BACHELOR OF SCIENCE IN NURSING:

NCM 107
RLE MODULE RLE UNIT WEEK
1 1 7
MEDICAL – SURGICAL NURSING
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

 Read course and laboratory unit objectives

 Read study guide prior to class attendance
 Read required learning resources; refer to course unit terminologies for jargons
 Participate in weekly discussion board (Canvas)
 Answer and submit course unit tasks

At the end of this unit, the students are expected to:

1. Discuss the disease process of chronic obstructive pulmonary disease and its contributing
factors.
2. Map out the course of the disease based on the given clinical scenario.
3. Formulate a care plan based on identified priority problems of the patient.
4. Explain the nursing responsibilities relative to the drugs prescribed.

Berman, Snyder & Frandsen. (2016). Kozier & Erb’s Fundamentals of Nursing. (10 th ed.).
Pearson
Lewis & Bucher. ((2017). Medical-Surgical Nursing: Assessment and management of Clinical
Problems. (10th ed.). C & E
Linton. (2020). Medical-Surgical Nursing. (7 th ed.). ELSMoore. (2018). Brunner & Suddarth’s
Textbook of Medical-Surgical Nursing.(14th ed.). Wolters Kluwer
Silvestri, L.A. (2018). Saunders Q & A Review for the NCLEX-RN Examination, 7 th ed.
Missouri: Elsevier
https://www.slideshare.net/rsmehta/3-monitoring-amp-devices-used-in-icu-ccu-53533107
https://www.slideshare.net/rsmehta/1-critical-care-53532785

Medical – Surgical Nursing is specialized and skilled branch of nursing. It can be considered
to be the foundation of nursing because it has several interdisciplinary advanced specialization
in several vital area of nursing, such as: Cardiology, Neurology, Oncology etc.

DEFINITION
Medical surgical nursing is a specialized branch of nursing that involve the nursing care of
adult patients, whose disease condition are treated medically, surgically and
pharmacologically. - Sharon L Lewis

Medical- surgical clinical nurses are specialist who are involved in the direct clinical practices
and play a vital role at several stages of treatment of the patient.

They served the responsibility of caring for the patient before, during as well as after the
surgical intervention for the treatment of the disease.

Clinical Nurses Responsibilities

1. Collection of information and setting care priorities
2. Applying novel method of care and treatment modalities and their evaluation.
3. Planning in individual care
4. Taking patient histories and performing physical examination.
5. Ordering laboratory test and diagnostic procedure.
ROLE OF MEDICAL-SURGICAL NURSE

 Get set of skills:

 They must have sound knowledge of all aspect of human health.
 They must be competent enough to provide care to individual, sick or well, utilizing the
various nursing processes.
 They must be able to asses the nursing requirement of patient from birth to death.
 They must able to preparing plan in crisis situation.
 They must be able to promote self care & practical prioritization of skills.
 They must be able to assist in research activities.

 Ability to advocate for the patients

 They must able to understand the importance of measuring and improving the quality of
care delivered.
 They must consider the safety of the patient as the top priority.
 They must support patient to the best of their health interests.
 They must be evaluate the effectiveness of the nursing care.
 They must able to work as a team with the team of health workers & must be use her
knowledge of good communication skills and relations at work.

 Ability to make a difference in a patient’s life everyday

 To provide psychological and physical comfort to the patient.
 They must use ethical values in professional and personal life.
 To assist patient in rehabilitative activities.
 They must posses the basic skills of educating and counseling of patient about the
preventive actions.

 Ability to become the backbone of health care system of the society

 They must participate as member of the health team in delivery of curative, preventive,
promotive and rehabilitative health care services.
 They must able to utilize their administrative skills and leadership qualities while working
in team for the cause of health and community welfare schemes.

Respiratory Disorders
Respiratory disorder, or respiratory disease, is a term that encompasses a variety of
pathogenic conditions that affect respiration. Respiration makes gas exchange that involves
taking oxygen into the body and expelling carbon dioxide. Respiratory disease occurs in the
respiratory tract, which includes the alveoli, bronchi, bronchioles, pleura, pleural cavity, trachea
and the nerves as well as muscles of breathing. 
There are three main types of respiratory disease: airway diseases, lung tissue diseases and
lung circulation diseases. Airway diseases affect the tubes that carry oxygen and other gases
into and out of the lungs. Airway diseases usually result in narrowing or blocking of the
passageways. Lung tissue diseases affect the structure of lung tissue and result in scarring or
inflammation of the lung tissue. This, in turn, makes breathing difficult. Lung circulation
diseases occur when the blood vessels in the lungs become clotted, inflamed or scarred.
These diseases affect the ability of the lungs to receive oxygen and produce carbon dioxide,
and they may affect the functioning of the heart.

