discharge summary 2.00 pm to Health education given regarding exercise,24-08-2010 4.00 pm activities and rest Accompanied him up to bus stop and sent him to home
Medical management: • Oxygen therapy: 2 to 3 L/minute • Intubation and mechanical ventilation if necessary • Monitoring: vital signs, I/O, pulse oximetry, and respiratory status • Position: high Fowler’s • Treatments: chest physiotherapy, postural drainage, intermittent positive pressure breathing, high-flow nebulizer treatments, and incentive spirometry • Diet: high-calorie diet • Dietary recommendations: fluids o 3 qt (L)/day if not contraindicated • I.V. therapy: saline lock • Activity: as tolerated • Laboratory studies: ABG values, WBCs, and sputum studies • Bronchodilator: Terbutaline (Brethine), aminophylline (Truphylline), isoproterenol (Isuprel), theophylline (Theo-Dur); via nebulizer: albuterol (Proventil), ipratropium (Atrovent), metaproterenol (Alupent) • Corticosteroids: hydrocortisone (Solu-CorteO, methylprednisolone (SoluMedrol) • Expectorant: guaifenesin (Robitussin)
• Antibiotics: ampicillin (Omnipen), tetracycline (Achromycin), cefixime(Suprax)• Antacid: aluminum hydroxide gel (AlternaGEL)• Beta-adrenergic medication: epinephrine (Adrenalin)• Mast cell stabilizer: cromolyn (Intal)Nursing interventions:a Assess respiratoty status• Administer low-flow oxygen• Monitor and record vital signs, I/O, pulse oximetry and laboratory studies• Provide chest physiotherapy, intermittent positive pressure breathing, turning,postural drainage, and suction; encourage coughing, deep breathing, and use ofincentive spirometry• Keep the patient in high Fowler’s position• Administer medications as prescribed• Reinforce pursed-lip breathing to prolong exhalation and to increase airwaypressure• Maintain the patient’s diet• Administer small, frequent feedings• Encourage fluids• Encourage the patient to express his feelings about difficulty breathing• Allow activity as tolerated -• Monitor and record the color, amount, and consistency of sputum• Provide emotional support to allay the patient’s anxiety• Weigh the patient daily
• Provide information about the American Lung Association• Individualize horn” care instructions— know about the disorder and its implicationsFollow instructions for medication use and be aware of possible adverse effectsStop smoking and avoid second-hand smokeControl weight and folic w dietary recommendationsIdentify ways to reduce stressRecognize the signs and symptoms of respiratory infection and respiratorydistressAdhere to activity limitationsKnow proper use of home oxygenDemonstrate pursed-lip and diaphragmatic breathingAvoid exposure to chemical irritants and pollutantsDemonstrate deep-breathing and coughing exercisesComplications: Carbon dioxide narcosis Acute respiratory failure Pneumonia From emphysema Pulmonary hypertension Right-sided heart failure Spontaneous pneumothoraxPossible surgical intervention: None
EVIDENCE BASED PRACTICE FOR NURSING: Women with COPD need social support and specific guideline for management of dyspnea and fatigue to cope well with the disease. (0’ Neil ,(2002), illness representation and coping of women with chronic obstructive pulmonary disease . A Pilot study. Heart and Lung, 31 (4), 295-302. The purpose of this qualitative study was to determine how women with chronic obstructive pulmonary disease (COPD) recognize and respond to symptoms. A total of 21 participants reviewed and kept symptom diaries. The most difficult physical problems for the subjects were fatigue and dyspnea. Other important findings included the high level of depression and stigma felt by the subjects. They also perceived a loss of social support and intimacy.Level of Evidence : 6—Uncontrolled descriptive qualitative study. Critique. The study designed followed acceptable procedures for qualitative research. Data were collected until redundancy was apparent. Information was obtained by audio taping direct interviews using an open guide with questions and probes to allow for flexibility of response. The interviewer also took notes. A professional transcriptionist transcribe tapes. Feedback from participants was used to verify the data. An independent researcher analyzed selective portions of transcripts for reliability. A drawback of the study was that all participants were also participating in a pulmonary rehabilitation program. Thus the sample may have different motivations and perceptions compared to women with COPD who do not choose or are unable to participate in a pulmonary rehabilitation program. Implications for Nursing. Nurses must provide more practical information on ways to manage dyspnea and fatigue. These physical problems have a large impact on the client’s (quality of life and degree of continued socialization. Nurses must individualize energy conservation plans to meet each client’s
needs rather than just provide a general listing of energy conservationmeasures. Iam applying this theory to my nursing process: Abdellab’s Typology of 21 ProblemsEvolution of Theory: Abdellah realized that for nursing to gain full professional status andautonomy, a strong knowledge base was imperative. Nursing also needed tomove away from the control on medicine and toward a philosophy ofcomprehensive patient-centered care. Abdellah and her colleaguesconceptualized 21 nursing problems to teach and evaluate students. Thetypology of 21 nursing problems first appeared in the 1960 edition of Patient-centered Approach to Nursing and had a far-reaching impact on the professionand on the development of nursing theories The patient or family presents with nursing problems that the nurse helpsthem address through her professional function. The nurse addresses 21problem categories: (I) Hygiene and physical comfort,(ii) Activity and rest,(iii) Safety,(iv) Body mechanics,(v) Oxygenation.(vi) Nutrition,(vii) Elimination,(viii) Electrolytes,(ix) Responses to disease,(x) Regulatory mechanisms,(XI) Sensory function,
