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Copd cares study
1. INTRODUCTION:
Breathing is a basic human function that tend to be unconscious. Breathing
is a physiologic function that is almost synonymous with being alive. Difficulty in
breathing as a threat to life itself. People with respiratory disorders are often very
anxious and fearful that they may die, perhaps agonizingly. Whether death is a real
possibility often has nothing to do with the fear.
Respiratory problems are widespread. They may be acute (short term) or
chronic( long term). Acute disorders range from minor inconveniences, such as
colds or flu, to more life-threatening problems, such as asthma some types of
pneumonia, 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 include
chronic obstructive pulmonary disease (COPD), now called chronic airflow
limitation, and certain restrictive lung diseases.
Respiratory problems have many causes: allergies, occupational factors,
genetic factors, smoking and tobacco use, infection, neuromuscular disorders, chest
abnormalities, trauma, pleural conditions, and pulmonary vascular abnormalities.
The most significant factor in chronic respiratory illness and lung cancer is
cigarette smoking.
Gas exchange is the primary function of the respiratory system. The
respiratory system takes oxygen from the atmosphere, transports it to the lungs,
exchanges the oxygen for carbon dioxide in the alveoli, and returns carbon dioxide
to the air.
2. 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.
3. CLIENT PROFILE:
Name of client : Mrs. Lakshmi
Age : 62 years
Sex : Female
I P No. : 3922
Ward : 11
Unit : III Mu
Marital Status : Married
Educational Qualification : 10th st
Religion : Hindu
Occupation : Cooly
Income : Rs.900/-
Address :
Admitted on : 26-5-11 at 11:05 a.m
Source of data : Patient
Diagnosis : COPD.
4. HISTORY COLLECTION
CHIEF COMPLAINTS:
Patient had a history of fever for 3 days, cough with scanty mucoid
sputum expectoration, breathlessness, wheezing for 5 years. No history of
vomiting, 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 took
treatment in private hospital but not getting well. No history of any previous
history of surgeries.
FAMILY HISTORY:
Mrs.Lakshmi husband died due to aging process. She had one son and two
daughters and son was married and had two children
No history of -> DM/IHD/ Allergies / no communicable disease.
5. FAMILY TREE:
70 yrs 62 yrs
40 yrs 35 yrs 32 yrs
30 yrs
10 yrs 8 yrs
MALE
FEMALE
DIED
6. FAMILY HEALTH HISTORY:
ALLERGIES : NIL
Chronic illness:
Asthma : Absent
Bronchiectasis : Present
Cancer : Absent
Cystic Fibrosis : Absent
Emphysema : Absent
Sarcoidosis : Absent
TB : Absent
PERSONAL HISTORY:
Alcohol drug abuse : NIL
PSYCOSOCIAL HISTOPRY:
Occupation exposure : to dust
Hobbies : Dust
Geographic location : Environment
Exercise : Not doing
7. SOCIO ECONOMIC CONDITION:
Patient`s son is the only bread winner for the family. No other source of
support .Her family income of Rs 900/ month . Her son is a cooly. Her family is
comes under low socio economic group. She is living in a hut rented house, having
one window and one door. Her house is electrified. She is getting water from
public pipe connection.
SPIRITUAL HISTORY:
Mrs.Lakshmi is Hindu. She visits temples once in a week. She celebrated
Diwali and pongal festival.
8. REVIEW OF SYSTEM
PHYSICAL ASSESSMENT
GENERAL HEALTH
Nourishment : Well nourished
Body built : Normally built
Health : Healthy
Activity : Dull
Skin condition:
Color : Pale
Texture : Warm
Temperature : 1oo F
Head and Face:
Scalp : Hair black and white
Face : Pale
Eyes:
Eye brow : Normal
Eye lash : Normal in color
Eye lid : No swelling
Eye ball : Normal
9. Conjunctiva and sclera : Not jaundice
Pupil : Normal
Lens :Opaque
Vision : Dim blurred vision
Ears:
External ear : No discharge
Tympanic membrane : Normal
Hearing : Normal
Nose : No bleeding/ No obstruction
Mouth:
Pharynx : No redness/ swelling/ No gum
Bleeding/ No gingivitis.
Teeth : Stained teeth/ No dental carries.
