I.

Introduction

Cor pulmonale as defined by Wikipedia (Latin cor, heart + New Latin

pulmōnāle, of the lungs) or pulmonary heart disease is enlargement of the right
ventricle of the heart as a response to increased resistance or high blood pressure in the
lungs.

The heart and lung are intricately related. Whenever the heart is affected by
disease, the lungs will follow and vice versa. Pulmonary heart disease is by definition a
condition when the lungs cause the heart to fail.

When there is lung disease present, like emphysema, chronic obstructive lung

disease (COPD) or pulmonary hypertension- the small blood vessels become very stiff
and rigid. The right ventricle is no longer able to push blood into the lungs and eventually
fails. This is known as pulmonary heart disease. Pulmonary heart disease is also known
as right heart failure or cor pulmonale.

Cor pulmonale accounts for about 25% of all types of heart failure. It’s most
common in areas of the world where the incidence of cigarette smoking and COPD is
high; cor pulmonale affects middle-age to elderly men more often than women.
Approximately 85% of patients with cor pulmonale have COPD, and 25% of patients with
COPD eventually develop cor pulmonale. (Professional Guide to Diseases;Eighth
Edition;2005)

Heart Diseases are the number one cause of death globally more people die
annually from this than from any other cause and by 2030, almost 23.6 million people
will die from CVDs, mainly from heart disease and stroke. These are projected to remain
the single leading causes of death. The largest percentage increase will occur in the
Eastern Mediterranean Region. The largest increase in number of deaths will occur in
the South-East Asia Regions. (World Health Organization)

In the national setting, Heart diseases had been the chief culprit of mortality in
the Philippines among both men and women in every major ethnic group since 1985.
Though there is a slight diversion in number since men are more predisposed to this

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disease. Nevertheless it covers a wide number of individuals notably a figure of 90.4
mortality rate in the year 2005 and its morbidity interchanges between ranks 7th and 8th
since 1981(DOH). Also, an estimated 92 percent of Filipinos 20 years and above have at
least one of the risk factors that may soon lead to heart disease or cardiovascular
disease if not addressed immediately. These risk factors include obesity, high blood
pressure and smoking. National Nutritionand Health Survey (NNHeS).

In Region 12, heart diseases held responsible for a number of a number of 823
deaths and is alleged to be the leading cause of mortality in the region, this is as
presented by the DOH statistical data in 2000.

Cor pulmonale instigated by COPD is a loathsome disease to anyone which may

advance to it. Its involvement in the society is undeniable. A father, an uncle or anyone
in the family can progress to such illness when early symptoms are not given due
attention and since the client was diagnosed first of COPD which is one of the major
non-communicable diseases in the country and also the one of the most preventable. It
is because of this reason that had caught our interest in pushing through with this study
for by this our efficiency as nurses will be put to work given this opportunity to apply all
the concepts that we have tackled in the classroom and applying them into real life
situations.

Subsequent inquiry about Cor Pulmonale can benefit the health care team, the
patients diagnosed with such disease and as well as the students for by this the students
can conduct significant actions to modify and improve the current situation of the client,
promote healthy activities of daily living and help him to be independent in identifying
health problems and finding ways to alleviate them. The patient’s case enables the
group to comprehend, analyze and formulate with every condition being presented. And
by this we may hopefully contribute to the development of the nursing practice, research,
and nursing education.

In the inclusive field of nursing it is inevitable that at one point or another we

may come to encounter clients manifesting the same disease and since we are
equipped with eloquent knowledge about the disease we may be able to render care
with utmost competence.

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II. Objectives

General

This case presentation seeks to deliver fine points about Cor Pulmonale, COPD in
an approach that will enhance the students’ knowledge which will fortify skills and
cultivate proficiency in the well esteemed field of nursing.

Specific

As the students try to achieve the wide ranging objectives stated above, we
endeavor to transpire with the succeeding objectives in just a span of 4 hours of case
presentation:

1. Present the patient’s personal data with precision

2. Accurately expound a comprehensive Nursing History of the client which
includes the Past and Present illness.
3. Discuss the Activities of Daily Living and Physical Assessment.
4. Thoroughly explain the Anatomy and Physiology of the affected system.
5. Trace the Pathophysiology of the disease, its clinical manifestation and
complication in relation to the client’s predisposing and precipitating
factors.
6. Effectively elaborate the Medical and Nursing Management done to the
client.
7. Provide a detailed presentation on the Medical and Physical Findings.
8. State the Diagnostic Tests and Laboratory Results that the client had gone
through and provide explicit interpretation for such.
9. Present a meticulous and commendable Study on the Drugs ordered by
the client’s physician.
10. Efficiently appraise the efficacy of the Health Teaching/Discharge Planning
carefully constructed to suite the client.
11. Devise a concrete Prognosis and with regards to the patient’s disease
condition.

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12. Skillfully formulate Nursing Care Plans for the different Problems identified.
13. List down the references used for the achievement of this case study.

4
III. Initial Data Base

Biological Data Findings

Name: Mr. S

Age: 77 y/o

Sex: Male

Civil Status: Widowed

Religion: Roman Catholic

Birth Date: June 15, 1933

Birth Place: Iloilo

Address: Small Spring, Brgy. Cebuano, South Cotabato

Occupation: Tenant

Nationality: Filipino

Educational Level: High School graduate

No. of Children 4

Clinical Data Findings

Chief Complain: Cough

Date of Admission: September 16,2010

Admitting Diagnosis: Cor Pulmonale,COPD

Final Diagnosis: Cor Pulmonale, COPD

Ward: Medical Ward

Room: 218

Attending Physician: Mr. S

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6
IV. Nursing Health History

A. History of Past and Present Illness

Past Illness

During our interview with Mr. S, he said that he started smoking at an early age
of 15, with an average of 10 sticks a day, and continued smoking from then on.

In the year 1974, he got married at the age of 41 years old. He worked as a
tenant since 1953 in Small Spring, Barangay Cebuano, South Cotabato, which served
as source of their income. His consumption of cigarettes increased to 2 packs per day,
even if he was advised by his wife and relatives to stop smoking.

In the year 1994, he was rushed to South Cotabato Provincial Hospital (SCPH)
due to cerebrovascular accident or stroke. After recovery, he still continued smoking.
Since he resided on a place far from the city proper, they had difficulties in terms of
transportation. This became their primary reason for not having any consultation or
check-up from any health care providers. Due to the fact that he was not aware of his
current condition, he paid no attention to what he was manifesting, this again had a great
contribution to his second attack in the year 2006, and was rushed to Allah Valley
Medical Specialists Center Inc. (AVMSCI), but luckily he was able to recover. After that,
he kept on consuming at least 2 packs of cigarettes per day. After his second stroke, he
lessened the consumption into 1 pack a day.

In the year 2009, his cigarette consumption decreased to half pack a day.
Though at least once a month he experienced cough, he did not mind that these will
progress into a more complicated diseases, because according to him cigarettes serves
as his means of relaxation.

Currently, he is residing in their house located at Purok Small Spring, Barangay

Cebuano, Tupi, South Cotabato together with a number of relatives and a nephew who
take care of him and monitor his every need. He was able to take all the prescribed
medications for his condition.

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Present Illness

Three (3) days prior to admission the patient experienced numbness of both legs
and cough with yellow-green mucus. Last September 16, 2010, at exactly 2:49PM, he
was brought to Allah Valley Medical Specialists Center Incorporated for treatment. Mr. S
was confined with a chief complaint of cough and an admitting diagnosis of Cor
Pulmonale; COPD. The Doctor restricted him to have a Low Salt Diet and medicated
with Isosorbide Mononitrate (Imdur) 60 mg ½ tabs OD and Levofloxacin 750 mg 1 tab
OD, and ordered to have Complete Blood Count (CBC) and Urinalysis (UA).

B. Activities of Daily Living

Activities
Personal Hygiene Past
Mr. S was a tenant, for this reason he woke up early to take a bath
and fixed whatever he needed for the whole day. He used to take a
bath twice a day, first was in the morning and before he slept at
night. He brushed his teeth regularly (three times a day). He
usually trimmed his nails once a week and changes his clothes
three times a day.

Present
Because of his condition, he takes a bath once a day unlike his
routine before. Before he goes to bed, he simply provides himself a
sponge bath with the help of his nephew.
Diet/nutritional Past
Mr. S loved to eat vegetables like horse raddish or malunggay, and
squash especially during lunch time. He was fond of eating beef
and pork without any limitation. He was able to eat three times a
day excluding light snacks. Instead of drinking milk early in the
morning, he rather chose to drink coffee. He usually consumed 6-7
glasses of water. After a meal, he used to buy 2 packs of cigarette.
He usually puffed cigarette when he was on his way to the farm.
He consumed at least 1-2 packs of cigarette for the rest of the day.

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 He ate more carbohydrates (rice) during breakfast and lunch time.

Present
Due to his condition, his doctor advises him to have a low fat and
low salt diet with limited fluid intake (2-3 glasses a day). At this
time, he drinks milk as he wakes up in the morning and before he
goes to bed.
Elimination Past
Mr. S usually defecated once a day. He urinated 12 times a day
(35-40cc per void).