Common Manifestations:

Respiratory system signs and symptoms

o Dyspnea: difficult or labored breathing, breathlessness, shortness of breath. Is a symptom

common to many pulmonary and cardiac disorders particularly when there is decreased lung
compliance or increased airway resistance. Sudden dyspnea in a healthy person may indicate
pneumothorax, acute respiratory obstruction. In immobilized patients sudden dyspnea may
denote pulmonary embolism. Orthopnea (inability to breathe easily except in an upright
position) may be found in patients with heart disease and occasionally in patients with COPD.
Placing the patient at rest with the head elevated and administering oxygen sometimes
achieve relief of the symptom.

o Cough: although cough is a reflex that protects the lungs form the accumulation of
secretions or the inhalation of foreign bodies, it can also be a symptom of a number of
disorders of the pulmonary system or it can be suppressed in other disorders. It results from
the irritation of the mucous membranes anywhere in the respiratory tract. The stimulus that
produces a cough may arise form an infectious process or from an air bone irritant such as
smoke, smog, dust, or a gas. A dry, irritative cough is characteristic of an upper respiratory
tract infection or viral origin. Coughing at night time may herald the onset of left-sided heart
failure or bronchial asthma. A cough in the morning with sputum production may indicate
bronchitis. A persistent cough may affect a patient’s quality of life and may produce
embarrassment, exhaustion, inability to sleep, and pain. Cough suppressants must be used
with caution, because they may relieve the cough but do no address the cause of the cough.

o Sputum production: a patient who coughs long enough almost invariably produces sputum.
Violent coughing causes bronchial spasm, obstruction, and further irritation of the bronchi and
may result in syncope (fainting).

 Bacterial infection: a profuse amount of purulent sputum thick and yellow, green, or rust-
colored.
 Viral bronchitis: thin, mucoid sputum
 Chronic bronchitis: gradual increase of sputum over time
 Cancer: pink-tinged mucoid sputum
 Pulmonary edema: profuse, frothy, pink material, often welling up into the throat
 Infection: foul-smelling sputum and bad breath point to the presence of a lung abscess,
bronchiectasis and infection caused by fusospirochetal or other anaerobic organisms.
Relief measures: if the sputum is too thick for the patient to expectorate, is necessary to
increase water content through adequate hydration and inhalation of aerosolized solutions.
Smoking is contraindicated because it interferes with ciliary action, increases bronchial
secretions causes inflammation. The nurse encourages adequate oral hygiene and wise
selection of food. Also, encourage the patient and family to remove sputum cups, emesis
basins and soiled tissues properly

o Chest pain: chest pain associated with pulmonary conditions may be sharp, stabbing, and
intermittent. Chest pain may occur with pneumonia, pulmonary embolism and pleurisy. The
nurse assesses the quality, intensity, and radiation of pain and identifies and explores
precipitating factors and their relationship to the patient’s position. Analgesic medications may
be effective in relieving chest pain.

o Wheezing: is often major finding in a patient with bronchocostriction or airway narrowing.

Oral or inhalant bronchodilator medications reverse wheezing in most instances

o Clubbing of the fingers: is a sing of lung disease that is found in patients with chronic
hypoxic conditions, chronic lung infections, or malignancies of the lung.

o Hemoptysis: expectoration of blood form the respiratory tract is a symptom of both

pulmonary and cardiac disorders. Diagnostic evaluation to determine the cause includes
several studies: chest x- ray, chest angiography, and bronchoscopy.

o Cyanosis: a bluish coloring of the skin is a very late indication of hypoxia. The presence or
absence of cyanosis is determined by the amount of unoxygenated hemoglobin in the blood. In
the presence of a pulmonary condition, observing the color of the tongue and lips assesses
central cyanosis. Peripheral cyanosis results from decreased blood flow to a certain area of
body, as in vasoconstriction of the nail beds or earlobes from exposure to cold.
RESPIRATORY TREATMENT MODALITIES
Numerous treatment modalities are used when caring for clients with various respiratory
conditions. The choice of treatment modalities is based on the oxygenation disorder and
whether there is a problem with gas ventilation, diffusion or both.

CLASSIFICATION OF RESPIRATORY MANAGEMENT MODALITIES

A. Non-invasive respiratory therapies

B. Invasive respiratory therapies

A. NON – INVASIVE RESPIRATORY THERAPIES

 Oxygen Therapy
 Incentive spirometry
 Mini – nebulizer Therapy
 Intermittent Positive –pressure breathing ( IPPB)
 Chest physiotherapy ( Postural drainage ,chest percussion, breathing retraining

B. INVASIVE RESPIRATORY MODALITIES

 Endotracheal intubation
 Tracheostomy
 Mechanical ventilation

A. NON – INVASIVE RESPIRATORY THERAPIES

 OXYGEN THERAPY
Oxygen therapy is the administration of oxygen at a concentration greater than that
found in the environmental atmosphere.