Tongue : No ulcer / normal
Neck :No lymph node enlargement/ Normal
Chest : Symmetry/wheezing present
Tachyapnea/ cough present
No hemoptysis
10. Heart : S1/S2 heard
Breast/axilla : Symmetry
Abdomen:
Inspection :No lesion /No swelling
Palpation :No tenderness
Percussion :No mass/ No distended bladder
Auscultation : Normal bowel sound
Genitals : No ulcer/ pain / itching/discharge
:No pain during urination/defecation
Rectum No hemorrhoids/No Melina
Upper extremities : Normal ROM
Lower extremities :Knee pain
11. SYSTEMIC ASSESSMENT
RESPIRATORY SYSTEM:
Chest movement : Symmetrical
Shape : Normal
INSPECTION
Chest wall Configuration : Normal
Symmetry of Chest Wall : Symmetrical
Presence of superficial veins : Absent
Angle of the Ribs : 45 Degree
Intercostals Space - Retraction : Absent
Muscles of Respiration : Use of accessory muscles: No
Respiration : 22/mt
Rate : Tachypnoea
Rhythm : Normal
Pattern : Tachypnoeal
Depth : Hyperphoea
Symmetry : Symmetrical
Audiblity : Audible
13. CARDIO VASCULAR SYSTEM
Heart rate : 78/min
Palpation : Present
Murmur : No murmur
Peripheral pulse : Palpable
GASTRO INTESTINAL SYSTEM
Abdomen No distention
Liver : Not palpable
Spleen : Not palpable
CENTRAL NERVOUS SYSTEM
Pupil reaction : Equally reacting
Response to stimuli : Present
MUSCULO SKELETAL SYSTEM
Movements : ROM normal
Joints : Knee pain present
INTEGUMENTARY SYSTEM
Skin color : pale
Nail : No clubbing
Temperature : 100 F
14. HEIGHT : 150 cm
WEIGHT : 50 kg
VITAL SIGNS:
TEMPERATURE : 100’F
PULSE : 78/min
RESPIRATION : 22/min
BP : 120/80 Hg
PAIN SCALE:
0 1 2 3 4 5 6 7 8 9
10
No Moderate Pain Worst Pain Possible Pain
16. DRUG CHART
NURSES
NAME OF DOSAG ROUT SIDE
ACTION RESPONSIBILI
THE DRUG E E EFFECTS
TY
Inj 1 gm bd IV Broad Head ache Nephro toxicity
cefatoxamie 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 pain
Inj 500mg Bd cell death anaphylusis
metromidazo Iv
le 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
18. Methylxanthine Mild CNS-irritability, Teach patients to
compound- bronchodilat restlessness, take at equal
relaxes muscle or, intervals
insomnia,
by maintenance throughout the
seizures in toxic
Therapy for day.
increasing cyclic ranges
bronchospas
adenosine 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 prevent
Sympathomimeti therapy for
Nervousness, toxicity.
c (beta2- bronchospas
tachycardia head
adrenergic m, works
ache, nausea,
against) with within
tremors. Observe
highly selective 30min MDI,
inhalation by
beta2 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
21. DRUGS/ PHARMACOL INDICATIO ADVERSE NURSING
OGIC NS
ADMINISTRAT EFFECTS CONSIDERATIO
EFFECTS
ION NS
Corticosteroids Patent anti- Acute CNS: Long term use Do
inflammatory- exacerbation Depresion; not stop abruptly
Hydrocortisone/p
activity of asthma or euphoria, mood due to adrenal
rednisone
bronchitis changes suppression
(DeItasone)
(intravenous (l.V GI : gastric Take oral form
preparation) irritation peptic with food.
Injection, oral
ulcer
preparation). 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 gain
CIPROFLOXACI
bacterial DNA
N
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 rash
Paracetamol
and antipyretic Avoid lon-term
Nausea, Epi
(500mg tds) effect use,
Pain and fever gastric distress,
skin rash Observe
complication
22. ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM
Upper Airway
Structure
Nasal Cavity
The nose is formed from both bone and cartilage. A very small portion of the
nose is bone; the nasal hone only forms the bridge of the nose. The remainder of
the nose composed of cartilage and connective tissue. The nasal cartilages form the
shape of the nose.
The openings of the nose on the face are called nostrils or nares. Each nostril
leads to a cavity, called a vestibule. The vestibule is lined anteriorly with skin and
hair (called vibrissae). The vibrissae filter foreign objects and prevent them from
being inhaled. The posterior vestibule is lined with mucous membrane. This
membrane is composed of columnar epithelial cells, which secrete mucus. The
portion of mucous membrane that is located at the top of the nasal cavity, just
beneath the cribriform plate of the ethmoid bone, is specialized epithelium, called
olfactory epithelium, which provides the sense of smell.The region is supplied by
the &factory nerve (cranial nerve I) which passes through holes in the cribriform
plate. 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 mucous
membrane-covered projections. They contain a very rich blood supply (from the
internal 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 in
which they lie—frontal, ethmoid, sphenoid, and maxillary. Passageways from the
paranasal sinuses drain into the nasal cavities. The nasolacrimal ducts, which drain
tears from the surface of the eyes, also drain into the nasal cavity.
The mouth is considered part of the upper airway, but only because the
mouth can be used to deliver air to the lungs. The mouth may be used for breathing
23. when the nose is obstructed or when high volumes of air are needed, such as
during 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 three
sections:
(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 is
depressed 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, the
eustachian tubes open into the nasopharynx. The pharyngeal tonsils are located on
the posterior wall of the nasopharynx. The tonsils are masses of lymphoid tissue;
they serve as an additional defense mechanism against bacterial infection. When
the pharyngeal tonsils become enlarged following repeated infections or are at their
point of maximum growth during adolescence, they are called adenoids.
The oropharynx serves both respiration and digestion. It receives air from the
nasopharynx and food from the oral cavity. Palatine (facial) tonsils are located
along the sides of the posterior mouth, and the lingual tonsil are located at the base
of the tongue.