Present
Due to his condition, Mr. S defecates four times a week. He
urinates 5 times a day (averaging from 25-30cc per void).
Rest and Sleep Past
Usually, Mr. S preferred to sleep in a supine position with 2 pillows
under his head. He went to sleep at 8pm and woke up at 4’oclock
in the morning. He consumed 8hrs of sleep every day. In the field,
after his work he usually took a rest and smoke.

Present
Mr. S sleeps in a semi-fowlers position with 1 pillow. He has
regular sleep at 8’oclock in the evening and wakes up at 7’oclock
in the morning. He consumed 11 hours of sleep every day.
Exercise Past
Doing exercises is not that important to Mr. S. According to him,
walking starting from their house to the farm was enough.

Present
Due to his present age and illness, he does his exercise every
morning by simply walking around their house with his nephew at
side to guide him. He does this at the maximum time his body can
tolerate.
Sexual life Past
They never used contraceptives; instead they used natural family

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 planning method and abstinence.

Present
He said that due to his age and condition, he is no longer sexually
active.
Social Life Past
Usually, he interacted very well with his neighbors and invited them
to their house. He was able to entertain his visitors well and shared
laughter with them. He usually prepares foods for the visitors such
as “kakanins”.

Present
Even with some difficulties in communication, he manages to
interact with other people by talking and sharing jokes. In addition,
he receives enough support and care from his family.
Religion Past
He is a pure Roman Catholic. He was an active member of their
church.

Present
As a result of his illnesses, he is unable to attend masses at times.
However, he watches mass on television and prays solemnly
inside his room.
Economic Status Past
As a tenant, he could earn 50-100 pesos a day. He uses this
money to buy their daily needs and as support to their children

Present
When asked where to get money to pay for his hospital bills, Mr. S
stated that he depends to the monthly support given by his children
working abroad. Mr. S stated that his condition posed a major
problem primarily because of huge hospital bills and the series of
medication regimen that are being done to him.

C. Physical Assessment

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1. General Survey

a. General Appearance

Mr. S’s body posture and body build show evidences of being under weight. His
height is 5 feet and 4 inches and has a weight of 110 lbs which are significantly
disproportional to each other. There were abnormalities noted such as weakness,
tiredness, and fast breathing. He has an IVF # 1 D5NSS 1L + 1 amp Benutrex C at the
level of 180cc running at 20gtts/min, hooked at right metacarpal vein, infusing well and
without Oxygen (O2) inhalation.

b. Mental Status

He is cooperative and responsive. Mr. S talks in a low voice manner.

c. Vital Signs

September 16, 2010 (Upon Admission 3:29 PM)

Patient’s Vital Signs Normal Range Remarks

Temperature 37.3 36.6 - 37.5 Normal

Pulse Rate 96 bpm 60 –100 bpm Normal
Respiratory 36 bpm 16 – 20 bpm Abnormal
Rate
Blood 140/100 mmHg Systolic: 100 - 140 mmHg Abnormal
Pressure
Diastolic: 60 - 90 mmHg

September 17, 2010 (8:00 AM)

Patient’s Vital Signs Normal Range Remarks

Temperature 36.6 36.6 - 37.5 Normal

Pulse Rate 79 bpm 60 –100 bpm Normal
Respiratory 31 bpm 16 – 20 bpm Abnormal

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 Rate
Blood 130/90 mmHg Systolic: 100 - 140 mmHg Normal
Pressure
Diastolic: 60 - 90 mmHg

2. Specific Survey

Area Findings
Skin  During the inspection of the skin, dryness was observed; skin is
slightly warm to touch.
 The color of the skin of body and extremities is uneven and with
wrinkles.
Hair and Scalp  The hair is unequally distributed, hair strands are white in color,
and there is no presence of dandruff noted.
 No parasites on scalp upon hair examination.
Skull and Face  Mr. S’s skull is round with smooth contour.
 He has a wrinkled face.
 His head is proportion with symmetrical movement.
Eyes  Conjunctivae are both pink in color.
 The scleras of both eyes are yellowish in color with no visible
capillaries.
 Blink reflex was present.
 Both eyes are reactive to light.
Nose and Smell  The nose which is at the midline has no discharges or
discoloration and has the same color with the face.
 No tenderness and lesions were noted.
 The nasal septum is intact and at the midline.
 Small number of short nasal hair was present.
Lips and Mouth  Lips are semi-black in color, slightly dry yet intact and no lesion
noted.
 Slight odor was noted.
 Dysphagia is also noted.
 The gums, buccal mucosa and palates were observed of dusky
discoloration.
 Teeth are yellow in color and no dentures noted.

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  He has 28 teeth.
Chest and Back  No lesions noted upon inspection.
 No palpable mass upon palpation.
 Abnormal breath sounds (wheezing) were auscultated to all
lung fields.
 Respiratory rate is abnormal (31bpm/ tachypnea).
Cardiovascular  Blood pressure is normal (130/90 mmHg).
 Heartbeat is normal (79bpm).
Abdomen  The abdomen was distended and round and symmetrically
inflating and deflating during ventilation.
Nails and nail beds  Nails are short and pale.
 Dryness was noted.
 Both finger nails and toenails were thick.
 Capillary refill of less than 2 seconds.

Assessment of CRANIAL NERVES

Cranial Nerve I Olfactory The patient was able to smell various
objects such as coffee, vinegar, and soy
sauce and was able to differentiate each

Cranial Nerve II Optic This was not accurately assessed due to

lack of equipment but the patient
displayed decrease in visual acuity as
evidenced by blurring of vision when
looking at far objects.

Cranial Nerve III Oculomotor The patient was able to follow the moving
objects. The patient’s eyes constricted
when pointed with light.

Cranial Nerve IV Trochlear The patient’s eyes were able to follow

objects moving up and side to side
symmetrically without moving his head.

Cranial Nerve V Trigeminal The patient was able to chew foods

provided to him and was able to
differentiate sharp and dull objects

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 touching his face. However, corneal reflex
is poor as evidenced by inability to see
objects beyond 3 meters clearly.

Cranial Nerve VI Abducens The patient was able to move eyes

upward symmetrically.

Cranial Nerve VII Facial The patient was able to demonstrate

different facial expressions such as those
of happy, sad, angry, and lonely.

Cranial Nerve VIII Acoustic The patient was able to hear whispers in
(Vestibulocochlear) both ears but wasn’t able to maintain
balance when standing.

Cranial Nerve IX Glossopharyngeal The patient was able to differentiate sweet

taste from sour, bitter and salty. In
addition, he was able to swallow with the
present of gag reflex.

Cranial Nerve X Vagus The patient was able to swallow foods

with observable gag reflex.

Cranial Nerve XI Spinal Accessory The patient was able to turn his head
laterally and to raise his elbow against the
pressure the examiner exerted.

Cranial Nerve XII Hypoglossal The patient was able to move his tongue
in all directions.

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V. Anatomy and Physiology

Respiratory System

 Gives a surface area for exchanging gases between the air and our circulating
blood.
 Involved in regulating blood pH and controlling blood pressure.
 Responsible for gaseous exchange between the circulatory system and the
outside world.
 Conducting portion ( nose, nasal cavity, pharynx, larynx, trachea, bronchi) and
Respiratory portion (respiratory bronchioles, alveolar ducts)

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Upper Respiratory Tract

NOSE

 Regions of the nose include the external nose and the nasal cavity. Air moves
from the nostrils to the back of the nasal cavity where it exits through the
posterior nares. The function of the nasal cavity is to clean, warm and dampen
the air that enters so that it can travel throughout the body.
 Air-resonating chamber for speech
 art-aisle internal nasal cavity which is separated into right and left nasal cavity by
a narrow vertical divider, called a septum

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  nasal cavity is lined with mucous membranes which contain very many so-called
nasal mucosa vasculature
 nasal mucosal surface is covered by the goblet cells secrete mucus continuously
and moving backward to the nasopharynx by cilia movement
 The nose serves as a channel for air flow to and from the lungs
 The nose also serves as a filter dirt and moisten and warm air that is inhaled into
the lungs
 Nose is also responsible for the olfactory because the olfactory receptors located
in the nasal mucosa, and this function is reduced in line with increasing age

PHARYNX

 Involved in diverting ingested material into the

esophagus and away from the lungs to prevent choking.
 Connects the nasal cavity and mouth to the larynx and
esophagus
 Is the common opening of the digestive and respiratory
systems.
 Pharynx or throat is like a tubal structure that connects the nose and mouth
cavities into the larynx
 Pharynx is divided into three regions: Nasal (nasopharynx), oral (oropharynx),
and larynx (laryngopharynx)
 Nasopharynx
o Is the superior region of the pharynx and extends from the external nares
to the level of the uvula--a soft process that extends from the posterior
edge of the soft palate.
o Is lined with a mucous membrane.
o Auditory tubes open here.
o Posterior surface contains the pharyngeal tonsil that protects the body
from infection.

 Oropharynx
o Extends from the uvula to the epiglottis.

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 o Oral cavity opens into the oropharynx through the fauces
o Food, drink, and air pass through the oropharynx.
o Is lined with stratified squamous epithelium that provides protection
against abrasion.
o Two (2) sets of tonsils (palatine and lingual) are located near the fauces.