(xii) Feelings and reactions,(xiii) Emotions and illness interrelationships,(xiv) Communication,(xv) Interpersonal relationships,(xvi) Spirituality,(xvii) Therapeutic environment,(xviii) Awareness of self,(xix) Limitation acceptance, (xx) Resources to resolve problems, (xxi) Role of social problems in illness. Nursing problems are both overt or obvious and covert. Nurses must be aware covert problems to meet care requirements. Overt and covert problems must be identified to make a nursing diagnosis. Identification of problems precedes solution. The nursing process is the method nurses-use to establish and focus on a nursing diagnosis. The overall goal is a client’s fullest possible functioning. Individualized patient care is important for nursing. Both patients and nurses should be aware of the wholeness of clients and the need for continuity of care from before hospitalization to afterward. Individualized care will require changes in the organization and administration of nursing services and education. Abdellah was influenced by the desire promote client centered comprehensive nursing care and described nursing “service to individuals and families and therefore, to Society.” Nursing is based an art and science that mould the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people, sick or well, cope with their health needs. Nursing may be carried out under general or specific medical direction.
Abdellah’s theory was derived from following premises of comprehensive nursing care. As a comprehensive service, nursing includes the following: • Recognizing the nursing problem of patient (client). • Deciding the appropriate courses of action to talk in terms of relevant nursing principles. • Providing continuous care to relieve pain and discomfort and provide immediate security for the in difficult. • Adjusting the total nursing care plan meet the patients (clients) individual needs. • Helping the individual to become more- self-directing in attaining or maintaining a healthy state of mind and body. • Instructing nursing personnel and family to help the individual do for himself that which he can within his limitations. • Helping the individual to his limitations and emotional problems. • Working with allied health professional in planning for optimum health on local, state, national and international level. • Carrying out continuous evaluation and research to improve nursing techniques and to develop new techniques to meet the health needs of people. These original premises have undergone evolutionary process. For example,“providing continuous cares of the individual’s total needs, was eliminated withoutany reason, but may be than it is impossible to provide continuous and total care. CONCEPTS USED BY ABDELLAH: Nursing:
Abdellah defined nursing as “Service to individuals. It is based upon an art and science which mould the attitudes, intellectual competences, and technical skills of the individual nurse into the desire and ability help people sick or well cope with their health needs and may be carried out under general or specific medical direction. Abdellah was clearly promoting the image the nurse who was not only kind and caring, but also intelligent, competent and technically well prepared to provide service the patient. Health: Abdellah never defined health per se, her concept of health may be defined as the dynamic pattern of functioning, whereby there is a continued interaction with internal and external forcer, that result in the optimal use of necessary resources that serve to minimize vulnerabilities. Emphasis should be placed upon prevention and rehabilitation with wellness as a lifetime goal. By performing nursing services through a holistic approach to the client, the nurse helps the client achieve a state of health. However, effectively performs these service the nurse must accurately identify the lacks or deficits are the client’s health needs.Nursing Problem: The client’s health needs can be viewed as problems. The nursing problem presented by the patients is condition faced by the patient or family which the nurse can assist him or them to meet through the performance of her professional functions. The problem can be either an overt or covert nursing problem. An overt nursing problem is an apparent conditions faced by the patient or family which the nurse can assist him or them to meet through the performance of her professional functions. The covert nursing problem is a concealed or hidden condition faced by the patient or family which the nurse can assist him or them to meet through the performance of her professional functions. Covert problems can be emotional, sociological and interpersonal in nature. They are often missed or perceived incorrectly. Yet many instances solving covert problems may solve the overt problem as well. Use of the term ‘nursing problem’ is more consistent with “nursing functions” or “nursing
goals” than with client- control problems. Although Abdellah spoke of thepatient-centered approaches she wrote nurses identifying and solving specificproblems. This identification and classification of problems was called the“typology of 21 nursing problems as listed below:1. To maintain good hygiene and physical comfort.2. To promote optimal activity, exercise, rest, sleep.3. To promote safety through prevention of accident, injury or other trauma andthrough the prevention of the spread of infection.4. To maintain good body mechanics and prevent and correct deformities.5. To facilitate the maintenance of a supply of oxygen to all body cells.6. To facilitate the maintenance of nutrition to all body cells.7. To facilitate the maintenance of elimination.8. To facilitate the maintenance of fluid and electrolytes balance.9. To recognize the physiological responses of the body to disease conditions—pathological, physiological and compensatory.10. To facilitate the maintenance of regulatory mechanisms and functions.11. To facilitate the maintenance of sensory function.12. To identify and accept positive and negative expressions, feelings andsanctions.13. To identify and accept interrelatedness of emotions and organic illness.14. To facilitate the maintenance of effective verbal and non-verbalcommunication.15. To promote the development of productive interpersonal relationship.16. To facilitate progress towards achievement of personal spiritual goals.17. To create and/or maintain a therapeutic environment.