INDICATIONS OF OXYGEN THERAPY

1. A change in the clients respiratory rate or pattern may be one of the earliest indications
of the need for oxygen therapy.
2. Hypoxemia or hypoxia

COMPLICATIONS OF OXYGEN THERAPY

 Oxygen toxicity
 Suppression of ventilation
 Combustion
METHODS OF OXYGEN ADMINISTRATION
 Low flow system
 High flow system

LOW FLOW SYSTEM

 Cannula
 Oropharyngeal catheter
 Simple mask
 Partial rebreather mask
 Non breather mask

HIGH FLOW SYSTEMS

 Transtracheal catheter
 Venturi mask
 Tracheostomy collar
 T – piece
 Face tent
 INCENTIVE SPIROMETRY ( SUSTAINED MAXIMAL INSPIRATION)
 Incentive spirometry is a method of deep breathing that provides visual feedback to
encourage the clients to inhale slowly and deeply to minimize lung inflation and prevent
or reduce atelectasis.

PURPOSE OF INCENTIVE SPIROMETRY

 The incentive spirometer that volume of air inhaled is increased gradually as the patient
takes deeper and deeper breaths.

TYPPES OF INCENTIVE SPIROMETRY

 Volume or Flow spirometry

INDICATIONS OF SPIROMETRY
 Incentive spirometry is used after surgery, especially Thoracic and abdominal surgery,
to promote the expansion of the alveoli and to prevent or trat atelectasis.

INSTRUCTIONS REGARDING SPIROMETRY USING

 Proper position
 Technique for using the spirometry
 Frequency of usage
  MINI-NEBULIZER THERAPY
 The mini-nebulizer is a handled apparatus that disperses a moisturizing agent or
mediation, such as bronchodilator or mucolytic agent, into microscopic particles and
delivers it to the lungs as the client inhales.

INDICATIONS OF MINI-NEBULIZER THERAPY

 In case of difficulty in clearing respiratory secretions
 Reduced vital capacity with ineffective deep breathing and coughing.
 Most commonly used in COPD clients

INTERMITTENT POSITIVE PRESSURE BREATHING

 Intermittent Positive- pressure breathing ( IPPB) is an older form of assisted or
controlled Respiration in which compressed gas is delivered under Positive pressure
into a person’s airways until a preset pressure is reached today.
 It is infrequently used currently

 CHEST PHYSIOTHERAPY ( CPT)

a. Chest physiotherapy includes Postural drainage, chest percussion, and chest vibration
and breathing retraining.
b. The goals of CPT are to remove bronchial secretions, improve ventilation, and
increases the efficiency of the respiratory muscles.

B.INVASIVE RESPIRATORY MODALITIES

 ENDOTRACHEAL INTUBATION
 Endotracheal intubation involves passing an endotracheal tube through the mouth or
nose into the trachea.
 Endotracheal intubation provides a patent airway when the patient is having respiratory
distress that cannot be treated with simpler methods and is the method of choice in
emergency care.

 TRACHEOSTOMY
 A tracheostomy is a surgical procedure in which an opening is made into the trachea.
 The indwelling tube inserted into the trachea is called a tracheostomy tube.
 A tracheostomy either Temporary or permanent.
COMPLICATIONS OF TRACHEOSTOMY
 Complications may occur early or late in the course of tracheostomy tube management.
 They may even occur after the tube has been removed.
EARLY COMPLICATIONS INCLUDING
 Bleeding
 Pneumothorax
 Air embolism
 Aspiration
 Subcutaneous or mediastinal emphysema
 Recurrent laryngeal nerve damage

LONG TERM COMPLICATIONS

 Airway instructions from accumulation of secretions
 Infection
 Rupture of the innominate artery
 Dysphagia
 Tracheoesophageal fistula
 Tracheal ischemia and necrosis

 MECHANICAL VENTILATION
 Mechanical ventilation may be required for a variety of reasons.
 To control the patient Respiration during surgery or during treatment of severe head
injury, to oxygenate the blood when the patient ventilatory efforts are inadequate

MECHANICAL VENTILATION
 A mechanical ventilator is a Positive or negative pressure breathing device that can
maintain ventilation and oxygen delivery for a prolonged period

INDICATIONS:
 Continues decrease in oxygenation (PaO2), an increase in arterial carbon dioxide levels
( PaCO2) and persistent acidosis ( decreased pH) mechanical ventilation may be
necessary. ( Any dramatic alterations in ABGs valves)
 Conditions such as Thoracic or abdominal surgery
 Drugs over dose
 Neuromuscular injury and inhalation injury
 COPD , multiple trauma, shock, multisystem failure and coma.
CLASSIFICATION OF VENTILATORS
 Negative- pressure ventilators 
 Positive- pressure ventilators