 Laryngopharynx
o Extends from the tip of the epiglottis to the openings of the larynx and
esophagus.
o Is lined with squamous epithelium.

LARYNX

 Connects pharynx with trachea

 Contains the membrane that vibrates in a controlled manner with the passage of
air to create the voice.
 Larynx or voice organ is an epithelial structure of the cartilage that connects the
pharynx and trachea
 Consists of an outer casing of nine (9) cartilages connected to each other by
muscles and ligaments. Six (6) of the cartilages are paired (arytenoid,
corniculate, cuneiform) and three (3) are unpaired (epiglottis, thyroid, cricoid).

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  Larynx is often called the voice box and consists of:
o Epiglotis: leaf valve of cartilage that covers the larynx during swallowing
direction
o Glottis: between the vocal cords in the larynx
o Thyroid cartilages: the largest cartilage of the trachea, a portion of this
form the Adam’s apple cartilage (Adam’s apple)
o Krikoid cartilages: the only complete ring of cartilage in the larynx
(located below the thyroid cartilage)
o Cartilages aritenoid: used in the movement of the vocal cords with the
thyroid cartilage
o Vocal: ligament, which is controlled by the movement of muscles that
produce the sound of the voice (vocal cords attached to the lumen of the
larynx)
 The primary function of the larynx is to allow the occurrence of vocalizations
o Vocal cords – false (ventricular) and true
 Vibration of vocal cords results in phonation
 Barrier against foreign bodies entering lower respiratory tract
 Larynx also serve to protect the lower airway from foreign body obstruction and
facilitate stone

TRACHEA

 Also called windpipe

 The end of the trachea branches into two bronchi called Carina
 larynx at division forming two primary bronchi at midthorax
 Is a membraneous tube that consists of dense regular
connective and smooth muscle reinforced with 15-20 "C"-
shaped pieces of cartilage.
 Posterior wall contains no cartilage and consists of a
ligamentous membrane and smooth muscle which can alter
the diameter of the trachea.

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  Trachea is lined with pseudostratified ciliated columnar epithelium that contains
numerous goblet cells
 Cilia propel mucus and foreign particles toward the larynx where they can enter
the esophagus and be swallowed
 Trachea divides into the right and left primary bronchi
o Right bronchus
 shorter and wider than the left and extends downward in a more
vertical direction. Because of the difference in size between the
two, objects are more easily inhaled (aspirated) into this portion of
the bronchi.
o Primary bronchi
 extend from the mediastinum to the lungs.
 narrow and positioned more horizontally than the right bronchus.
 The lining of the bronchi is the same as the trachea and the bronchi are
supported by "C"-shaped cartilage rings.

Lower Respiratory System

LUNGS

 Are the principal organs of respiration and on a volume basis, they are one of the
largest organs of the body.
 Each lung is conical in shape with its base resting on the diaphragm and its apex
extending superiorly to a point approximately 2.5 cm superior to each clavicle.
 Paired, cone-shaped organs in the thoracic cavity
 Separated by heart and other mediastinal structures
 Right lung is larger than the left lung.
 Right lung has three (3) lobes and left lung two (2).

Lobes and Fissures

 Lungs divided into lobes by fissures

o Both have an oblique fissure extending forwards and downwards
 Separates upper and lower lobes on left
 Separates upper, middle and lower lobes on right

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 o Right lung also has horizontal fissure
 Separates upper and middle lobes
 Each lobe has its own secondary (lobar) bronchus
o Named according to the lobe supplied

BRONCHIAL TREE

 Bronchial tree-The bronchia tree consists of

bronchi, bronchioles, and alveoli.
 Bronchi are formed as the lower part of the
trachea divides into two tubes. The primary
portion enters the lungs at a region called the
hilus. The primary branch forms a secondary
branch, which then branches into smaller
tertiary bronchi.
o Primary (main) bronchi
 Incomplete cartilage rings
 Stratified columnar epithelium as in trachea
 Right main bronchus
 To right lung
 Shorter, wider, and more vertical than left
- More prone to foreign bodies lodging
o Secondary bronchi (lobar)
 One for each lobe of each lung
 3 on the right
 2 on the left
o Tertiary bronchi (segmental)

 Bronchioles
o Smaller tube divisions of the bronchi.
o Its walls contain smooth muscle and no cartilage. This allows contraction
and relaxation, thereby regulating air flow to the alveoli.
o Bronchioles (under 1mm in diameter)

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 o Terminal bronchioles (less than 0.5mm)

 Alveoli
o Tiny ends of the alveolar ducts.
o Cup-shaped outpouhings
o Clustered in alveolar sacs
o Lined by epithelium
o Thin elastic basement membrane
o These tiny air sacs function to exchange oxygen and carbon dioxide in
the blood. Certain respiratory diseases cause a thickening of the alveoli
walls, which restricts movement, causing breathing difficulties.
o Lined by type I alveolar cells with occasional type II alveolar cells
 Type II cells secrete alveolar fluid and surfactant
 Surfactant acts to reduce surface tension of alveolar fluid (like
detergent), helping to keep alveoli from snapping shut
o Alveolar macrophages (dust cells)
 Phagocytes that remove dust and debris from alveolar spaces
 Derived from peripheral blood monocytes
o Alveolar surrounded by capillary network to facilitate gas exchange
 Single layer of endothelium and basement membrane

Mechanics of Breathing

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  Inspiration – an active process
o Diaphragm lowers
o Ribs pivot upwards
 Intercostal muscles contract
 Action similar to swinging
bucket handle
o Intra-thoracic pressure lowers
 Intrapleural pressure is
normally 4mmHg lower than
atmospheric pressure, ‘sucking’ the lungs outwards
o Lung expands
 As volume increases, pressure decreases –Boyle’s Law
o Air flows from higher atmospheric pressure (760mmHg) into low pressure
of the lungs (758mmHg)

 Expiration –passive
o Inspiratory muscle relax
 Ribs move downwards
 Diaphragm relaxes and its dome rise
 Elastic recoil of the lungs due to Relaxation of diaphragm and inter
costal muscle.
 Positive pressure created in lungs
 Gas pushed out

Mechanics of Respiration

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  External (pulmonary) respiration
o Exchange of O2 and CO2 between respiratory
surfaces and the blood (breathing)
 Internal respiration
o Exchange of O2 and CO2 between the blood
and cells
 Cellular respiration
o Process by which cells use O2 to produce
ATP

External respiration

 Exchange of O2 and CO2 between alveoli and blood

 Partial pressure of O2 higher in alveoli (105mmHg) than blood (40mmHg) so CO2
diffuses into blood
 Partial pressure of CO2 higher in blood (45mmHg) than alveoli (40mmHg), so CO2
moves into alveoli in opposite direction and gets exhaled out.

Gas partial pressures

Gas Atmospheric air Alveolar air Exhaled air

O2 21 % (159m mmHg) 14 % (104 mHg) 16% (120 mmHg)
N2 78% (597 mmHg) 75 % (569 mmHg) 75 % (566 mmHg)
CO2 0.04 % (0.03 mmHg) 5% (40 mmHg) 4 % ( 27 mmHg)
H2O 0.5 % (4 mmHg) 6 % (47 mmHg) 6 % (47 mmHg)

Internal respiration

 Exchange of O2 and CO2 between blood and tissues

 Pressure of O2 higher in blood than tissues so O2 gets release into tissues.
 Pressure of CO2 higher in tissue than in blood so CO2 diffused in opposite
direction into blood
 CO2 is a waste product
 O2 used in cellular respiration

Gas transport in blood

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  Carbon dioxide
o 70 % as bicarbonate ion (HCO3-) dissolved in plasma
o 23 % bound to hemoglobin
o 7 % as CO2 dissolve din plasma
 Oxygen
o 99 % bound to hemoglobin
o 1 % as O2 dissolved in plasma

Control of breathing

 Respiratory centre in reticular formation of the brain stem

o Medullary rhythmicity centre
 Controls basic rhythm of respiration
 Inspiratory (predominantly active) and expiratory (usually inactive
in quiet respiration) neurons
 Drives muscles of respiration
o Pneumotaxic area
 Inhibits inspiratory area
o Apneustic area
 Stimulates inspiratory area, prolonging inspiration

Regulation of respiratory centre

 Chemical regulation
o Most important
o Central and peripheral chemoreceptors
o Most important factor is CO2 (and pH)
  in arterial CO2 causes  in acidity of cerebrospinal fluid (CSF)
  in CSF acidity is detected by pH sensors in medulla
 Medulla  rate and depth of breathing
o Cerebral cortex
 Voluntary regulation of breathing
o Inflation reflex
 Stretch receptors in walls of bronchi/bronchioles

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Cardiopulmonary System


Three (3) main functions:

o Transport of nutrients, oxygen, and hormones to cells throughout the

body and removal of metabolic wastes (carbon dioxide, nitrogenous
wastes, and heat).
o Protection of the body by white blood cells, antibodies, and complement
proteins that circulate in the blood and defend the body against foreign
microbes and toxins. Clotting mechanisms are also present that protect
the body from blood loss after injuries.
o Regulation of body temperature, fluid pH, and water content of cells.