The laryngopharynx (hypopharynx) is the most inferior portion of the
pharynx. 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 cervical
vertebrae. The upper esophagus is just posterior to the larynx.
24. The larnyx is formed by nine cartilages: three paired and three single
cartilages. The three large unpaired cartilages are the epiglottis, thyroid, and
cricoid; the three paired cartilage , which are smaller, are the arytenoid,
corniculate, and cuneiform. The cartilages are held together and attached to the
hyoid hone above the trachea and below the trachea by muscles aids ligaments.
The larynx consists of the endolarynx and a surrounding triangle-shaped bone and
cartilage. The endolarynx is formed by two pairs of folds of tissue, which forms
the 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 the
larynx. When food or liquids are swallowed, the epiglottis closes over the larynx,
protecting the lower airways from aspiration. The thyroid cartilage protrudes in
front of the larynx, forming the Adam’s apple. The cricoid cartilage lies just below
the thyroid cartilage and is the anatomic site for an artificial opening into the
trachea (tracheostomy). These cartilages are all connected by ligaments that
prevent the larynx from collapse during inspiration and swallowing the internal
portion 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 the
larynx is through the branches of the thyroid arteries. The nerve supply is through
the 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 the
nurse to appreciate the function of the upper airway.
In various disorders and in the treatment of some disorders, this function is
lost or altered. For example, when a client has a cold, it is difficult to breathe
through the swollen nose, and mouth breathing is common. When the client
breathes through the mouth, the normal functions of the nose (smell, taste,
humidification, and filtering) are lost.
25. The upper airway is lined with mucous membranes to assist in warming and
humidifying inspired air. Regardless of the temperature of air inspired, by the time
the air reaches the lung (in about 0.25 seconds) the air has been warmed to 36° to
37° C (96.8° to 98° F) and humidified to 70% to 80%. The mucus also helps trap
foreign particles. The cilia of the membrane assist in moving the particles down
into the pharynx. The posterior part of the nasal cavity opens into the internal nares
and 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. The
part of the mucous membrane covering the cribriform plate is modified for
olfaction. The nose provides a sneeze reflex, which is similar to the cough reflex.
Irritation of the nasal passages causes receptors in the trigeminal nerve (cranial
nerve V) to stimulate the respiratory centre in the medulla. The medulla stimulates
a 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 resonating
chambers.
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 counterclockwise
helical bands, is found in all of these structures. This muscle is subject to spasm in
many airway disorders.
Trachea:
26. The trachea (windpipe) extends from the larynx to the level of the seventh
thoracic vertebrae where it divides into two main bronchi (also called primary
bronchi). The point at which the trachea divides is called the carina. The trachea
rests 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 pseudostratified
ciliated columnar epithelium that contains numerous goblet (mucus-secreting)
cells. Because the cilia beat upward, they tend to carry foreign particles and
excessive mucus away from the lungs to the pharynx. No cilia are present in the
alveoli.
Bronchi and Broncholes:
The right main-stem bronchus is shorter and wider, and extends more
vertically downward, than the left. Thus, foreign bodies are more likely to lodge in
the right main- stem bronchus than in the left main-stem bronchus.
The segmental and sub-segmental bronchi are subdivisions of the main
bronchi and are spread in an inverted, treelike formation through each lung.
Cartilage surrounds the airway in the bronchi. This structure contrasts
with the bronchioles, the final pathway to the alveoli, which contain no cartilage
and thus can collapse and trap air. The terminal bronchioles are the last airways of
the conducting system. This area does not have gas exchange and is called the
anatomical dead space. Inspired air that remains in the dead space is what allows
artificial respiration (mouth-to-mouth resuscitation).
Function:
The lower airways continue to warm, humidify, and filter inspired air that is
en route to the lungs. In addition, they provide several defense mechanisms.
The respiratory gas-exchanging membrane has a surface area that is almost
the size of a tennis court. The size of the membrane of the lungs and the daily
exposure of the lungs to atmospheric pollutants requires efficient protective
mechanisms. The elaborate defense mechanisms of the lungs fall into three
categories:
(1) Clearance mechanisms,
27. (2) Immunologic responses in the lung, and
(3) Pulmonary reaction to injury. An intact respiratory epithelium and mucociliary
system 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 a
one-cell--layer thick squamous ciliated cell. The cilia are microscopic, hair-like
projections that protect the airways with a rapid, coordinated, unidirectional
sweeping motion toward the mouth. The movement of the cilia propels a mucus
blanket toward the mouth. This blanket is produced by goblet cells located on the
mucosal surface. The mucociliary system propels debris (pollutants and infectious
agents) to the mouth within 30 minutes for the large bronchi, 2.5 hours for most of
the bronchial tree, and 5.6 hours for the peripheral airways. At the mouth, the
debris is removed from the airways by swallowing or coughing. Sputum is mucus
expelled by coughing.