COMPLICATIONS
 Alterations in cardiac function
 Barotrauma ( trauma to the trachea or alveoli secondary to Positive pressure)
 Ventilator associated pneumonia
 Pulmonary infection
 Sepsis

WEANING THE PATIENT FROM THE VENTILATOR

 Respiratory weaning, the process of withdrawing the patient from dependence on the
ventilator, takes place in three stages, the patient is gradually removed from the
ventilator, then from the tube, and finally from oxygen.
CHEST PHYSIOTHERAPY
 Best time - morning upon arising, 1 hr before meals or 2-3 hrs after meals
 Stop if pain occurs
 Provide mouth care

CONTRAINDICATIONS OF CHEST PHYSIOTHERAPY (CPT)

 Increased respiratory distress
 History of fractures
 Chest incisions

POSTURAL DRAINAGE
 use of the gravity

NURSING CARE
 Position the client
 Best time – A.M. upon arising, 1 hr before meals, 2-3 hrs after meals
 Stop if cyanosis or exhaustion occurs
 Maintain position 5-20 mins after
 Provide mouth care after the procedure

CONTRAINDICATIONS OF POSTURAL DRAINAGE

 Unstable V/S
  Increased ICP
 CLIENT INSTRUCTIONS FOR INCENTIVE SPIROMETRY
 Use the lips to form seal around the mouth piece
 Inspire deeply
 Hold inspiration for a few seconds
 Forcefully exhale
 Avoid the use of spirometry at mealtime - it may cause nausea

RESPIRATORY DIAGNOSTIC PROCEDURES AND LABORATORY EXAMS

1. Chest x-ray film (radiograph)

Description
 provides information regarding the anatomical location and appearance of the lungs.

Pre procedure
a. Remove all jewelry and other metal objects from the chest area.
b. Assess the client’s ability to inhale and hold breath.
c. Question females regarding pregnancy or the possibility of pregnancy.

Post procedure:
 Assist the client to dress.

2. SPUTUM SPECIMEN
Description
 a specimen obtained by expectoration or tracheal suctioning to assist in the
identification of organisms or abnormal cells.

Pre procedure
a. Determine specific purpose of collection and check with institutional policy for appropriate
collection of specimen.
b. Obtain an early morning sterile specimen from suctioning or expectoration after a respiratory
treatment, if a treatment is prescribed.
c. Obtain 15 ml of sputum.
d. Instruct the client to rinse the mouth with water before collection.
e. Instruct the client to take several deep breaths and then cough deeply to obtain sputum.
f. Always collect the specimen before client begins antibiotic therapy.
Post procedure
a. Transport specimen to laboratory STAT.
b. Assist the client with mouth care.

3.SUCTIONING PROCEDURE -- SPUTUM SPECIMEN

 Aseptic technique
 Hyperoxygenate
 Lubricate the catheter with sterile water

Tracheal suctioning : 4 inches

Nasotracheal suctioning : insert to induce cough reflex
 Don’t apply suction while inserting
 Suction intermittently for 10-15 seconds
 Rotate and withdraw
 Hyperoxygenate & deep breaths

4.BRONCHOSCOPY
Description
 direct visual examination of the larynx, trachea, and bronchi with a fiberoptic
bronchoscope

Pre procedure
a. Obtain informed consent.
b. Maintain NPO status for client from midnight before the procedure.
c. Obtain vital signs.
d. Assess the result of coagulation studies.
e. Remove dentures or eyeglasses.
f. Prepare suction equipment.
g. Administer medication for sedation as prescribed.
h. Have emergency resuscitation equipment readily available.

Post procedure
a. Monitor vital signs.
b. Maintain client in semi-Fowler position.
c. Assess for the return of the gag reflex.
d. Maintain NPO status until gag reflex returns.
e. Have an emesis basin readily available for client to expectorate sputum.
f. Monitor for bloody sputum.
g. Monitor respiratory status, particularly if sedation was administered
h. Monitor for complications, such as bronchospasm, bronchial perforation indicated by facial
or neck crepitus, dysrhythmias, fever, bacteremia, hemorrhage, hypoxemia, and
pneumothorax.
i. Notify the physician if fever, difficulty in breathing, or other signs of complications occur
following the procedure.

5.PULMONARY ANGIOGRAPHY
Description
a. Pulmonary angiography is an invasive fluoroscopic procedure in which a catheter is inserted
through the antecubital or femoral vein into the pulmonary artery or one of its branches.
b. Pulmonary angiography involves an injection of iodine or radiopaque or contrast material.