18. To facilitate awareness of self as an individual with varying physical, emotional and developmental needs. 19. To accept the optimum possible goals in the light of limitations, physical, emotional. 20. To use community resources as an aid in resolving problems arising from illness. 21. To understand the role of social problems as influencing factors in the cause of illness. Abdellah, typology was divided into three areas: 1. The physical, sociological and emotional needs of the patients (clients). 2. The types of interpersonal relationships between of the nurse and the patients (clients). 3. The common elements of patient (client)Care: In the process of identifying overt and covert nursing problems and interpreting, analyzing and selecting appropriate course action to solve these problems. “Quality professional nursing care requires that nurses be able to identify and solve overt and covert nursing problems. These requirements can be met by the problem-solving pertinent data, formulating hypotheses, testing hypotheses, through the collections of data, and revising hypothesis when necessary on the basis conclusion obtained from the data. Many of these steps parallel to the steps of the nursing process. The problem- solving approach was selected because of the assumption that the correct identificationnursing problems influences the nurse’s judgment in selecting the next steps in solving the client’s nursing problems. The problem- solving approaches is also consistent with such basic elements of nursing practice espoused by Abdellah as observing, reporting and interpreting the signs and
symptoms that comprise the deviations from health and constitute nursing problems and with analyzing the nursing problems and selecting the necessary course of action. An examination of the 21 problems yields similarity to other viz., Virginia Henderson (1991), Abraham Marsow theory of hierarchy of needs (1954).PARADIGM OF ABDELLAH’S TYPOLOGY: Abdellah does not clearly specify each of the four major concepts: human being, health, environment/society and nursing. Human Being She does describe the recipient of nursing as individuals (and families) although she does not delineate her beliefs or assumption about the nature of human beings. She describes people as having physical, emotional and sociological needs. These needs may be overt, consisting largely physical needs, or covert, such as emotional and social needs. The typology and nursing problem is said to evolve from the recognition of a need for patient-centred approach to nursing. The patient is described as the only justification for the existence of nursing. People are helped by the identification and alleviation of problems they are experiencing. Health As Abdellah discusses in “patient-centred” approaches to nursing in a state mutually exclusive of illness. Health is defined implicitly as a state when the individual has no unmet needs and no anticipated or actual impairments. Achieving of health is the purpose of Nursing Services. Although Abdellah does not give a definition of health, she speaks of ‘total health needs” and ‘a healthy state of mind and body’ in her description of nursing as a comprehensive nursing service. Environment The environment is the least-discussed concept in her model. Nursing problem number 17 from the typology is ‘ito create and/or maintain a therapeutic environment and she also states that if the nurses reaction to the patient is
hostile or negative, the atmosphere in the room may be hostile, or negative.This suggests that patient interest and respond to their environment. Society isincluded in the premises of comprehensive nursing care, i.e. planning foroptimum health on local, state, national and international.Nursing Nursing is a helping profession. Nursing care is doing something to or forthe person or providing information to the person with goal meeting needs,increasing or restoring self- help-ability, or alleviating an impairment. Nursing is broadly grouped into the 21 problems areas to guide care andpromote the use of nursing judgment. Abdellah considers nursing to be acomprehensive service that is based on an art and science and aims to helppeople sick or well, cope with these health needs.NURSING PROCESS AND ABDELLAH Abdellah’s typology of 21 nursing problems helps nurses practice in anorganized systematic way. The use of this scientific base enables the nurse tounderstand the reason for her actions. Their use in the nursing process isprimarily to direct the nurse indirectly to the client’s benefits.In assessment phase, each of the identified 21 nursing problems relevant dataare collected. The overt or covert nature of the problems necessitates a direct orindirect approach, respectively For Example the overt problem of nutritionalstatus can be assessed by direct measures of weight, food intake andbody size, whereas the covert problem of maintaining a therapeuticenvironment requires more indirect approach to data collected. The nursingproblems can be divided into those that are basic to all clients and those thatreflect sustainable, remedial or restorative care needs.Nursing diagnosis: is the result of data collection would determine the client’sspecific overt and/or covert problems. These specific problems would begrouped under one or more of the broader nursing problems.In planning phase of nursing process, her statements of nursing problems mostclosely resemble goal statements. Therefore, once the problem has been