The alveolar lining is made up of flat, membranous pneumocytes (type I
cells). Rounded granular cells (type II) are also found there. These type II cells are
resistant to injury and cover most of the alveolar surface after exposure to
infectious agents. Alveolar macrophages, derived from blood monocytes that
migrate into the lungs, are also found over the surface o the alveoli. Alveolar
macrophages are active phagocytes that remove deal cells and protein.
Macrophages are also metabolically active cells that synthesize and secrete
substances that regulate the immune system. They leave the lung by either the
mucociliary 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 connect
posteriorly to the transverse processes of the thoracic vertebrae of the spine.
28. Anteriorly, the first seven pairs of ribs are attached to the sternum by cartilage. The
8th , 9th, and 10th ribs (false ribs) are attached to each other by costal cartilage. The
11th and 12th ribs (floating ribs) allow full chest expansion because they are not
attached iii any way to the sternum.
At the top of the thorax in the neck area are two accessory muscles of
inspiration—the scalene and sternocleidomastoid muscles. The scalene muscles
elevate the first and second ribs during inspiration to enlarge the upper thorax and
stabilize the chest wall. The sternocleidomastoid muscle elevates the sternum. The
parasternal, trapezius, and pectoralis muscles are also accessory inspiratory
muscles and are used during increased work of breathing.
Between the ribs are the inter-costal muscles. The external intercostal
muscles pull the ribs upward and forward, thus increasing the transverse and
anteroposterior diameter. The internal inter-costal muscles decrease the
anteroposterior diameter of the chest wall. The diaphragm serves as the lower
boundary of the thorax.
The diaphragm is dome shaped in the relax position, with central muscular
attachments to the xiphoid process of the sternum and the lower ribs. The
diaphragm’s nerve supply (phrenic nerve) comes through the spinal cord at the
level 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 the
top of the diaphragm. The parietal pleura joins the visceral pleura at the hilus (a
notch in the. medial surface of the lung, where the main-stem bronchi, pulmonary
blood 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 the
moist pleural membranes to adhere, creating a pulling force that helps to hold the
29. lungs in an expanded position. The action of pleura is analogous to coupling two
sheets of glass by a thin film of water. It is extremely difficult to separate the
sheets of glass at right angles to their surfaces, even though they readily slide past
each other. Because of the nature of this coupling, the movement of the kings
closely follows the movement of the thorax. If air or increased amounts of serous
fluid, blood, or pus accumulates in the space, the lungs are compressed and
respiratory difficulties follow. These conditions are called pneumorhorax (air in the
pleural space) or hemothorax (blood in the pleural space).
Function:
The function of the thorax and diaphragm is to alter pressures in the thorax
to move fresh air in and out. The movement of air depends on pressure differences
between the atmosphere and the air in the lungs. Air flows from regions of higher
pressure 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 the
volume of the thorax and the lungs. As volume increases, pressure decreases and
air 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. Doubling
the length of the airway doubles the resistance. You can experiment with this
change by trying to breathe through a straw and noting the increased effort that is
required to move air. Decreasing the diameter by half creates a 16-fold increase in
resistance. Thus, a decreased diameter of the airways due to bronchial muscle
contraction or to secretions in the airways increases resistance and decreases the
rate of air flow. This is a common finding in obstructive airway diseases such as
asthma.
During quiet breathing, expiration is usually passive, that is, expiration does
not require the use of muscles. The chest wall, in contrast to the lungs, has a
tendency to recoil outward. The opposing forces of lung and chest wall create a
sub-atmospheric (negative) force of about -5 cm H20 in the intrapleural space at
the end of quiet exhalation. Exhalation is also due to the elastic recoil of the lungs,
which is discussed later in the chapter.
30. Forced expiration and coughing bring the internal intercostal muscles and the
abdominal muscles into play. The abdominal muscles force the diaphragm upward
to its dome-shaped position. The intercostals muscles contract, pulling the ribs
inward.
The Lungs and Alveoli:
Structure:
Lungs:
The lungs lie within the thoracic cavity on either side of the heart. The lungs
are cone shaped, with the apex above the first rib and the base resting on the
diaphragm. Each lung is divided into superior and inferior lobes by an oblique
fissure. The right lung is further divided by a horizontal fissure, which bounds a
middle lobe. The right lung, therefore, has three lobes, whereas the left lobe has
only two. In addition to these five lobes, which are visible externally, each lung
can be subdivided into about 10 smaller units called bronchopulmonary segments.
Each bronchopulmonary segment represents the portion of the lung that is supplied
by a specific tertiary bronchus. These segments are important surgically, because a
diseased 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 the
thymus gland are located in the mediastinum.
Alveoli:
The lung parenchyma is the working area of the lung tissue. The
parenchyma consisting of millions of alveolar units. It is estimated that 24 million
alveoli are present in humans at birth. By age 8 years, the number of alveoli has
increased to the adult number of 300 million. The total working alveolar surface
area is approximately 750 to 860 ft2. The large number of alveoli and the large
surface area are necessary to meet both resting and exercise oxygen requirements.