Pre procedure
a. Obtain informed consent
b. Assess for allergies to iodine, seafood, or other radiopaque dyes.
c. Maintain NPO status of client for 8 hours before procedure.
d. Monitor vital signs
e. Assess results of coagulation studies
f. Establish and intravenous access
g. Administer sedation as prescribed
h. Instruct the client to lie still during the procedure
i. Instruct the client that he or she may feel an urge to cough, flushing, nausea, or salty taste
following injection of the dye
j. Have emergency resuscitation equipment available

Post procedure
a. Monitor vital signs
b. Avoid taking blood pressures for 24 hours in the extremity used for injection
c. Monitor peripheral neurovascular status of the affected extremity
d. Assess insertion site for bleeding
e. Monitor for delayed reaction to the dye

6.THORACENTESIS (thoracocentesis)
Description
 removal of fluid or air from the pleural space via a transthoracic aspiration for diagnostic
or therapeutic purposes.
Pre procedure
a. Obtain informed consent
b. Obtain vital signs
c. Prepare the client for ultrasound or chest radiograph, if prescribed, before procedure
d. Assess results of coagulation studies
e. Note that the client is positioned sitting upright, with the arms and head supported by a table
at the bedside during the procedure.
f. If the client cannot sit up, the client is placed lying in bed on the unaffected side with the
head of the bed elevated 45 degrees
g. Instruct the client not to cough, breath deeply, or move during the procedure.

Post procedure
a. Monitor vital signs
b. Monitor respiratory status
c. Apply a pressure dressing, and assess the puncture site for bleeding and crepitus.
d. Monitor for signs of pneumothorax, air embolism, and pulmonary edema

7.LUNG BIOPSY
Description
a. A percutaneous lung biopsy is performed to obtain tissue for analysis by culture or
cytological examination
b. A needle biopsy is done to identify pulmonary lesions, changes in lung tissue, and the cause

Pre procedure
a. Obtain informed consent
b. Maintain NPO status.
c. Inform the client that a local anesthetic will be used but that sensation of pressure during
needle insertion and aspiration may be felt.
d. Administer analgesics and sedatives as prescribed

Post procedure
a. Monitor vital signs
b. Apply dressing to the biopsy site and monitor for drainage or bleeding
c. Monitor for signs of respiratory distress, and notify physician if they occur
d. Monitor for signs of pneumothorax and air emboli, and notify physician if they occur
e. Prepare the client for chest radiography if prescribed

8.VENTILATION PERFUSION LUNG SCAN

Description
a. The perfusion scan evaluates blood flow to the lungs.
b. The ventilation scan determines the patency of the pulmonary airways and detects
abnormalities in ventilation.
c. A radionucleotide may be injected for the procedure

Pre procedure
a. Obtain informed consent
b. Assess client for allergies to dye, iodine, or seafood
c. Remove jewelry around the chest area
d. Review breathing methods that may be required during testing.
e. Establish an intravenous access
f. Administer sedation if prescribed
g. Have emergency resuscitation equipment available.

Post procedure
a. Monitor client for reaction to nucleotide
b. Instruct client to wash hands carefully with soap and water for 24 hours following the
procedure.

9. SKIN TEST
Description
 A skin test is an intradermal injection used to assist in diagnosing various infectious
diseases

Pre procedure:
 Determine hypersensitivity or previous reactions to skin tests

Procedure
a. Use test injection test that is free of excessive body hair, dermatitis, and blemishes.
b. Apply the injection at the upper one third of inner surface of the left arm
c. Circle and mark the test site
d. Document the date, time, and test site

Post procedure
a. Advise the client not to scratch the test site so as to prevent infection and abscess formation
b. Instruct the client to avoid washing the test site.
c. Interpret the reaction at the injection site 48 to72 hours after administration of the test
antigen
d. Assess the test site for the amount of induration (hard swelling) in millimeters and for the
presence of erythema and vesiculation (small blisterlike elevations)

10.ARTERIAL BLOOD GASES

Description
 measurement of the dissolved oxygen and carbon dioxide in the arterial blood to reveal
the acid-base state and how well the oxygen is being carried to the body

Pre procedure
a. Perform Allen’s test before drawing radial artery specimens.
b. Have the client rest for 30 minutes before specimen collection.
c. Avoid suctioning before drawing ABG sample.
d. Do not turn off oxygen unless the ABG sample is ordered to be drawn with client breathing
room air.

Post procedure
a. Place the specimen on ice.
b. Note the client’s temperature on laboratory form.
c. Note the oxygen and type of ventilation that the client is receiving on the laboratory form.
d. Apply pressure to the puncture site for 5 to 10 minutes and longer if the client is taking
anticoagulant therapy or has a bleeding disorder.
e. Transport the specimen to the laboratory within 15 minutes.

11.PULSE OXIMETRY
Description
a. Pulse oximetry is a noninvasive test that registers the oxygen saturation of the client’s
hemoglobin.
b. This arterial oxygen saturation (SaO 2 ) is recorded as a percentage.
c. The normal value is 95% to 100%.
d. After a hypoxic client uses up the readily available oxygen (measured as the arterial oxygen
pressure, PaO 2 , on ABG testing), the reserve oxygen, that oxygen attached to the
hemoglobin (SaO 2 ), is drawn on to provide oxygen to the tissues.
e. A pulse oximeter reading can alert the nurse to hypoxemia before clinical signs occur.