diagnosed, the goals have been established. Many of the nursing problems statements can be considered goals for either the nurse or the client. In implementation, nurse using the goals as the framework, a plan is developed and appropriate nursing intervention are determined. Again holism tends to be negated in implementation because of the isolated particular nature of the nursing problems. Evaluation: The plan is evaluated in terms of client’s progress or lack of progress toward the achievement of the goals. Abdellah’s Work and Characteristics of Theory Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomena. 1. Abdellah, theory has interrelated concepts of health, nursing problems and problem solving as she attempts to create a different way of viewing nursing phenomena. The results the statement that nursing is the use of the problem- solving approach with key nursing problems related to the health needs of the people. 2. Theoretical statement places heavy emphasis on problem-solving an activity that is inherently logical in nature.3. Theory is appearing to be limited to use which seems to focus quite heavily onnursing practice with individuals. Theory does not provide the framework onhuman and society in general. This somewhat limits the ability to generalize,although the problem solving approach readily generalizable to clients withspecific health needs and specific nursing problem.4. One of the most important questions that arises when considering her work is therole of the client within the framework, a question that could generate hypothesesfor testing. The results of testing such hypothesis would contribute to the generalbody of nursing knowledge.5. Abdella’s problem-solving approach can easily be used by practitioners to guidevarious activities within their nursing practice. This is especially true when
considering nursing practice that deals with clients who have specific needs andspecific problem.6. Abdellah theory consistent with other validated theories, such as those ofMaslows and Henderson. Although the consistency exists, many questions remainunanswered.Evaluation of Theory The typology is very simple and is descriptive of nursing problems thoughtto be common among patients. The concepts of nursing, nursing problems, and theproblem-solving process, which are central to this work, are defined explicitly. Theconcepts of person, health, and environment, which are associated with the nursingparadigm today, are implied. There are no stated relationships between Abdellah’smajor concepts or those of the nursing paradigm in her writing. This model has alimited number of concepts, and its only structure is a list. A somewhat mixed approach to concept definition is present in this work.Nursing and nursing problems are connotatively defined, while the problem-solving process is defined denotatively. These approaches to definitions do notseem to detract from the clarity of definitions. The typology does not yet constitutea theory because it lacks sufficient relationship statements. The 21 nursingproblems are general and linked to neither time nor environment. “Sheacknowledges that her list is neither exhaustive nor listed according to priorities.”Assuming that persons experience similar needs, the nursing goals stated in the listof 21 problems could be used by nurses in any time frame to meet patients’ needs.However, according to this model, some persons do not need nursing. Other service professions could use the typology of 21 nursing problems tofocus on the psychosocial and emotional needs presented by patients. The goals ofthis model vary in generality. The broadest goal is to positively affect nursingeducation, while sub goals are to provide a scientific basis on which to practice andto provide a method of qualitative evaluation of educational experiences forstudents. The goals are appropriate for nursing. • The concepts are very specific with empirical references that are easily identifiable. The concepts are within the domain of nursing. Ready linkage of
the concepts and the typology to reality is secondary to an inductive approach to theory development. Validation of the typology was done by the faculty of 40 collegiate schools of nursing. The typology provided a general framework in which to act, but continued neither specific nursing actions nor patient-centered outcomes, despite the title of the book. However, two subsequent publications did address outcome measures (effect variables) and suggested models for organizing curricula to emphasize patient-centered outcomes. Except for stating the importance of nursing the whole patient, today’s idea of holism is not apparent in this work. The skills list includes skills thought necessary for nurses to meet patients’ needs but is not prescriptive. Abdellah suggests nursing research as a method for validating treatments toward resolution of patients’ needs. The emphasis on problem-solving is not limited by time or space and therefore provides a means for continued growth and change in the provision of nursing care. The problem-solving process and the typology of nursing problems can be respectively considered precursors of the nursing care process and classification of nursing diagnoses in evidence today. In Patient-centrered Approaches to Nursing Care, Abdellah addressed nursing education problems linked to the use of the medical model. Her typology provided a new way to qualitatively evaluate experiences and emphasized a practice based on sound rationales rather than note. “She proposes that nurses could take a leadership role in making the public aware that quality nursing health care is available. Quality is defined as the care that the patient needs. Need is determined by a classification system that identifies the medical treatment and nursing care essential for that individual.” Abdellah has made significant contributions to patient care, education, and research nursing and health care in this country and throughout the world. NURSING DIAGNOSIS Ineffective breathing pattern related to hypertrophy of cardiac muscle as evidenced by use of accessory muscles
Ineffective airway clearance related to secretions in the bronchi as evidenced by auscultation Hyperthermia related to inflammatory process as evidenced by temperature assessment Intolerance level II as evidenced by increased heart rate after walking Imbalanced nutritional status less than body requirement related to less intake of food as evidenced by Hb level Disturbed sleep pattern related to breathlessness as evidenced by increasing irritability Fatigue related to increase physical exertion as evidenced by breathlessness Anxiety mild, related to unconscious conflict about values of life as evidenced by sympathetic stimulation like facial tension Deficient knowledge therapeutic regimen related to inaccurate follow up as evidenced by non compliance of medications Ineffective role performance related to changes in physical health as evidenced by change in usual patterns of responsibility Subject Data : Patient Complaints, “ I am having difficulty in breathing” Objective Data : patient looks dull, anxious, worried, and having increased respiratory rate. Nursing Diagnosis : Ineffective breathing pattern related to hypertrophy of cardiac muscle as evidenced by use of accessory muscles Expected outcome : Patient will establish effective respiratory pattern Planning Implementation Rationale Evaluation