Each alveolar unit is supplied with 9 to 11 pre-pulmonary and pulmonary
capillaries. The blood supply for these capillaries comes from the right ventricle of
the heart. The major function of the alveolar unit is the exchange of oxygen and
carbon dioxide between pulmonary capillaries and alveoli. Because of the
31. extensiveness of the capillary system, the flow of blood in the alveolar wall has
been described as a “sheet” of flowing blood.
The entire alveolar unit (respiratory zone) is made up of respiratory
bronchioles, alveolar ducts, and alveolar sacs, This is the region where gas
exchange takes place. The respiratory zone consists of the respiratory bronchioles,
the alveolar ducts, and alveolar sacs. Alveoli, small air sacs at the end of the
respiratory bronchioles, permit exchange of the oxygen and carbon dioxide. The
alveolar walls are extremely thin, and within them is an almost solid network of
interconnecting capillaries.
Oxygen and carbon dioxide are exchanged through a respiratory membrane
that is about 0.2 m thick.The average diameter of the pulmonary capillary is only
about 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 and
carbon dioxide need not pass through significant amounts of plasma as they
diffuse. The thickness of the respiratory membrane occasionally increases (e.g.,
with pulmonary edema or fibrosis), Increases in thickness of the membrane
interfere 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 dioxide
well. These cells produce surfactant and differentiate into type I cells. These cells
are important in lung injury and repair. When lung tissue has been damaged, type
II cells are produced, which eventually: differentiate into type 1 cells. During the
transition, oxygenation is impaired due to the thickness of the cells.
Function:
The function of the lungs is to deliver oxygen to the mitochondria to
liberate energy stored in molecular bonds of adenosine triphosphate (ATP) and
remove carbon dioxide. Cellular processes for life require ATP. Ventilation, gas
exchange, the relationship of ventilation and perfusion, and oxygen transport are
discussed in the following text.
Gas Exchange:
32. Oxygen Transport
After oxygen diffuses into the pulmonary capillaries, it is transported
throughout the body by the circulatory system. The oxygen is dissolved in the
plasma (3%) or bound with hemoglobin (97%) in ferrous ion. The combination of
ferrous iron and oxygen forms oxy-hemoglobin, which releases oxygen to tissues
that have a low partial pressure of oxygen. Tissues take up oxygen at varying rates.
The most metabolically active tissues receive it first. Methemoglobin, carbon
monoxide, and other chemicals impair the uptake of oxygen by tissues.
The oxy-hemoglobin dissociation curve represents the relationship
between Pa02 and the saturation of hemoglobin. This saturation reflects the
amount of oxygen available to the tissues. In plotting the normal curve, it is
assumed that the client’s temperature’ is 37° C, p1-I is 7.40, and Pa02 is 40 mm
Hg. 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 small
changes in oxygen saturation. The opposite is true as the slope of the curve
steepens. At the steepest portion the curve, with the Pao2 below 60 mm Hg, small
changes in the Pao2 result in large drops in ‘oxygen saw- ration.
The oxy-hemoglobin curve is affected by a number of factors, including
temperature, pH, Pco2, enzymes in the red blood cell (2, 3-diphosphoglycerate
[2,3,-DPGJ), presence of carbon monoxide, and abnormal hemoglobin. Changes in
affinity of oxygen for hemoglobin cause the oxy-hemoglobin to move from its
normal contour, or shift.
A shift to the left of the oxy-hemoglobin dissociation curve increases the
affinity of the hemoglobin molecule for oxygen. It is easier for oxygen to bind to
hemoglobin, 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. Clinical
situations 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 the
tissue level. It is more difficult for oxygen to bind in the lungs, but it releases
easily at the cells. This shift protects the body by allowing oxygen attached to
hemoglobin to be released in the tissues in an attempt to maintain adequate tissue
33. oxygenation. Clinical situations that cause decreased affinity include acidosis,
hypercapnia, hyperthermia, hyperthyroidism (which increases 2, 3-DPG), anemia
and chronic hypoxia.
Carbon Dioxide Transport
Carbon dioxide is the waste product of tissue metabolism. It is carried by
the 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 red
blood cells as carbonic acid. It rapidly breaks down into hydrogen ions and
bicarbonate ions. As venous blood enters the lungs for gas exchange, these
chemicals 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-base
balance of the body. Pulmonary disorders that change the carbon dioxide level in
the 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 respiratory
alkalemia.
The effectiveness of ventilation is best measured by the partial pressure of
carbon dioxide in the arterial blood (Paco2). Because the respiratory system is
normally set to maintain a PaC02 between 35 and 45 mm Hg at sea level, a PaC02
above this range represents hypoventilation. Anesthetic agents, sedatives, and
narcotics all tend to increase the resting Paco2.
34. Chronic Obstructive Pulmonary Disease
DEFINITION:
Chronic obstructive pulmonary disease (COPD), also called chronic obstructive
lung disease (COLD), refers to several disorders that affect movement of air in
and out of the lungs.