 The cardiovascular system refers to the heart, blood vessels and the blood.
o At rest, the heart pumps about 59 cc (2 oz) of blood per beat and 5 l (5 qt)
per minute.
o During exercise it pumps 120-220 cc (4-7.3 oz) of blood per beat and 20-
30 l (21-32 qt) per minute.
o The adult human heart is about the size of a fist and weighs about 250-
350 gm (9 oz).
 The heart is the pump responsible for maintaining adequate circulation of
oxygenated blood around the vascular network of the body.

26
 It is a four-chamber pump, with the right side receiving deoxygenated blood from
the body at low pressure and pumping it to the lungs (the pulmonary circulation)
and the left side receiving oxygenated blood from the lungs and pumping it at
high pressure around the body (the systemic circulation).
 Blood contains oxygen and other nutrients which your body needs to survive.
The body takes these essential nutrients from the blood. At the same time, the
body dumps waste products like carbon dioxide, back into the blood, so they can
be removed.
 The vascular system consists of the arteries, veins and capillaries:
o The arteries are vessels that carry blood away from the heart to the
periphery
o The veins are the vessels that carry blood to the heart
 Blood in the veins is low in oxygen (as it has been taken out by
the body) and high in carbon dioxide (as the body has unloaded it
back into the blood). All the veins drain into the superior and
inferior vena cava which then drains into the right atrium.
o The capillaries are lined with squamous cells; they connect the veins and
arteries.

 The right atrium pumps blood into the right ventricle. Then the right ventricle
pumps blood to the pulmonary trunk, through the pulmonary arteries and into the
lungs.
 In the lungs the blood picks up oxygen that we breathe in and gets rid of carbon
dioxide, which we breathe out. The blood is becomes rich in oxygen which the
body can use. From the lungs, blood drains into the left atrium and is then

27
 pumped into the left ventricle. The left ventricle then pumps this oxygen-rich
blood out into the aorta which then distributes it to the rest of the body through
other arteries.
 The main arteries which branch off the aorta and take blood to specific parts of
the body are:

o Carotid arteries: which take blood to the neck and head

o Coronary arteries: which provide blood supply to the heart itself
o Hepatic artery: which takes blood to the liver with branches going to the
stomach
o Mesenteric artery: which takes blood to the intestines
o Renal arteries: which takes blood to the kidneys
o Femoral arteries: which take blood to the legs

The body is then able to use the oxygen in the blood to carry out its normal
functions. This blood will again return back to the heart through the veins and the cycle
continues.

The Heart

 The heart is a hollow, muscular organ about the size of a fist.

 It is responsible for pumping blood through the blood vessels by repeated,
rhythmic contractions. The heart is composed of cardiac muscle, an involuntary
muscle tissue that is found only within this organ.

o Myocardium
 The myocardium is the muscular tissue of the heart. The
myocardium is composed of specialized cardiac muscle cells with
an ability not possessed by muscle tissue elsewhere in the body.

o Pericardium
 The pericardium is the thick, membranous sac that surrounds the
heart. It protects and lubricates the heart.
 There are two layers to the pericardium: the fibrous pericardium
and the serous pericardium.

28
  The serous pericardium is divided into two layers; in between
these two layers there is a space called the pericardial cavity.

o Epicardium
 The layer next to the heart is the visceral layer, also known as the
Epicardium.
 This is the innermost layer and consists of connective tissue.

Heart Chambers

The heart has four chambers, two atria and two ventricles. The atria are smaller
with thin walls, while the ventricles are larger and much stronger.

 Atrium
o There are two atria on either side of the heart.
o The right side
 The atrium that contains blood which is poor in oxygen.
 Receives de-oxygenated blood from the superior vena cava and
inferior vena cava
o The left atrium
 Contains blood which has been oxygenated and is ready to be
sent to the body.
 Ventricles
o The ventricle is a heart chamber which collects blood from an atrium and
pumps it out of the heart
o There are two ventricles: Right Ventricle and Left Ventricle
 Right Ventricle
-Pumps blood into the pulmonary circulation for the lungs
 Left Ventricle
- Pumps blood into the systemic circulation for the rest of the
body
- Has thicker walls than right ventricle because it needs to
pump blood to the whole body.
o Ventricles have thicker walls than the atria, and thus can create the
higher blood pressure.

29
Passage of Blood through the heart

 The right pump pumps the blood to the lungs or the pulmonary circulation at the
same time that the left pump pumps blood to the rest of the body or the systemic
circulation.
 Venous blood from systemic circulation (deoxygenated) enters the right atrium
through the superior and inferior vena cava.
 The right atrium contracts and forces the blood through the tricuspid valve (right
atrioventricular valve) and into the right ventricles. The right ventricles contract
and force the blood through the pulmonary semilunar valve into the pulmonary
trunk and out the pulmonary artery. This takes the blood to the lungs where the
blood releases carbon dioxide and receives a new supply of oxygen
 The new blood is carried in the pulmonary veins that take it to the left atrium. The
left atrium then contracts and forces blood through the left atrioventricular,
bicuspid, or mitral, valve into the left ventricle.
 The left ventricle contracts forcing blood through the aortic semilunar valve into
the ascending aorta. It then branches to arteries carrying oxygen rich blood to all
parts of the body.

Conducting System of the Heart

 Consists of:
o SA node – the pacemaker
o AV node – slowest conduction
o Bundle of His – branches into the right
and the left bundle branch
o Purkinje fibers – fastest conduction

 The Heart Sounds

o S1- due to closure of the AV valves
o S2- due to the closure of the semi-lunar valves
o S3 – due to increased ventricular filling

30
o S4 – due to forceful atrial contraction

31
VI. Pathophysiology

32
33
34
A. Pathophysiology of Cor Pulmonale

1. Predisposing and Precipitating Factors

a. Age
For individuals aging 65 and above, there’s a 30% probability in surviving
5 years. Thus, mortality in aging individuals is significantly high. This is due to the
fact that aging individuals has suppressed immune system, less elastic lungs and
bronchioles, and likely to have accumulated more chemical irritants. Mr. S is 77
years old.

b. Gender
Based from the data of World Health Organization (WHO) gathered from
151 countries, 7% of adolescent girls smoke cigarettes as opposed to 12% of
adolescent boys. In the Philippines, smoking percentage of Filipinos in the age
group 13-15 years is 22.7% with more boys smoking than girls who are,
nonetheless, catching up. Despite the passage of the Tobacco Control Act of
2003, more young Filipinos are smoking today. And based on research on
tobacco adult male users, Philippines ranks 24 compared to tobacco adult female
users that ranks 69. This means that smoker males are greater than females,
thus, males are at higher risk of developing chronic obstructive pulmonary
disease and cor pulmonary.

c. Smoking
The most common cause of Cor Pulmonale is the Chronic Obstructive
Pulmonary Diseases (COPD) at approximately 85%. It has been estimated that
50% of smokers developed COPD. Numbers of studies have shown that the risk
of developing COPD and Cor Pulmonale increases with the number of cigarettes
smoked.

3 Main Components of Cigarettes:

1. Nicotine – it is absorbed in the blood and affects the brain within 10 seconds.
It causes a surge of heart rate, blood pressure and adrenaline. Because of

35
 the nature of addiction, when the effects of nicotine on the brain and body
wear off, the smoker feels worse than before. This reinforces the craving for
another cigarette.

2. Tar – it contain many poisonous substances to the body, it is a thick sticky

substance, and when inhaled it sticks to the cilia of the lungs. The tar also
coats the walls of respiratory system, narrowing the tubes that transport air
and reducing elasticity of the lungs.

3. Carbon monoxide – a poisonous chemical that decreases the amount of

oxygen in the blood, which deprives all the organs of oxygen too.

d. Air Pollution
Most farmers in urban areas use pesticides in their farms in forms of
spray which are harmful for human health and can be absorbed by the body
through skin, swallowing, and inhalation and affect the body’s neurologic and
immune system.

e. Poor health seeking behavior

Diseases develop and progress at a faster pace without any diagnosis
and treatment being done to address it. Thus, further complications appear and
prognosis becomes poorer. Mr. S exhibited a poor health seeking behavior by
not consulting any health care providers regarding the illnesses he felt unless it’s
already horrific enough for him to handle.

B. Clinical Manifestation

Cor Pulmonale originates from Chronic Obstructive Pulmonary Disease which is

commonly caused by cigarette smoking. It is an alteration in structure and function of
the right ventricle of the heart initiated by respiratory system disorders such as
COPD, having the pulmonary hypertension as its link. The common signs and
symptoms are: heart enlargement, tiredness, dyspnea, wheezing, coughing, swelling
of the feet or ankles, chest pain, bluish color to the skin, distension of the neck veins,
ascites, enlargement of the liver, and abnormal heart sounds.