Assess clients Client rates 2 in the To identifyrespiratory rate modified Borg baseline datausing dysnoea category scalescale Monitored oxygen To diagnoseMonitor cardiac saturation level is 8o degree offunction studies % respiratory compromiseAdminister 4liters of O2Oxygen as administered as To improveprescribed by prescribed saturation level Through all thesedoctor measures patient’s Administered as breathing pattern isAdminister prescribed To Reduce improved as evidencedmedication as Bronco dilator drugs breathing by oxygen saturationprescribed by difficulty level is 90%doctor Client is encouraged to identify the To reduce theEncourage self situation and avoid workload ofassessment & stress producing heart & thussymptom situation preventsmanagement complication Reassessed the breathing level is To know theReassess normal , oxygen condition of thebreathing pattern saturation level patient increased to 90%Subject Data : Patient Complaints, “ I am having difficult in expectoration ofsputum”
Objective Data : patient is having difficult to expel the sputum, dull , sweating.Nursing Diagnosis : Ineffective airway clearance related to secretions in the bronchi asevidenced by auscultation.Expected outcome : client will expectorate secretions & maintain patent airway Planning Implementation Rationale EvaluationAssess ability to protect own Client is able to protect To know baseline Throughairway airway but coughing data. these entire effort is ineffective and measuresEvaluate amount & type of unable to expel sputum. clientsecretions being produced To assess the maintained Secretions is excessive difficulty in clearProvide proper position & sticky maintaining airway as airway evidenced Semi fowler’s position byGive expectorant as prescribed provided using back Upright position diminished rest. facilities crackles on respiratory auscultatioAuscultate breath sounds after Administered function by use of n.administering expectorant expectorant corex syrup gravity 5ml oral as prescribedTeach about breathing Expectorantsexercise, pursed lip breathing On auscultation, stimulateexercise. crackles reduced bronchial secretionsReassess breathing pattern Taught deep breathing To assess the & coughing exercise, effectiveness of pursed lip breathing expectorants To reduce risk of Crackle reduced on pneumonia auscultation To identify
improvementSubject Data : Patient Complaints, “ I am having fever and headache, unable to takefood.Objective Data : patient is having temperature 100’ F, lethargy, anxiety, dull.Nursing Diagnosis : Hyperthermia related to inflammatory process as evidenced byelevated temperature.Expected outcome : Client will maintain core temperature within normal range Planning Implementation Rationale EvaluationMonitor temperature by oral Oral temperature is To know baseline Through allroute 100ºF data these measures patientMonitor blood pressure & temperature isand ECG, and oxygen Monitored ECG & Pre existing reduced tosaturation level oxygen saturation cardiovascular 98.4ºF. level ,ECG shows symptoms canAdminister antipyretic as sinus tachycardia & cause changes inordered oxygen saturation hemodynamic level is 80% status.Administer supplemental Administered Inj . Antipyretic act onOxygen as prescribed paracetamol 1 amp as the hypothalamus prescribed by doctor. to reduce fever.Administer fluids asprescribed by physician Administered 4ltrs of To reduce cardiac Oxygen by mask as work load
Provide dry cloth to the prescribed by doctorpatient To replace fluids Administered 1000ml lost throughReassess the temperature of oral fluids per day perspiration Provided clean and To reduce dry cloth to the patient shivering & thus reduce cardiac Reassessed the workload temperature is 98.4’F To evaluate the effectiveness of careSubject Data : Patient Complaints, “ I am having difficulty in breathing whilewaking.Objective Data : patient is having dyspnea, sweating, anxiety.Nursing Diagnosis : Activity intolerance level II as evidenced by increased heart rateafter walkingExpected outcome : Client will breathe normally. Planning Implementation Rationale Evaluation
Assess Assessed heart rate To know the Cardiopulmonary after activities like base line data response to physical walking . activity Provided rest in To reduce Provide rest in between between activities fatigue activities Assisted with To maintain Through all these Assist with activities activities like bathing, mobility measures patient feeding & walking breathing level is improved. Administer oxygen as Administered oxygen To maintain per physician advice 4/l as per physician oxygen advice saturation level. Reassess activity level Client heart rate is 78/ min after walking To identify improvement.Subject Data : Patient Complaints, “I am unable to take adequate food.Objective Data : Client looks dull, lethargy, anxiety.Nursing Diagnosis : Imbalanced nutritional status less than body requirement related toless intake of food as evidenced by unable to
Do daily living activities.Expected outcome : Client nutritional level will be improved. Planning Implementation Rationale EvaluationObtain diet history Patient takes less food due To know to breathing difficulty baseline dataAdvise to take small & Advised to take smallfrequent diet quantity of food every 2 Heavy meal hourly aggravates breathing Through allPlan diet menu to the patient Provided planned diet difficulty these menu to the patient. Measures theTeach food sources rich in To monitor patientprotein, iron, carbohydrate. Taught about protein iron nutritional nutritional carbohydrate rich foods status level is like ragi, drumstick leaves, improved. dates, dhal, pulses, bread.Reassess the knowledge about To improvediet. Client list out certain food the like drumstick, ragi.pulses, nutritional dhal , bread. level To know the progress.