The most important of these disorders are obstructive bronchitis,
emphysema, and asthma. Although bronchitis, emphysema, and asthma may
occur in a “pure form,” they most commonly coexist, and clinical
manifestations overlap the term COPD is commonly used
COPD may occur as a result of increased airway resistance secondary
to bronchial mucosal edema or smooth muscle contraction. It may also be a
result of decreased elastic recoil, as seen in emphysema. Elastic recoil, like the
recoil 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 smoking
among females, however, the incidence of COPD among women is steadily
rising.
35. 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
36. is even greater, and the bronchial walls become inflamed and thickened.
Chronic bronchitis initially affects only the larger bronchi, but eventually all
airways are involved.
The thick mucus and inflamed bronchi obstruct airways, especially
during expiration. The airways collapse and air is trapped in the distal portion
of the lung. This obstruction leads to reduced alveolar ventilation. An abnormal
V/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 of
erythrocytes) occurs.
Emphysema
Emphysema is a disorder in which the alveolar walls are destroyed. This leads
to permanent over distention. Air passages are obstructed as a result of these
changes, rather than from mucus production, as in chronic bronchitis. Although
the precise cause of emphysema is unknown. Research has shown that the
enzymes protease elastase can attack and destroy the connective tissue of the
lungs . Emphysema may_resuIt from a breakdown in the lung’s normal defense
mechanisms(alpha antitrypsin or AAT), against these enzymes. Difficult
expiration emphysema is the result of destruction of the walls (septa) between
the alveoli, partial airway collapse, and loss of elastic recoil. As the alveoli and
septa collapse, pockets of air form between the alveolar spaces (blebs) and
within the lung parenchyma (bullae). This process leads to increased
ventilatory 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 to
exchange oxygen and carbon dioxide. Emphysema also causes destruction of
the pulmonary capillaries, further decreasing oxygen perfusion arid ventilation.
There are three types of emphysema).Centrilobular emphysema, the most
common type, produces destruction in the bronchioles, usually in the upper lung
region. Inflammation develops in the bronchioles, but usually the alveolar sac
remains intact. Panlobular emphysema affects both the bronchioles and alveoli
and most comnonly involves the lower lung. These form of emphysema occur
most often in smokers. Paraseptal (or panacinar) emphysema destroys the
37. alveoli in the lower lobes of the lungs resulting in isolated blebs along the lung
periphery. Paraseptal emphysema is believed to be the likely cause spontaneous
pneumothorax, Paraseptal emphysema occurs in the elderly and in clients with
an inherited deficiency of AAT.
CLINICAL MANIFESTATION
BOOK PICTURE PATIENT
PICTURE
• 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
______________
39. Triglyceride : < 150 normal < 160
Total Lymphocyte count : 1500 - 1800 cells/mm3 1600 cells/mm3
Albumin : 3.5 – 5.0 gm/dl 4 gm/dl
Glucose : 85 – 125 mg/dl 80 mg/dl
Creatinine : 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 the
16-05-2011 patient and her relatives..
10.30 a.m to Bed making done
40. 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 laboratory
17-05-2011 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 given
18-05-2011 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 collect
19-05-2011 the result of the investigations
4.00 pm to 7.00 pm Clarified the client’s doubts regarding the
results
7.00 am to
20-05-2011 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 done
21-05-2011 4 pm to 7 pm Vital parameters checked
Collected all the investigations reports
Nebulization given.
Administered medication.
41. DATE TIME WORK PLAN
11.00 am to Bed making done
1.00 pm Nebulization given
23-05-2011 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 checked
24-05-2011 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 exercize
26-05-2011 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
42. 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 given
28-05-2011 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 dietary
30-05-2011 Habit
7:30 am to
9.00 am Bedmaking done
Vital parameters checked
31-05-2011 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
43. 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)
44. • 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 of
incentive spirometry
• Keep the patient in high Fowler’s position
• Administer medications as prescribed
• Reinforce pursed-lip breathing to prolong exhalation and to increase airway
pressure
• 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
45. • Provide information about the American Lung Association
• Individualize horn” care instructions
— know about the disorder and its implications
Follow instructions for medication use and be aware of possible adverse effects
Stop smoking and avoid second-hand smoke
Control weight and folic w dietary recommendations
Identify ways to reduce stress
Recognize the signs and symptoms of respiratory infection and respiratory
distress
Adhere to activity limitations
Know proper use of home oxygen
Demonstrate pursed-lip and diaphragmatic breathing
Avoid exposure to chemical irritants and pollutants
Demonstrate deep-breathing and coughing exercises
Complications:
Carbon dioxide narcosis
Acute respiratory failure
Pneumonia
From emphysema
Pulmonary hypertension
Right-sided heart failure
Spontaneous pneumothorax
Possible surgical intervention: None
46. 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
47. needs rather than just provide a general listing of energy conservation
measures.
Iam applying this theory to my nursing process:
Abdellab’s Typology of 21 Problems
Evolution of Theory:
Abdellah realized that for nursing to gain full professional status and
autonomy, a strong knowledge base was imperative. Nursing also needed to
move away from the control on medicine and toward a philosophy of
comprehensive patient-centered care. Abdellah and her colleagues
conceptualized 21 nursing problems to teach and evaluate students. The
typology of 21 nursing problems first appeared in the 1960 edition of Patient-
centered Approach to Nursing and had a far-reaching impact on the profession
and on the development of nursing theories
The patient or family presents with nursing problems that the nurse helps
them address through her professional function. The nurse addresses 21
problem 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,
48. (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.