36
By the book and other Actual observation
sources
 Heart enlargement All of the following were assessed by the group and
 Tiredness were stated by the patient upon the interview of his

 Dyspnea past and present illnesses:

 Wheezing breath  Heart enlargement

sounds  Tiredness

 Decreased breath  Dyspnea

sounds  Wheezing breath sounds
 Coughing  Decreased breath sounds
 Swelling of the feet or  Coughing
ankles  Ascites
 Chest pain  Abnormal heart sounds
 Bluish color to the
skin
 Distension of the
neck veins
 Ascites
 Enlargement of the
liver
Abnormal heart sounds
Diagnostic tests that can be Signs noted:
used to detect Cor ( This diagnostic test finding was done at Allah Valley
Pulmonary: Medical Center Specialist, Inc. ):
 Electrocardiography
(ECG)  Electrocardiography (ECG)
 Complete Blood Remarks:
Count (CBC) - Elevated P waves (right ventricular
 Chest x-ray hypertrophy)
 Spirometry
 CT scan of the chest  Complete Blood Count (CBC)
 Echocardiogram Remarks:
 Lung biopsy (rarely - Anemia

37
 performed)
 Measurement of These tests were not done:
blood oxygen by  Spirometry
arterial blood gas  CT scan of the chest
(ABG)  Echocardiogram
 Pulmonary function  Lung biopsy (rarely performed)
tests  Measurement of blood oxygen by arterial
 Right heart blood gas (ABG)
catheterization  Pulmonary function tests
 Ventilation and  Right heart catheterization
perfusion scan of the  Ventilation and perfusion scan of the
lungs (V/Q scan) lungs (V/Q scan)
 Bronchoscopy  Bronchoscopy

C. Complications
1. Right ventricular failure
Right ventricle acts more on volume pump than pressure pump, but ,as a
result of pulmonary vasoconstriction, pulmonary hypertension occur, creating
pressure between the lungs and the right ventricle. This causes the right
ventricle to hypertrophy and later dilate which causes the right ventricle to fail
with the work required of it.

2. Left ventricular failure

As the right ventricle hypertrophies, intraventricular septum is pushed into
the left ventricle causing it to be compromised. This leads to left ventricular
failure.

3. Shock

38
 Medically, shock is defined as a condition where the tissues in the body
don't receive enough oxygen and nutrients to allow the cells to function which
leads to cellular death. This is caused by failure of the heart to pump blood,
thus, blood doesn’t receive much oxygen and poorly delivers nutrients due to
poor circulation.

4. Death
Mortality among patients aging 65 and above diagnosed with Cor
Pulmonale is high since patients only have a 30% chance of surviving 5 years.

39
VII. Medical and Nursing Management

A. Diagnostic Tests and Laboratory Results

HEMATOLOGY September 16, 2010

Physical Properties Result Normal Value Interpretation

WBC Count 15.03 5-10x10^9/L Presence of Infection

Hemoglobin (Hgb) 125 g/L 140-170 g/L Anemia

mass concentration
Segmenter 0.76 0.55-0.65 Acute Infection, Respiratory
disease
Lymphocytes 0.18 0.26-0.36 Suggest Immunodeficiency
Disease
Eosinophils 0.25 0.02-0.04 Allergic and Infected
Monocytes 0.01 0.03-0.06 Viral disease
(May be seen on patient with
Cancer)
Platelet Count 251 150-350x10^9/L Normal

Hematocrit 0.55 0.45-0.50 vol. % Dehydration

URINALYSIS September 17, 2010

Physical Properties Result Normal Value Interpretation

Color Yellow/ Straw, amber Bacteremia, Infection
Appearance Hazy
Reaction 6.0 4.5-8 Normal
Specific Gravity 1.015 1.010-1.025 Normal

Sugar Negative Negative Normal

Albumin Trace Negative Normal
RBC 0-2hpf 1-2hpf Normal

B. Drug Studies

40
 Here is a list of drugs that were ordered to Mr. S with a diagnosis of Cor
Pulmonale, COPD.

1. Isosorbide Mononitrate (Imdur) 60 mg ½ tab OD.

2. Loratidine (Zylohist) 1 amp 1tab OD

3. Salbutamol (Ventolin) 1 Nebule T.I.D

4. Ampicillin (Excillin) 500 mg IVTT q6 hours.

5. Cefuroxime (Zinnat) 500 mg 1tab T.I.D q8 hours.

6. Hyoscine 1 amp IVTT stat.

Drug Study #1

41
 Generic Name: Isosorbide mononitrate
Name of the drug
Brand Name: Imdur
Functional
Classification Cardiovascular system drug

Chemical
Classification Antianginal, vasodilator

Doctor’s Order Isosorbide Mononitrate (Imdur) 60 mg ½ tab OD

Date Ordered September 16, 2010

Isosorbide may interact with nitrate receptors in vascular smooth-

muscles membranes. By interacting with nitrate receptors’
sulfhydryl groups, the drug is reduced to nitrate oxide. Nitrate oxide
Mechanism of Action activates the enzyme guanylate cyclase, increasing intracellular
formation of cyclic guanosine menofusfate (cGMP). An increase
cGMP level may relax vascular smooth muscle by forcing calcium
out of muscle cells, causing vasodilation. This improves cardiac
output by reducing primarily preload but also afterload.
Specific Indication To treat or prevent angina.

Contraindicated to patients hypersensitive to drug.

Contraindication Angle-closure glaucoma, head trauma.

Ideal Dosage Adults: 5 to 40 mg q 6 hr, adjusted as needed (dinitrate); 20 mg in

2 doses given 7 hours apart (mononitrate).
CNS: agitation, confusion, dizziness, headache, insomnia,
restlessness, syncope, vertigo, weakness.
CV: arrhythmias, orthostatic hypotension, palpitations, peripheral
edema, tachycardia.
Adverse Reaction EENT: blurred vision, diplopia (all drug forms); sublingual burning
(S.L. form)
GI: abdominal pain, diarrhea, indigestion, nausea, vomiting
GU: dysuria, impotence, urinary frequency

42
 HEME: hemolytic anemia
MS: arthralgia, muscle twitching
RESP: bronchitis, pneumonia, upper respiratory tract infection
SKIN: diaphoresis, flushing, rush
Other antihypertensive agents, e.g. beta-blockers, calcium
Drug Interaction antagonists; vasodilators; neuroleptics or tricyclic antidepressants
(TCADs), alcohol; dihydroergotmine, non-steroidal anti-
rheun=matic drugs, sildefenil, narcotics, antihistamines,
anticholinergics.
1. Observe patients ’10 rights’ in drug administration.
2. Monitor patient’s vital signs to serve as baseline data and
to determine the effectiveness of the drug.
3. Use isosorbide cautiously in patients with hypovolemia or
mild hypotension. Monitor for increased hypotension and
reduced cardiac output.
Nursing 4. Give drug 1 hour before or 2 hours after meals. Give with
Responsibilities meals if patient experiences severe headache or adverse
GI reactions.
5. Know that patient may experience daily headaches from
isosorbide’s vasodilating effects. Give acetaminophen, as
prescribed, to relieve pain.
6. WARNING: Be aware that abrupt drug discontinuation may
cause angina and increase the risk of MI.
7. Teach patient and family to recognize signs and symptoms
of angina, including chest pain, fullness, or pressure which
commonly is accompanied by sweating and nausea. Pain may
radiate down the left arm or into the neck or jaw.
8. Advice patient not to crush or chew isosorbide E.R.
capsules or tablets or S.L. tablets unless specifically ordered
to do so.
9. Instruct patient to take drug before any situation or activity
that might precipitate angina.
10. Advice patient to carry isosorbide with him at all times.
11. Warn patient that abrupt drug discontinuation may cause
angina and increase the risk of MI.

43
 12. Instruct patient to report blurred vision, fainting,
increase angina attacks, rash, and severe or persistent
headache.
13. Advice patient to avoid potentially hazardous activities until
drug’s Central Nervous System effects are known.
It is used as a direct vasodilator to treat congestive heart failure,
Rationale which involve decreased blood supply leading to poor healing.

Drug study #2

Name of drug: Generic name: Loratidine

Brand name: Zylohist

Functional Respiratory Tract Drug

Classification:
Chemical Antihistamine, second generation, piperidine.
Classification:
Doctor’s Order: Loratidine (Zylohist) 1 amp 1tab OD

Date Ordered: September 17, 2010

Mechanism of Action: Loratadine is chemically related to azatadine. It is given in single

daily doses by mouth for symptomatic relief of hypersensitivity
reactions including rhinitis and skin disorders.

Loratadine is a potent long-acting antihistamine with a high

degree of specificity for histamine H1-receptor. Loratadine does
not generally cause sedation or antimuscarinic effects. It has very
limited penetration into the Central Nervous System. The result is
virtual freedom from untoward sedative side effects.
Specific Indication: Treatment of seasonal allergic rhinitis, perennial rhinitis, urticaria,
allergic dermatologic disorders, angioedema and conjunctivitis.
Loratadine is generally considered to be ineffective in asthma.
Contraindication: Loratadine is contraindicated in patients with history of

44
 hypersensitivity to the drug. This group of patients has an
increased susceptibility to antimuscarinic effects.
Ideal Dosage: Adults and Children >30 kg: 10 mg daily.