Subject Data : Patient Complaints, “Iam unable to sleep during night due to breathingdifficulty..Objective Data : patient looks dull, lethargy, worried, anxiety. Pulse rate is increased.Nursing Diagnosis : Disturbed sleep pattern related to breathlessness as evidenced byincreasing irritabilityExpected outcome :patient sleeping pattern will be improved. Planning Implementation Rationale EvaluationAssess sleep pattern Patient awoke 7 To know baseline data Through all thesedisturbance associated with times at night due Measures patientbreathlessness to breathlessness is able to sleep at Patient looks To assess the level of least for 5 hrs inObserve for physical signs restless & fatigue night as evidencedof sleeplessness & fatigue irritable by reduced awoke during night.Administer medication for Inj. Deriphylline l To induce sleepbreathlessness as amp IV given as adequatelyprescribed by doctor. prescribed by doctor.Advise to avoid activitiesthat causes breathlessness Advised to avoid Heavy meal & caffeineat night provide sedation heavy meal, impair breathing caffeine content patternReassess sleep pattern at night To induce sleep Provided Tab. Diazepam 1 Hs as To identify progress. per doctor advice Patient sleeps for
5 hours without Interruption.Subject Data : Patient Complaints, “I am unable to do my routine activity.Objective Data : patient looks dull, irritable, lethargy.Nursing Diagnosis : Fatigue related to increase physical exertion as evidenced bybreathlessnessExpected outcome : patient activity level will be improved. Evaluati Planning Implementation Rationale on
Assess the activity level Patient is having To know breathlessness baselineAssess severity of fatigue respiratory rate is 30 datausing 0-10 scale breaths / min Patient rates 5 in the To identifyMeasure physiological fatigue rating scale the intensityresponse to activity especially of fatiguerespiratory rate. Patients respiratory rate It indicate is 30 breaths / min need forProvide fowler’s position intervention Through all these measures Semi fowler’s position patientProvide adequate rest is provided using back To improve relieved from rest. the lung breathlessnessProvide small frequent diet expansion as evidenced Provided adequate rest by respiratory rate is 22/minReassess the activity level Provided small frequent To reduce diet like fluid, Idly, cardiac dhal. work lode Patient rates 4 in To provide fatigue rating scale & energy, and respiratory rate is 22 reduce breaths / min while breathlessne doing self care activities ss. To know the base line data
Subject Data : Patient Complaints, “ I am worried about my body condition.Objective Data : patient is worried, pulse rate is increased, dull lethargy.Nursing Diagnosis : Anxiety moderate, related to bronchial congestion as evidenced byworried , and irritable and tensed facial expression.Expected outcome : patient anxiety level will be reduced. Planning Implementation Rationale EvaluationAssess the level of anxiety Patient had To know Through all moderate anxiety baseline data these measuresDevelop interpersonal level patient is freerelationship To improve from anxiety. Improved confidence. . interpersonal relationship, showsObserve and listen patient empathy to thecomplaints patient To know the patient inner thoughtProvide assistance to self care Observed andactivity listened patient complaints of To reduce having anxiety activity level about his future life.Explain about the diseasecondition in simple way Provide assistance to daily living To reduce activities by family anxiety members.Reassess anxiety level. Explained about the
disease condition, To know the allergy and stress anxiety level provoking situation in simple way. Patient controlled his anxiety levelSubject Data : Patient asks, “ May I know about the disease condition and itstreatment. and home care .Objective Data : patient looks worried, and asking many question.Nursing Diagnosis : Deficient knowledge therapeutic regimen related to inaccurate followup`as evidenced by non compliance of medicationsExpected outcome : patient will able to know the disease condition, treatment, and home careactivities within a week. Evalua Planning Implementation Rationale tion
Assess the level of Assessed the knowledge the To knowknowledge including patient is not knowing the baselineeducational status. disease, and he studied up to data. 10th stdExplain about the disease Explained about the diseasecondition and home care ,in a condition and treatment, and Patientsimple way. home care activities in a knowledge simple way by using level is A.V.Aids improved.Allow the patient to express Through alltheir doubt Allowed the patient to To-relieve these express their doubt, he is anxiety measures the asking many questions. patient knowledgeAnswer all the question, that level isthe patient asked Answered all the questions in To improve improved. simple way with explanation the patient knowledgeProvide written materialsregarding diet & medication. Provided discharge plan To help for containing in formations taking proper regarding diet & medication. diet andReassess knowledge about Patient verbalize about diet medicationhome care and ,drug regimen to be followed at home To know about progress.