49. 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 without
any reason, but may be than it is impossible to provide continuous and total care.
CONCEPTS USED BY ABDELLAH:
Nursing:
50. 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
51. goals” than with client- control problems. Although Abdellah spoke of the
patient-centered approaches she wrote nurses identifying and solving specific
problems. 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 and
through 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 and
sanctions.
13. To identify and accept interrelatedness of emotions and organic illness.
14. To facilitate the maintenance of effective verbal and non-verbal
communication.
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.
52. 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
53. 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
54. hostile or negative, the atmosphere in the room may be hostile, or negative.
This suggests that patient interest and respond to their environment. Society is
included in the premises of comprehensive nursing care, i.e. planning for
optimum health on local, state, national and international.
Nursing
Nursing is a helping profession. Nursing care is doing something to or for
the 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 and
promote the use of nursing judgment. Abdellah considers nursing to be a
comprehensive service that is based on an art and science and aims to help
people sick or well, cope with these health needs.
NURSING PROCESS AND ABDELLAH
Abdellah’s typology of 21 nursing problems helps nurses practice in an
organized systematic way. The use of this scientific base enables the nurse to
understand the reason for her actions. Their use in the nursing process is
primarily to direct the nurse indirectly to the client’s benefits.
In assessment phase, each of the identified 21 nursing problems relevant data
are collected. The overt or covert nature of the problems necessitates a direct or
indirect approach, respectively For Example the overt problem of nutritional
status can be assessed by direct measures of weight, food intake and
body size, whereas the covert problem of maintaining a therapeutic
environment requires more indirect approach to data collected. The nursing
problems can be divided into those that are basic to all clients and those that
reflect sustainable, remedial or restorative care needs.
Nursing diagnosis: is the result of data collection would determine the client’s
specific overt and/or covert problems. These specific problems would be
grouped under one or more of the broader nursing problems.
In planning phase of nursing process, her statements of nursing problems most
closely resemble goal statements. Therefore, once the problem has been
55. 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 on
nursing practice with individuals. Theory does not provide the framework on
human and society in general. This somewhat limits the ability to generalize,
although the problem solving approach readily generalizable to clients with
specific health needs and specific nursing problem.
4. One of the most important questions that arises when considering her work is the
role of the client within the framework, a question that could generate hypotheses
for testing. The results of testing such hypothesis would contribute to the general
body of nursing knowledge.
5. Abdella’s problem-solving approach can easily be used by practitioners to guide
various activities within their nursing practice. This is especially true when
56. considering nursing practice that deals with clients who have specific needs and
specific problem.
6. Abdellah theory consistent with other validated theories, such as those of
Maslows and Henderson. Although the consistency exists, many questions remain
unanswered.
Evaluation of Theory
The typology is very simple and is descriptive of nursing problems thought
to be common among patients. The concepts of nursing, nursing problems, and the
problem-solving process, which are central to this work, are defined explicitly. The
concepts of person, health, and environment, which are associated with the nursing
paradigm today, are implied. There are no stated relationships between Abdellah’s
major concepts or those of the nursing paradigm in her writing. This model has a
limited 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 not
seem to detract from the clarity of definitions. The typology does not yet constitute
a theory because it lacks sufficient relationship statements. The 21 nursing
problems are general and linked to neither time nor environment. “She
acknowledges that her list is neither exhaustive nor listed according to priorities.”
Assuming that persons experience similar needs, the nursing goals stated in the list
of 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 to
focus on the psychosocial and emotional needs presented by patients. The goals of
this model vary in generality. The broadest goal is to positively affect nursing
education, while sub goals are to provide a scientific basis on which to practice and
to provide a method of qualitative evaluation of educational experiences for
students. 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
57. 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
58. 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
59. Assess clients Client rates 2 in the To identify
respiratory rate modified Borg baseline data
using dysnoea category scale
scale
Monitored oxygen To diagnose
Monitor cardiac saturation level is 8o degree of
function studies % respiratory
compromise
Administer 4liters of O2
Oxygen as administered as To improve
prescribed by prescribed saturation level Through all these
doctor measures patient’s
Administered as breathing pattern is
Administer prescribed To Reduce improved as evidenced
medication as Bronco dilator drugs breathing by oxygen saturation
prescribed by difficulty level is 90%
doctor Client is encouraged
to identify the To reduce the
Encourage self situation and avoid workload of
assessment & stress producing heart & thus
symptom situation prevents
management complication
Reassessed the
breathing level is To know the
Reassess normal , oxygen condition of the
breathing pattern saturation level patient
increased to 90%
Subject Data : Patient Complaints, “ I am having difficult in expectoration of
sputum”
60. Objective Data : patient is having difficult to expel the sputum, dull , sweating.
Nursing Diagnosis : Ineffective airway clearance related to secretions in the bronchi as
evidenced by auscultation.