Procedure
a. A sensor is placed on the client’s finger, toe, nose, ear lobe, or forehead to measure oxygen
saturation, which then is displayed on a monitor.
b. Maintain the transducer at heart level.
c. Do not select an extremity with an impediment to blood flow.
d. Results lower than 91% necessitate immediate treatment.
e. If the SaO 2 is less than 85%, the tissues of the body have a difficult time becoming
oxygenated; an SaO 2 of less than 70% is life threatening.

12. SPIROMETRY - PULMONARY FUNCTION TESTS

Spirometry is a physiological test that measures how an individual inhales or exhales volumes
of air as a function of time.
Spirometry assesses the integrated mechanical function of the lung, chest wall, and respiratory
muscles by measuring the total volume of air exhaled from a full lung (total lung capacity
[TLC]) to maximal expiration (residual volume [RV]).

INDICATIONS FOR SPIROMETRY

• Diagnostic to establish baseline lung function.
 To evaluate symptoms like dyspnea, signs or abnormal laboratory tests to detect or
screen individuals at the risk of pulmonary disease
 To measure the effect of disease on pulmonary function
 To assess pre-operative risk
 To assess prognosis
• Monitoring to assess therapeutic intervention
 To describe the course of diseases that affect lung function
 To monitor people exposed to injurious agents and surveillance of occupation related lung
disease.
 To monitor for adverse reactions to drugs with known pulmonary toxicity to assess
patients as part of a rehabilitation program.

HOW IS THE TEST PERFORMED

 The patient is instructed to inhale as much as possible and then exhale rapidly and
forcefully for as long as flow can be maintained. The patient should exhale for at least
six seconds.
 At the end of the forced exhalation, the patient should again inhale fully as rapidly as
possible. The FVC ( force vital capacity) should then be compared with that inhaled
volume to verify that the forced expiratory maneuver did indeed start from full inflation.
  The FVC and the FEV1 (1st Forced Expiratory Volume) should be repeatable to within
0.15 L upon repeat efforts unless the largest value for either parameter is less than 1 L.
In this case, the expected repeatability is to within 0.1 L of the largest value.

FVC Interpretation of % Predicted:

 80 -120% - Normal
 70 – 79% - Mild
 50 – 69% - Moderate
 <50% - Severe

The severity of reductions in the FEV1% can be characterized by the following scheme:
 •Mild - Greater than 70% of predicted
 •Moderate - 60-69% of predicted
 •Moderately severe - 50-59%
 •Severe - 35-49% of predicted
 •Very severe - Less than 35% of predicted

13. Peak expiratory flow rate (PEFR)

Measurements of lung function provide an assessment of the severity, reversibility, and
variability of airflow limitation, and help confirm the diagnosis of asthma in patients older than 5
years.

Peak Flow Meters

A portable device that can help measure air flow in and out of the lungs May not be useful for
children under the age of 5 Can be a good indicator of air flow in and out of the lungs in those
over age 5

 Peak Expiratory Flow Rate (PEFR) Normal Values: Normal values vary based on a
person's age, sex, and height. Peak flow measurements are most useful when a person
compares the number on a given day to his or her "personal best."
 Normal Values: Normal values are related to the patient's height as follows: An easy to
remember approximation is: PEFR (L/min) = [Height (cm) - 80] x 5
 The "personal best" peak flow rate is the highest peak flow rate you can reach over a
two- to three-week period when you feel good and have no asthma symptoms.
 This flow rate serves as a benchmark in the daily self-management plan.

SURGICAL MANAGEMENT
1.Chest Tube Thoracotomy
 Chest Tubes/Water seal drainage
 Insertion of a catheter into the intrapleural space to maintain constant negative pressure
when air/fluid have accumulated
 Chest tube is inserted to underwater drainage to allow for the space of air/fluid and
prevent reflux of air into the chest
 For evacuation of air, chest tube is placed in the second or third intercostal space,
anterior or midaxillary line (air rises to upper chest)
 For drainage of fluid, chest tube is place in the eight or ninth intercostal space,
midaxillary line.
 Chest tube is connected to tubing for the collection system; the distal end of the
collection tubing must be placed below the water level in order to prevent atmospheric
air from entering the pleural space.
 Drainage system: water-seal drainage system can be set up using one, two, or three
bottles; or a commercial, disposable device (e.g., Pleur-evac) may be used.