Subject Data : Patient Complaints, “ I am unable to continue my job”Objective Data : patient is having confusion, worried.Nursing Diagnosis : Ineffective role performance related to changes in physical health asevidenced by change in usual patterns of responsibilityExpected outcome :Patient will able to continue his role and responsibility Evaluatio Planning Implementation Rationale nIdentify type of role Patient shows role To knowdysfunction dysfunction baseline dataobserve stress providingsituation Observed stress Helps client to providing situation and accept realityDiscuss perceptions & avoid the situation.significance of the situationas seen by client Reassessment Provides showsAdvise the family members Discussed about the opportunity to verbalizationto assisst the patient disease condition & its clarify any of realistic management misperception perception of role change .Reassess about roledysfunction Advised the family Provides members to assist the ongoing patient in daily activities. support To know about progress. Patient verbalize about change of occupation
HEALTH EDUCATIONCommunity and Home Care Considerations:1. Encourage patient to live within the limitations that emphysema imposes.2. Help to relax and work at a slower pace. Obtain occupational therapy consult tohelp employ work simplification techniques such as sitting for tasks, pacingactivities, using dressing aids (grabber, sock aid, long-handled shoe horn), showerbench, and handheld shower head.3. Encourage enrollment in a pulmonary rehabilitation program where availableand Better Breathers club or other support group found through the American LungAssociation or the American Association for Cardiovascular and PulmonaryRehabilitation . Components include breathing retraining techniques, proper use ofmedications and inhalers, secretion clearance. techniques, prevention andmanagement of respiratory infection, panic control, controlling dyspnea withADLs and stair climbing, control of pulmonary irritants, monitored and supervisedexercise, proper use of oxygen systems, and group support.4. Suggest vocational counseling to help patient maintain gainful employmentwithin his physical limits for as long as possible: -5. Warn patient to avoid excessive fatigue, which is a factor in producingrespiratory distress.6. Advise to adjust activities per individual fatigue patterns.7. Advise to try to cope with emotional stress as positively as possible. Such stresstriggers attacks of dyspnea. Teach coping strategies, such as relaxation techniques,meditation, guided imagery.
8. Stress that progression of worsening lung functions may be slowed throughclose medical follow-up for rest of life.Patient Education and Health Maintenance:General Education1. Give the patient a clear explanation of the disease, what to expect, how to treatand live with it. Reinforce by frequent explanations, reading material,demonstrations, and question and answer sessions.2. Review with the patient the objectives of treatment and nursing management.3. Work with the patient to set goals (eg, stair climbing, return to work).4. Encourage patient involvement in disease self management techniques,identification and prompt reporting of respiratory infection or respiratorydeterioration. Encourage patient to have open communication and partnership withprimary care provider.Avoid Exposure to Respiratory IrritantsAdvise patient to stop smoking and avoid exposure to second-hand smoke.avoidbronchospasm and dyspnea. a. Keep a warm mask or scarf over nose and mouth, and drink a warm beverageto warm inspired air in cold weather. b. Stay indoors with air condition in when air pollution level is high. c. Try to avoid abrupt environmental changes. d. Shower in warm water.5. Instruct patient to humidify indoor air in winter to maintain 30% to 50%humidity for optimal mucociliary function.6. Suggest the use of a HEPA air cleaner to remove dust, pollen, and otherparticulates; this is controversial as to the belief to the patient.