Expected outcome : client will expectorate secretions & maintain patent airway
Planning Implementation Rationale Evaluation
Assess ability to protect own Client is able to protect To know baseline Through
airway airway but coughing data. these entire
effort is ineffective and measures
Evaluate amount & type of unable to expel sputum. client
secretions being produced To assess the maintained
Secretions is excessive difficulty in clear
Provide proper position & sticky maintaining airway as
airway evidenced
Semi fowler’s position by
Give expectorant as prescribed provided using back Upright position diminished
rest. facilities crackles on
respiratory auscultatio
Auscultate breath sounds after Administered function by use of n.
administering expectorant expectorant corex syrup gravity
5ml oral as prescribed
Teach about breathing Expectorants
exercise, pursed lip breathing On auscultation, stimulate
exercise. crackles reduced bronchial
secretions
Reassess 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
61. improvement
Subject Data : Patient Complaints, “ I am having fever and headache, unable to take
food.
Objective Data : patient is having temperature 100’ F, lethargy, anxiety, dull.
Nursing Diagnosis : Hyperthermia related to inflammatory process as evidenced by
elevated temperature.
Expected outcome : Client will maintain core temperature within normal range
Planning Implementation Rationale Evaluation
Monitor temperature by oral Oral temperature is To know baseline Through all
route 100ºF data these measures
patient
Monitor blood pressure & temperature is
and ECG, and oxygen Monitored ECG & Pre existing reduced to
saturation level oxygen saturation cardiovascular 98.4ºF.
level ,ECG shows symptoms can
Administer antipyretic as sinus tachycardia & cause changes in
ordered oxygen saturation hemodynamic
level is 80% status.
Administer supplemental Administered Inj . Antipyretic act on
Oxygen as prescribed paracetamol 1 amp as the hypothalamus
prescribed by doctor. to reduce fever.
Administer fluids as
prescribed by physician Administered 4ltrs of To reduce cardiac
Oxygen by mask as work load
62. Provide dry cloth to the prescribed by doctor
patient To replace fluids
Administered 1000ml lost through
Reassess 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
care
Subject Data : Patient Complaints, “ I am having difficulty in breathing while
waking.
Objective Data : patient is having dyspnea, sweating, anxiety.
Nursing Diagnosis : Activity intolerance level II as evidenced by increased heart rate
after walking
Expected outcome : Client will breathe normally.
Planning Implementation Rationale Evaluation
63. 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 to
less intake of food as evidenced by unable to
64. Do daily living activities.
Expected outcome : Client nutritional level will be improved.
Planning Implementation Rationale Evaluation
Obtain diet history Patient takes less food due To know
to breathing difficulty baseline data
Advise to take small & Advised to take small
frequent diet quantity of food every 2 Heavy meal
hourly aggravates
breathing Through all
Plan diet menu to the patient Provided planned diet difficulty these
menu to the patient. Measures the
Teach food sources rich in To monitor patient
protein, 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 improve
diet. Client list out certain food the
like drumstick, ragi.pulses, nutritional
dhal , bread. level
To know the
progress.
65. Subject Data : Patient Complaints, “Iam unable to sleep during night due to breathing
difficulty..
Objective Data : patient looks dull, lethargy, worried, anxiety. Pulse rate is increased.
Nursing Diagnosis : Disturbed sleep pattern related to breathlessness as evidenced by
increasing irritability
Expected outcome :patient sleeping pattern will be improved.
Planning Implementation Rationale Evaluation
Assess sleep pattern Patient awoke 7 To know baseline data Through all these
disturbance associated with times at night due Measures patient
breathlessness to breathlessness is able to sleep at
Patient looks To assess the level of least for 5 hrs in
Observe for physical signs restless & fatigue night as evidenced
of sleeplessness & fatigue irritable by reduced awoke
during night.
Administer medication for Inj. Deriphylline l To induce sleep
breathlessness as amp IV given as adequately
prescribed by doctor. prescribed by
doctor.
Advise to avoid activities
that causes breathlessness Advised to avoid Heavy meal & caffeine
at night provide sedation heavy meal, impair breathing
caffeine content pattern
Reassess sleep pattern at night
To induce sleep
Provided Tab.
Diazepam 1 Hs as To identify progress.
per doctor advice
Patient sleeps for
66. 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 by
breathlessness
Expected outcome : patient activity level will be improved.
Evaluati
Planning Implementation Rationale on
67. Assess the activity level Patient is having To know
breathlessness baseline
Assess severity of fatigue respiratory rate is 30 data
using 0-10 scale breaths / min
Patient rates 5 in the To identify
Measure physiological fatigue rating scale the intensity
response to activity especially of fatigue
respiratory rate.
Patients respiratory rate It indicate
is 30 breaths / min need for
Provide fowler’s position intervention
Through all
these measures
Semi fowler’s position
patient
Provide adequate rest is provided using back To improve
relieved from
rest. the lung
breathlessness
Provide small frequent diet expansion
as evidenced
Provided adequate rest
by respiratory
rate is 22/min
Reassess 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