One-Bottle System 
Two-bottle system
a. One bottle serves as a drainage collection chamber, the other as a water seal.
b. The first bottle is the drainage collection and has two short tubes in the rubber stopper. One
of these tubes is attached to the drainage tubing coming from the client; the other is attached
to the underwater tube of the second bottle (the water-seal bottle). The air vent of the water-
seal bottle must be left open to the atmospheric air. If suction is used, the first bottle serves as
drainage collection and water-seal chamber, and the second bottle serves as the suction
chamber

Two-way Bottle System 

Nursing care: without suction
1. Examine the entire system to ensure air tightness and absence of obstruction from kinks or
dependent loops of tubing
2. Note oscillation of the fluid level within the water-seal tube. It will rise on inspiration and fall
on expiration due to changes in the intrapleural pressure. If oscillation stops and system is
intact, notify physician.
3. Check the amount, color, and characteristics of the drainage. If drainage ceases and system
is not blocked, assess for signs of respiratory distress from fluid/ air accumulation

Three-Bottle System
a. This system has a drainage collection, a water seal, and a suction-control bottle.
b. The third bottle controls the amount of pressure in the system. The suction control bottle has
three tubes inserted in the stopper, two short and one long. One short tube is joined with the
tubing to former air vent of the water-seal; the second short tube is connected to suction. The
third (long) tube (or suction-control tube) is located between the short tubes and has one end
open to the atmosphere and other below the water level.

Nursing care: with suction

1. Attach suction tubing to suction apparatus, and chest catheter to drainage system
2. Open suction slowly until a stream of bubbles is seen in the suction chamber. There should
be continuous bubbling in this chamber and intermittent bubbling in the waters seal. Check for
an air leak in the system if bubbling in water seal is constant; notify physician if air leak
3. Check drainage, keep drainage system below level of client’s chest, keep Vaseline gauze at
bedside, encourage coughing and deep breathing, and provide ROM
4. Always keep drainage system lower than the level of the client’s chest
5. Keep Vaseline gauze at bedside at all times in case chest tube falls out
6. Encourage coughing and deep breathing to facilitate removal of air and drainage from
pleural cavity
7. Never clamp chest tubes.
8. Removal of the chest tube: instruct the client to perform Valsalva maneuver; apply Vaseline
pressure dressing to the site
9. If the water-seal bottle should break, immediately obtain some type of fluid-filled container to
create an emergency water seal until a new unit can be obtained

MEDICAL MANAGEMENT

1. Antibiotics for bacterial infection and as supportive treatment for viral infections, considered
to for respiratory support measures . like Penicillin, Tetracycline, Microlides (Zethromax)
Azethromycin (Side Effect: Ototoxicity) Broad Spectrum Antibiotic is given for patients with
MRSA like vaconmycin is used.

2. Bronchodilators to relieve bronchospams and reduce airway obstruction by allowing

increased oxygen distribution throughout the lungs and improving alveolar ventilation, example
is albuterol. It is given via inhalation or metered dose inhalaer or MDI for 5 minutes , example
is Beta-2 agonist- salmetrol, salbutamol

3. Diuretics is used to decrease the fluids retained on the lungs, example is Furosemide
(Lasix)
4.Corticosteroids used to decrease inflammation of the alveoli. This is the most potent and
effective anti inflammatory medications, example is Budesonide, Mometasone (Nebulized}

5. Influenza (flu) vaccines that used to given every year.

6. Antipyretics - Paracetamol

7.Mucolytics/Expectorants - Ambroxol, carbocistein/ Guaifenesin

8. Anticholinergic – ipratropium

9.Phosphodiesterase inhibiting agent for COPD , example is teophylline

10. Mucomyst/ N- acetylcysteine (acetylceisteine)

11. Anti histamine - Loratadine, citirizine

12. Beta adrenergic agonist - Long acting medications example is Albuterol (Ventolin) to
control asthma symptoms at night

13. Leukotriene modifiers are potent bronchoconstrictors that also dilate blood vessels and
alter permeability, example is Montelukast sodium (Singulair)

14. Decongestant ( phenylephrine )

15. Antihistamine ( chlorphenamine )

NURSING CARE MANAGEMENT

1. Teaching patient self care.

2. Nutritional support
3. Patient and Family education
4. Achieving Airway Clearance
5. Improving Breathing Pattern
6. Improving activity Tolerance
7. Monitoring and Managing complications
8. Promoting Rest
 9. Providing skin Care
10. Reducing Risk of Injury

CLINICAL SCENARIO:

NURSING HEALTH HISTORY

A. Patient’s Profile
Name: Patient TOS
Birthday: March 25, 1946
Age: 74 years old
Sex: Male
Nationality: Filipino
Religion: Roman Catholic
Marital Status: Married
Address: Obando, Bulacan
Date of Admission: August 20, 2020
Time of Admission: 5:00 PM

Chief Complaint: Shortness of breath

Admitting Diagnosis: COPD

History of Present Illness

One (1) day prior to admission, the patient was unable to speak in full sentences as verbalized
by the wife, he had a productive cough but unknown color of the sputum, (+) audible wheezing
since last night. Five (5) hours prior to admission his wife has noted no change in his alertness,
the patient complaint of mild chest tightness, shortness of breath, cough worsen in the
morning, productive of gray sputum which prompted to seek consultation at Valenzuela
Medical Center and was admitted.