Prevent and Treat Respiratory Infections1. Warn against exposure to people with respiratory infections; a respiratoryinfection makes symptoms worse and can produce further irreversible damage.2. Advise patient to avoid crowds and areas with poor ventilation.3. Stress the importance of obtaining influenza vaccine (annual) and pneumococcalvaccine to decrease likelihood of developing these infections.4. Teach patient how to recognize and report evidence of respiratory infectionpromptly—changes in character of sputum (amount, color, or consistency—becoming purulent), increasing cough, wheezing, increasing shortness of breath,fever, chills, increasing difficulty in raising sputum, chest pain.5. Instruct the patient to discuss with health care provider taking prescribedantimicrobial at first sign of infection and adding oral corticosteroids forexacerbation of COPD.Reduce Bronchial Secretions1. Advise patient to maintain an adequate fluid intake (8 to 10 glasses daily); markdown the amount of liquid consumed daily.2. Encourage use of bronchodilators as directed.3. Teach postural drainage exercises as prescribed. a. Stay in each position 5 to 15 minutes as tolerated. b. Use controlled cough after each position.4. Use other secretion clearance techniques, such as PEP valve, flutter valve, huffcough and, possibly, chest percussion if needed for enhanced secretion clearance.Improve Airflow
1. Teach the proper technique for inhalation of medication to maximize aerosoldeposition in the bronchial tree. a. Use spacer device, breathe out normally place MDI (attached to spacerdevice) in mouth, make tight seal around mouthpiece (if not using spacer device:place inhaler 1 inch [2.5 cm] in front of open mouth). b. Actuate cartridge to release soray and inhale slowly over 5 seconds. c. Pause, holding breathe for about 10 seconds; exhale slowly.2. Encourage routine use of a spacer device or holding chamber to allow easierinhalation of bronchodilator medication and enhanced medication deposition.Follow manufacturer’s instructions for use of holding chambers.3. If using a dried powder inhaler, instruct in proper use according tomanufacturer’s instructions. Spacer devices are not necessary.DRUG ALERT Instruct patient in proper sequence of medic lions, usingbronchodilator first, followed by inhaled corticosteroid. Instruct patient to use aspacer device with inhaled corticosteroids, and rinse and spit after using inhaledcorticosteroid to prevent oral candidacies.Breathing Exercises1. Explain that goal is to strengthen and coordinate muscles of breathing. to lessenwork of breathing and help lung empty more completely.2. Stress the importance of controlled breathing. 3. Teach diaphragmatic breathing and pursed-lip breathing for episodes ofdyspnea and stress.4. Encourage muscle toning by regular exercise.General Health1. Teach good habits of wel1-baanced, nutritious intake.2. Encourage high-protein diet with adequate mineral, vitamin, and fluid intake.
3. Advise to avoid hard-to-chew foods (causes tiring) and gas-forming foods,which cause distention and restrict diaphragmatic movement.4. Encourage five to six small meals daily to ease shortness of breath during andafter meals.5. Suggest rest periods before and after meals if eating produces shortness ofbreath.6. Warn against potassium depletion. Patients with COPD tend to have lowpotassium levels; also, patient may be taking diuretics. a. Watch for weakness, numbness, tingling of fingers, leg cramps. b. Encourage foods high in potassium include bananas, dried fruits, dates,figs, orange juice, grape juice, milk, peaches, potatoes, tomatoes.7. Advise patient on restricting sodium as directed.8. Limit carbohydrates if CO2 is retained by patient, because they increase CO2.9. Use community resources, such as Meals On Wheels or a home care aide ifenergy level is low.
CONCLUSION: Through this care study presentation, I got an opportunities to enrich myknowledge, skill, about the COPD, and physical assessment, and its definition,causes, pathophysiology , medical and nursing management, and the way to applytheory in nursing process. And I had a chance of referring current information from the Net referenceand Journals. I am very much thankful to our honorable madam for having given me awonderful opportunity like this.
BIBLIOGRAPHY: Arnold Bloom, 1979,’Toohey’s medicine for nurses,’ Twelth Edition, The English language Book society and Churchill living stone ,pp350 Anne Waugh Allison Giant, 2004,’Anatomy and physiology in health and illness , Ninth Edition, Churchill livingstone, pp 295-306. B.T. Basavanthappa, 2007, ‘ Nursing Theories’, Jaypee Brothers, Medical publishers (p) Ltdspp 52-60. Brunner &Suddarth B, 2009,’ Test book of Medical Surgical Nursing,’ Eleventh Edition, Joyce young johnson, Lippincott, Williams &wilkinspp 607. Christopher R.W. Edwards, 1995,’ Principles and practice of medicine ,Seventeeth Edition, Churchill living stone, pp 426-434. Datta T.K, 2005,’Fundamentals of operation theatre services,’ Second Edition, Jaypee Brothers, Medical publishers, (p) Ltds, pp 2. Joyce M.Black,’Medical – Surgical Nursing,’ Fifth Edition ,W.B.Saunders Company, pp 1022-1050 Jenet Weber, R.N.EdD,2007,’ Health Assessment in Nursing,’ Third Edition, Lippincott, Williams & Wilkins, pp 450-456. Lippincott,2006,’Manual Nursing Practice’, Eighth Edition, Jaypee Brothers, Medical publishers, (p) LTD, PP 203 -316. Straight A’s, 2008,’Medical- Surgical Nursing,’ Second Edition, WoltersKlowerLippincott, Williams & Wilkins, pp 79-130 Swaminathan,M, 1997,’Hand Book of food and nutrition, The Bangalore printing & publishing co, Ltd,pp249.Net Reference: Respiratory system, Wikipedia, free encyclopedia.