Adverse Reaction: CNS: headache, drowsiness, fatigue, insomnia, nervousness

GI: dry mouth
Drug Interaction: Warfarin and acarbose, concurrently may increase the
anticoagulant effect of warfarin. Sucrose and foods containing
sucrose. Met for min, insulin. Digoxin. Avoid cholestyramine,
intestinal absorbents and digestive enzyme products. Drugs that
produce hyperglycemia (e.g. corticosteroids, diuretics, thyroid
preparations). May lead to glucose control. Hypoglycaemia may
occur with concurrent sulfonylurea treatment.
Nursing 1. Observe patients ’10 rights’ in drug administration.
Responsibilities: 2. Monitor patient’s vital signs to serve as baseline data and
to determine the effectiveness of the drug.
3. List reasons for therapy, type, onset, characteristics of
signs & symptoms. List other agents trialed; outcome.
4. Monitor LFT’s; reduced dose with dysfunction. Assess
elderly and clients with hepatic and renal impairment for
increasing somnolence.
5. Note pulmonary findings; assess throat, cervical nodes,
turbinate, skin testing when necessary.
6. Identify triggers contributing to allergic S&S. advice patient
to remove carpet, enclose mattress and pillows in plastic,
control dust, vacuum regularly, removed pets and plants
from sleeping area.
7. Review drug profile. Cautiously co-administer with drugs
that inhibit hepatic metabolism (i.e., macrolides antibiotics,
cimetidine, ranitidine, ketoconazole or teophylline).
Rationale: To treat for seasonal allergic rhinitis, perennial rhinitis, urticaria,
allergic dermatologic disorders, ashma, and conjunctivitis.

Drug study #3

45
Name of drug: Generic name: Salbutamol

Brand name: Ventolin

Functional Selective beta 2-adrenergic agonist, sympathomimetic ;
Classification: Respiratory Tract Drug
Chemical Bronchodilator
Classification:
Doctor’s Order: Salbutamol (Ventolin) T.I.D

Date Ordered: September 17, 2010

Stimulates beta-2 receptors of bronchioles by increasing levels of

cAMP which relaxes smooth muscles to produce brochodilatation.
Mechanism of Action: Also cause CNS stimulations, cardiac stimulation, increase
diuresis, skeletal muscles tremors, and increased gastric acid
secretions. Longer acting than isoproterenol.
Relief bronchospasm in bronchial ashma, chronic bronchitis,
Specific Indication: emphysema and other reversible, obstructive pulmonary disease.
Also useful for treating bronchospasm in patients with coexisting
heart disease of hypertension.
Patients with a history of hypersensitivity to any of the components
Contraindication: of Ventolin, Ventolin Expectotant Syrup, Ventolin Inhaler, Ventolin
Nebules and Ventolin Rotacaps.
Salbutamol has a duration of action of 4-6 hrs in most patients.
Ideal Dosage: Capsule: Adults and Children >12 years: 1-2 caps 2 or 3 times a
day.

CNS: tremor, nervousness, dizziness, insomnia, headache,

hyperactivity, weakness, CNS stimulation, malaise
CV: tachycardia, palpitations, hypertension
EENT: dry and irritated nose and throat with inhaled form, nasal
Adverse Reaction: congestion, epistaxis, hoarseness
GI heartburn, nausea, vomiting, anorexia, bad taste, increased
appetite
Metabolic: hypokalemia
Musculoskeletal: muscle cramps
Respiratory: bronchospasm, cough, wheezing, dyspnea,

46
 bronchitis, increased sputum
OTHER: hypersensitivity reactions
Beta-adrenergic blockers. Concomitant use of theophylline and
other xanthine derivatives, steroids and diuretics may potentiate
salbutamol-induce hypokalemia in acute severe asthma.
Drug Interaction: Sedatives, tricyclic antidepressants(TCAs), monoamine oxidase
inhibitors(MAOIs) and hypoglycemic drugs. Corticosteroids,
digitalis. Other adrenergic stimulants or sympathomimetic amines
ephedrine, and diuretics.
1. Observe patients ’10 rights’ in drug administration.
2. Monitor patient’s vital signs to serve as baseline data and
to determine the effectiveness of the drug.
3. Salbutamol may decrease sensitivity of spirometry used for
diagnosis of asthma.
Nursing 4. Alert: patient may use tablets and aerosol together. Monitor
Responsibilities: these patients closely for signs and symptoms of toxicity.
5. Alert: Don’t confuse albuterol with atenolol or albutein of
flomax with volmax.
6. Warn patient about possibility of paradoxical
bronchospasm. Tell him to stop drug immediately if it
occurs.
7. Teach patient to perform oral inhalation correctly. Give the
following instruction for using MDI:
- Shake the inhaler
- Clear nasal passage and throat.
- Breath out, expelling as much air from lungs as
possible.
- Place mouth piece well into mouth, seal lips around
mouth piece, and inhale deeply as you release a dose
from inhaler. Or, you may hold inhaler about 1 inch from
your open mouth; inhale while dose is released
- Hold breath for several seconds, remove mouthpiece,
and exhale slowly.
8. If prescriber orders more than 1 inhalation, tell patient to

47
 wait at least 2 minutes before repeating procedures.
9. Tell patient that use of an aerochamber may improve drug
delivery to lungs.
10. Tell patient to remove canister and wash inhaler with warm,
soapy water at least once a week.
11. Advise patient not to chew or crush extended-release
tablets and not to mix them with food.
Rationale: To relief bronchospasm in conditions such as asthma and chronic
obstructive pulmonary disease.

Drug study #4

Name of Drug: Generic name: Ampicillin

Brand name: Excillin

Functional: Antibiotic/ Anti-infectives

Classification:
Chemical Semisynthetic amonoenicillin: Penicillins
Classification:
Doctor’s Ordered: Ampicillin (Excillin) 500 mg IVTT q6 hours.

Date of Ordered: September 17, 2010

Mechanism of Action: Inhibits bacterial cell wall synthesis. The rigid, cross-linked cell wall
is assembled in several steps. Ampicillin exerts its effects on
susceptible bacteria in the final stage of the cross-linking process
by binding with and in activating penicillin-binding proteins
(enzymes responsible for linking the cell wall strands). This action
causes bacterial cell lysis and death.
Specific Indication: Infections of the respiratory tract, ENT, GIT, GUT, systemic
infections.
Contraindication: Hypersensitivity to penicillins or cephalosporins. Infectious
mononucleosis, lymphocytic leukemia. Pregnancy & lactation.
Ideal Dosage: Adult 2-6 g daily.

Nausea, vomiting, diarrhea. In rare cases, jaundice or hepatitis.

48
 Very rarely, pseudomembranous colitis. Hypersensitivity reactions
including anaphylactic shock, in patients whose anamnesis reveals
Adverse Reaction: the existence of allergies, asthma, hay fever or urticaria.
Appearance of erythema is particularly common in infectious
mononucleosis. Isolated cases: Eosinophilia, neutropenia,
agranulocytosis, thrombocytopenia, anemia & renal function
disorders.
Allopurinol: increased risk of rash, particularly in hyperurisemic
patient
Aminiglycosides: possibly inactivated action of aminoglycoside and
Drug Interaction: ampicillin when given together
Heparin, oral anticoagulants: increased risk of bleeding
Probenicide: Possibly increased serum ampicillin level and
ampicillin toxicity
Tetracyclines: possibly impaired action of ampicillin
1. Observe patients ’10 rights’ in drug administration.
2. Monitor patient’s vital signs to serve as baseline data and
Nursing to determine the effectiveness of the drug.
Responsibilities: 3. Expect to administer ampicilin for 48 to 72 hours after
patient becomes asymptomatic. For streptococcal infection,
expect to administer ampicillin for at least 10 days after
cultures shows streptococcal eradication to reduce risk of
rheumatic fever or glomerulonephritis.
4. To dilute ampicillin fo I.M. use, add 1.2 ml of sterile water or
bctreiostatic water for injection to each 125-mg vial, 3.5 ml
of diluents to each 2-g vial.
5. WARNING: infuse I.V. over 3 to 5 minutesfor each 125 or
500 mg or over 10 to 15 minutes for each 1 or 2 g. more
rapid infusion may cause seizures.
6. Monitor patient closely for anaphylaxis, which may be may
be life-threatening. Patients at greater risk are those with
historyof multiple allergies, hypersensitivity to
cephalosphorins, or history of asthma, hay fever, or
urticaria.
7. If long-term or high-dose ampicillin therapy is required,

49
 closely monitor results of renal and liver function test and
CBCs.
8. Teach patient to recognize signs of allergic reaction
reaction and, if they occur, to withhold next ampicillin dose
nd contact prescriber immediately.

Rationale: Ampicillin is a beta-lactam antibiotic that has been used

extensively to treat bacterial infections.

Drug study #5

Name of Drug: Generic Name: Cefuroxime

Brand Name: Zinnat

Functional Antibiotic/Anti-infectives
Classification:

Chemical Second generation Cephalosporin, 7-amonicephalosporanic acid.

Classification:

Doctor’s Ordered: Cefuroxime (Zinnat )500 mg 1tab T.I.D q8 hours.

Date of Ordered: September 18-20, 2010

It is a well-characterized and effective antibacterial agent which

has bactericidal activity against a wide range of common
pathogens, including β-lactamase-producing strains.

Mechanism of Action: Cefuroxime has good stability to bacterial β-lactamase, and

consequently is active against many ampicillin-resistant or
amoxicillin-resistant strains.