Past Medical History

Patient TOS has hypertension and he had a history of heart failure followed by myocardial
infarction at the age of 68 years. He was diagnosed with COPD and he is taking medications
that include: Lisinopril 20 mg twice daily, Metoprolol 50 mg twice daily, Spironolactone 25 mg
daily, Furosemide 40 mg daily, Salmeterol/ fluticasone 50/500 dry powdered inhaler (PDI) one
puff inhaled twice daily, Albuterol/ ipratropium metered-dose inhaler (MDI) or solution for
nebulization every 6 hrs as needed, Levalbuterol MDI two puffs every 4 to 6 hours as needed,
with back up oxygen inhalation 2LPM via nasal cannula at home. He has no known allergy to
food and medication. He underwent an appendectomy when he was 20 years old.

Family History

(+) Hypertension
(+) Diabetes Mellitus
(+) Heart failure
1. Father died of myocardial infarction at age of 59 years (diabetes, hypertension, smoker)
2. Mother alive (atrial fibrillation, heart failure)
3. Healthy siblings

Personal and Social History

The patient is a 30-pack-year smoking history (quit after myocardial infarction). He denied drinking alcohol. He
prefers to eat rice, fish, and vegetables. He enjoys his leisure time in gardening. Usually, he can help around the
house with light work and fixing things. He has three children.

Admission Order

The patient was admitted on August 15, 2020, at 5:00 pm with a chief complaint of shortness
of breath, he was hooked to NM 1L to run for 12 hrs. The patient was subjected to the
following laboratory procedures: CBC, Serum Na, K, Creatinine, ABG. The patient was given
Lisinopril 20 mg BID PO, Metoprolol 50 BID PO, Spironolactone 25 mg OD PO , Furosemide
40 mg OD PO, Salmeterol/ fluticasone 50/500 dry powdered inhaler (PDI) one puff inhaled
twice daily, Albuterol/ ipratropium metered-dose inhaler (MDI) or solution for nebulization every
6 hours as needed, Levalbuterol MDI two puffs every 4 to 6 hours as needed. The chest x-ray
shows hyperinflation and right lower lobe pneumonia. Doxycycline 100mg OD for one week,
Prednisone 35 mg OD for one week was started. The ABG result was Ph 7.24, PO2- 35 mm
Hg, PCO2 60 mmHg , HCO3 30, O2 sat – 70. Spirometry with FEV1 35% predicted that does
not change significantly after inhaled bronchodilators. ECG was ordered.

Bedside care is implemented to the patient that includes proper positioning, bedrest was
encouraged. The vital signs were monitored including the level of consciousness, neurologic
status, and fever. Continue observation for hypotension and difficulty of breathing. Crackles
were also monitored including respiratory distress. Intake and Output monitoring.

The patient was also provided oxygen therapy via nasal cannula. A cardiac monitor and pulse
oximeter was attached to the patient, Nebulization every 6 hours followed by chest
physiotherapy was done and physical examinations were conducted.

Care of clients:

Pharma
Drug 1 - Lisinopril
Drug 2 - Salmeterol
Drug 3 - Albuterol
Drug 4 - Doxycycline

To facilitate the practice of students’ web navigation skills, the following rules must be
implemented:

1. The use of search engines (e.g. Google, Yahoo) are allowed.

2. Use navigation techniques as mentioned in the required readings.
3. Students must submit this accomplished worksheet through email or Canvas upload

1. Conceptualize the pathophysiological alterations related to the case.

 Trace the pathophysiological changes and highlight problems that are
 experienced by the client.
 Connect the pertinent nursing care and medical – surgical management to the
various signs and symptoms presented by the client.

Intrinsic Factors Patient Extrinsic Factors

2. Make a care plan for 2 priority nursing problems identified.

3. Make a drug study of the medication prescribed to the patient to include; dosage, action, classification,
indication, contraindication, mechanism of action, common side-effects, and nursing considerations.

Berman, Snyder & Frandsen. (2016). Kozier & Erb’s Fundamentals of Nursing. (10 th ed.).
Pearson
Lewis & Bucher. ((2017). Medical-Surgical Nursing: Assessment and management of Clinical
Problems. (10th ed.). C & E
Linton. (2020). Medical-Surgical Nursing. (7 th ed.). ELSMoore. (2018). Brunner & Suddarth’s
Textbook of Medical-Surgical Nursing.(14th ed.). Wolters Kluwer
Silvestri, L.A. (2018). Saunders Q & A Review for the NCLEX-RN Examination, 7 th ed.
Missouri: Elsevier
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