The bactericidal action of cefuroxime results from inhibition of cell

wall synthesis by binding to essential target proteins.
Upper respiratory tract infections eg, ear, nose and throat
Specific Indication: infections, eg, otitis media, sinusitis, tonsillitis and pharyngitis.

50
 pneumonia, chronic bronchitis, pyelonephritis, cystitis, urethritis
Contraindication: Known hypersensitivity to cephalosporin antibiotics.

Ideal Dosage: Adults: tablets. 250 to 500 mg b.i.d for 10 days.

IMMUNE SYSTEM DISORDERS: Hypersensitivity reactions

including: Skin rashes, Urticaria, pruritus, Drug fever, serum
sickness, anaphylaxis.

NERVOUS SYTEM DISORDERS: Common: Headache, dizziness.

Adverse Reaction:
GASTROINTESTINAL DISORDERS: Common: Gastrointestinal
disturbances including diarrhea, nausea, abdominal pain.
Uncommon: Vomiting. Rare: Pseudomembranous colitis.

HEPATOBILIARY DISORDERS: Common: Transient increases of

hepatic enzyme levels, [ALT (SGPT), AST (SGOT), LDH]. Very
rare:Jaundice (predominantly cholestatic), hepatitis.

SKIN AND SUBCUTANEOUS TISSUE DISORDERS: Very

rare:Erythema multiforme, Stevens-Johnson syndrome, toxic
epidermal necrolysis (exanthematic necrolysis).
Drugs which reduce gastric acidity may result in a lower
bioavailability of Zinnat compared with that of the fasting state and
Drug Interaction: tend to cancel the effect of enhanced absorption after food.
In common with other antibiotics, Zinnat may affect the gut flora,
leading to lower estrogen reabsorption and reduced efficacy of
combined oral contraceptives.
1. Observe patients ’10 rights’ in drug administration.
2. Monitor patient’s vital signs to serve as baseline data and to
determine the effectiveness of the drug.
3. Use cepheroxime cautiously in patients hypersensitive to
penicillin because cross sensitivity has occurred in 10 % of
such patients.
Nursing 4. if possible, obtain culture and sensitivity results, as
Responsibilities: ordered, before given drugs.
5. Give oral form with food to decrease GI distress, as needed.

51
 6. Store reconstituted parenteral drug for up to 24 hours at
room temperature or 96 hours in refrigerator.
7. Monitor Blood Urine Nitrate and serum creatinine levels to
detect signs of nephrotoxicity. Also monitor fluid intake and
output; decreasing urine output may indicate nephrotoxicity.
8. Monitor patient for allergic reaction a few days after therapy
starts.
9. Assess bowel pattern daily; severe diarrhea may indicate
pseudomembranous colitis.
10. Urge patient to complete prescribed course of therapy.
To treat Upper respiratory tract infections such as ear, nose and
Rationale: throat infections, otitis media, sinusitis, tonsillitis and pharyngitis.
pneumonia, chronic bronchitis, pyelonephritis, cystitis, urethritis

Drug study #6

Name of Drug: Generic Name: Scopolamine

Brand Name: Hyoscine

Functional Autonomic nervous system drug

Classification:

Chemical Anesthesia adjunct, anticholinergic, antiemetic, antispasmodic,

Classification: antivertigo

Doctor’s Ordered: Hyoscine 1 amp IVTT stat.

Date of Ordered: September 18, 2010

Competitively inhibits acetylcholine at autonomic postganglionic

cholinergic receptors. Because the most sensitive receptors are
the salivary, bronchial, and sweat glands, this action reduce
secretions from these glands. Scopolamine reduces GI smooth-
muscle tone; decrease gastric secretions and GI motility; reduces
nasal, oropharyngeal , and bronchial secretions; and decreases

52
Mechanism of Action: airway resistance by relaxing smooth muscle in the bronchia and
bronchioles.
Scopolamine also blocks neutral pathways in the inner ear. This
action relieves motion sickness and depresses the cerebral cortex
to produce sedation and hypnotic effects.
To treat billary tract disorders, enuresis, nausea and vomiting, and
Specific Indication: nucturia

Angle-closure glaucoma; hemorrhage with hemodynamic

instability; hepatic dysfunction; hypersensitivity to barbiturates,
scopolamine, other belladonna alkaloids, or their components,
ilues; intestinal atony; myasthenia gravis; myocardial ischemia;
Contraindication: obstructive GI disease, such as pyloric stenosis; obstructive
uropathy, as in prostatic hyperplasia; renal impairment,
tachycardia; toxic megacolon; ulcerative colitis.
Ideal Dosage: Adults: IVTT 300 to 600 mcg as a single dose

CNS: Dizziness, drowsiness, euphoria, insomnia, memory loss,

paradoxical, stimulation.
CV: palpitations, tachycardia.
Adverse Reaction: EENT: Blurred vision; dry eyes, mouth, nose and throat,
mydriasis.
GI: Constipation, dysphagia,
GU: urinary hesitancy, urine retention
SKIN: decreased sweating, dry skin, flushing
OTHER: Injection site irritation or redness.
Many drugs interact with nonprescription (over-thecounter) drugs
and herbal remedies. Patients should always tell their health care
providers about these remedies, as well as prescription drugs they
are taking. Patients should also mention if they are on a special
diet such as low salt or high protein.
Scopolamine interferes with the absorption of ketoconazole
Drug Interaction: (Nizoral), an antifungal drug, sometimes used to treat prostate
cancer. It may also interact with other anticholinergic drugs (drugs
that block nerve impulses), antidepressants, and antihistamines.

53
 Scopolamine decreases the absorption of phenothiazines
(antipsychotic drugs), and interfers with the effectiveness of
levodopa, a drug given to treat Parkinson's disease.
Tell your doctor of all prescription and nonprescription medication
you may use, especially: antihistamines (e.g., chlorpheniramine,
diphenhydramine), certain antidepressants (tricyclics such as
amitriptyline or nortriptyline), quinidine, amantadine, disopyramide,
dicyclomine, metoclopramide, MAO inhibitors (e.g., furazolidone,
linezolid, phenelzine, procarbazine, selegiline, tranylcypromine),
adrenalin-like drugs (e.g., ephedrine, pseudoephedrine). Do not
start or stop any medicine without doctor or pharmacist approval.

1. Observe patients ’10 rights’ in drug administration.

2. Monitor patient’s vital signs to serve as baseline data and to
determine the effectiveness of the drug.
3. For IV injection, dilute scopolamine with sterile water for
injection.
4. Assess for bladder distension and monitor urine output
Nursing because drug’s antimuscarinic effects on the ureters and
Responsibilities: bladder can cause urine retention
5. Monitor for pain. In presence of pain drug may act as a
stimulant and produce delirium if used without morphine or
meperidine.
6. Monitor heart rate for transient tachycardia, which may occur
with high dose of scopolamine. Expect normal rate to return
within 30 minutes.
7. Instruct patient to avoid alcohol while taking oral forms of
scopolamine.
8. If patient complains of dry eyes, suggest lubricating drops.

To treat billary tract disorders, enuresis, nausea and vomiting, and

Rationale: nucturia.

54
C. Health Teaching

MEDICATION

1. Inform the patient and the significant others about the medications indicated for
home regimen, their purpose, route and frequency of administration.

® To promote wellness and faster recovery and maintenance of good condition of the
client.

2. Educate about the purpose of the medications.

®In order to promote trust and what to expect during the drug therapy.

3.    Instruct/emphasize the importance of taking the medication at prescribe dose,

prescribe time and frequency.

®In order to avoid accidents in medications such as drug toxicity or over dosage

4.    Client should be aware of the different side effects and adverse effect of each drug.

®In order for the patient to act appropriately in the given side effects

5. Instruct the client and family not to take medicines which are not prescribed.

® To avoid unnecessary complications

EXERCISE

1. Encourage significant others to let patient have non-strenuous exercises such as

walking.

® To promote good blood circulation

2. Instruct Family to provide client with enough sleep and rest periods.

® To assist in healing process and avoid unnecessary use of energy which might stress
the client

55
3. Encourage to have deep breathing exercise.

® This prevents over-exerting the heart 

TREATMENT

1. Encourage to comply treatment regimen

®To attain the maximum effectiveness and wellness of the therapy.

2. Instruct client that not to take any medications that is not prescribed by the
physician.

®To prevent unwanted side/adverse effect

3. Instruct on how to prepare oral medicines and their frequency and dosage when
taking the medicines.

® To prevent under and / or over dosing that can alter the effectiveness of the
drug

4. Emphasize the importance of submitting self in a health care institution not just when
there is an occurrence of an illness but for the purpose of monitoring current health
status as well.

® Prevention is better than cure, and it is much easier to deal with an illness detected
earlier in the disease process.

HYGIENE

1. Encourage continuity of hygienic measures practiced at present such as daily

bathing, wearing footwear, brushing of teeth, grooming of self, and maintaining own
supplies/ items for personal necessities.

56
® Hygiene promotes comfort and cleanliness to the patient. Owning personal
accessories for hygienic purposes keep client away from contamination and infectious
disease.

2. Inform client and family in providing clean environment

® Clean environment is important to prevent occurrence of another infection which will

place him at risk.

3. Encourage to wash hands properly before and after eating and after using the toilet,
after coughing or sneezing.
® To deter the spread of the microorganism

OUTPATIENT ORDER

1. Inform the patient that follow-up check up is important to have continuous

monitoring and care even after attainment of course medical therapy.

® Through constant visits as outpatient, the physician would know the progress of the
therapeutic intervention availed by the patient.

2. Educate about the importance of the complying the doctor’s order

® The Physician’s order is the most important thing to be followed in order to treat any
abnormalities felt by the client

3. Instruct to promote healthy lifestyle by eating nutritious foods, exercising regularly

and avoiding stress as much as possible.

®Taking good care of our body plays a big role in the good prognosis of the disease
process.

DIET

1. Discourage much eating of sweet, fatty and salty foods and also limit intake of soft
drinks and alcohol.

®Very sweet, salty and fatty foods do not give healthy benefits to our body. Moreover,
sweet foods and beverages may cause an increase in the sugar level of the body that
isn’t good for her condition.

57
 2. Instruct to comply with the dietary prescription to the client.

® following dietary prescription is necessary since diet is one of the factors contributing
to the occurrence of the disease.

3. If there are cases that he is not in a good appetite, encourage her to take small
frequent feedings as possible.

® Providing small frequent feedings for instance of altered good appetite may prevent
occurrence of problems and further complications.

D. Prognosis

Poor Fair Good Justification

1.) Duration of Illness The patient is having the signs and

symptoms of the disease for a long
time, yet diagnosed at the age of 77.

2.) Onset of Illness The onset of patient’s disease was

not given immediate attention.

3.) Precipitating Factors The patient admits he used to smoke

1-2 packs a day and usually eats
salty and fatty foods.

4.) Willingness to take He is submissive to whatever

medications treatment he has to undergo to
suppress his condition.

5.) Age The patient is already 77 years old

which means his body function is
already decreasing.

6.) Environment At the moment the patient is

currently at Purok Small Spring Brgy.
Tupi South Cot. a place where clean
and soothing surrounding, but

58
 exposed to harmful toxins during
spraying of pesticides.

7.) Family Support Once they learned of the patient’s

confinement, the family has been
very supportive in physiological,
emotional and financial aspect. They
are all willing to assist the patient in
his treatment, yet his children were
not present during the entire
admission, due to their occupations
abroad.

Computation: Scoring for general prognosis

1x4=4 1- 1.6 = POOR

2x2=4 1.7- 2.3 = FAIR

3x1=3 2.4 – 3.0 = GOOD

11/ 7 = 1.57 = POOR

General Prognosis:

Overall, the prognosis is POOR. This is for the reason that the patient’s condition
has been transpiring for years. He had attacks in the past and his condition has
complications already. Regardless of the patient’s willingness to comply with all the
medical regimens that would possibly help his condition there is only small hope.

59
E. Problem Lists and NCPs

a. Problem list

NURSING DIAGNOSIS CUES

SUBJECTIVE:
“Gina-hapo ako.”

OBJECTIVE:
Ineffective Airway Clearance related to -RR= 31bpm (tachypnea)
presence of tracheobronchial secretions. -dyspnea noted
-wheezing upon auscultation noted
-productive cough: color: yellow-green;
consistency:sticky
-labored breathing noted.
-difficulty in vocalizing noted
-weak peripheral pulses noted

SUBJECTIVE:
“Medyo nabudlayan ako mag-ginhawa.”

Impaired gas exchange related to alveolar

wall destruction. OBJECTIVE:
-RR= 31 bpm (tachypnea)
-dyspnea noted
-body malaise noted
-restlessness noted
-labored breathing noted
-difficulty in vocalizing noted

60
 SUBJECTIVE:
“Nag-luya ang tiil ko, hindi ako makalakat.”

OBJECTIVE:
Ineffective tissue perfusion related to -RR= 31bpm (tachypnea)
impaired ciliary action. -dyspnea noted
-wheezing upon auscultation noted
-body malaise noted
-labored breathing noted
-difficulty in vocalizing noted
-weak peripheral pulses noted
-claudication noted.
-altered mental status noted

SUBJECTIVE:
“Hindi ako makalakat.”
Activity Intolerance to imbalance oxygen
supply and demand. OBJECTIVE:
-restlessness noted
-claudication noted
-poor muscle strength and tone noted
-quivering upon hand movement noted
-difficulty in vocalizing noted
-decreased ROM noted

Altered Nutrition: less than body SUBJECTIVE:

requirements related to fatigue and “Wala ako gana mag-kaon,”
dyspnea.

OBJECTIVE:

61
 - RR= 31bpm (tachypnea)
-dyspnea noted
-restlessness noted
-body malaise noted
-labored breathing noted
-dry lips noted
-poor muscle strength and tone noted
-decreased in food and fluid intake

b. Nursing Care Plan

62
 NURSING CARE PLAN

Date Assessment Needs Nursing Background Planning Intervention with Evaluation

Diagnosis Knowledge Rationale

S SUBJECTIVE: P Ineffective Presence of secretions GENERAL: INDEPENDENT: After 8 hours of

E H Airway in the bronchi will result nursing
P “Gina-hapo Y Clearance into a blockage of air After 8 hours of 1. Monitored vital interventions, goal
T ako.”, as stated S related to that will enter the body nursing signs, especially was partially met.
E by the patient. I presence of and thus producing interventions, the respiratory rate to Patient was able to
M O tracheobronc insufficient air needed patient will be able determine any improve airway
B L hial by the body. And to improve airway abnormalities. patency,
E O secretions. inability to maintain patency. 2. Auscultated lungs expectorated
R OBJECTIVE: G clear airway. This for adventitious secretions, and
I obstruction is further breath sounds which respiratory rate
17, -RR= 31bpm C heightened by  SPECIFIC: could indicate decreased from 31
(tachypnea) bronchospasm due to serious to 29 bpm.
2 -wheezing the contraction of the 1. The patient will complications.
0 upon N smooth muscles in the expectorate 3. Assessed
1 auscultation E bronchi. This is caused secretions characteristics of
0 noted. E by parasympathetic properly. secretions: quantity,
-productive D stimulation of the 2. Patient’s color, consistency to
cough: color: S muscarinic2 receptors Respiratory note for
yellow-green; as well as by chemical Rate will abnormalities.
consistency:sti mediators released in decrease from 4. Assisted patient to
cky response to the 31 to 25 bpm. assume a position of
-labored presence of allergen comfort by elevating
breathing the head of the bed
noted. to facilitate
-difficulty in breathing.
vocalizing By: 5. Observed
noted. characteristics of
NursesLabs
-weak – January 28, cough to monitor the
2010Posted in: Nursing
peripheral severity of the
Care Plans,
pulses noted. Respiratory disease.
6. Assisted in position
http://nurseslabs.com/n
ursing-care- changes to promote
plans/bronchial-
comfort.
asthma-nursing-care-
plans/ 7. Maintained patient
on moderate high
back rest to facilitate
breathing.
 NURSING CARE PLAN
Date Assessment Needs Nursing Background Planning Intervention with Evaluation
Diagnosis Knowledge Rationale

S SUBJECTIVE: P Impaired gas The alveolar GENERAL: INDEPENDENT: After 8 hour of

E H exchange destruction leading to nursing
P “Medyo Y related to airspace enlargement After 8 hours of 1. Established rapport interventions, goal
T nabudlayan S inflammation in patients with end- nursing interventions, to obtain trust from was partially met.
E ako mag I of alveolar stage chronic the patient will the patient. Patient improved
M ginhawa”, as O walls. obstructive pulmonary improve gas 2. Monitored vital gas exchange,
B stated by the L disease (COPD) is exchange. signs, especially respiratory rate
E patient. O frequently progressive, respiratory rate to decreased from 31
R G despite smoking determine to 29, expectorated
I cessation. Several SPECIFIC: abnormalities. secetions, labored
17, OBJECTIVE: C laboratories have 3. Evaluated current breathing was
-RR= 31 bpm accumulated data 1. Patient’s smoking status to minimized, and
2 (tachypnea) demonstrating the Respiratory rate obtain baseline promoted adequate
0 -body malaise N presence of immune will decrease from data. rest and sleep.
1 noted. E cells in bronchial 31 to 25 bpm. 4. Auscultated breath
0 -restlessness E biopsy specimens and 2. Patient will sounds which could
noted. D lung tissue sections expectorate indicate serious
-labored S from patients with secretions readily. complications.
breathing COPD. Recently, the 3. Labored breathing 5. Evaluated current
noted. accumulation of T and will be minimized. exposure to toxins
-difficulty in B lymphocytes, often 4. Promote adequate or pollutants which
vocalizing forming follicles, in the rest and sleep. could be one factor
noted. lung parenchyma from in the disease
patients with severe process.
COPD has been 6. Educated regarding
reported. In addition, it the hazards of
has been postulated smoking and it’s
that there might be an relation to COPD.
autoimmune 7. Positioned into a
component to COPD. high back rest to
T-cell receptor analysis facilitate breathing.
has provided data 8. Instructed patient to
consistent with the have adequate rest
concept of T-cell and sleep to reduce
clones in the lung patient’s tissue
tissue from patients oxygen demand.
with COPD. 9. Recorded intake
and output to
AUTHORS: monitor patient’s
Laima Taraseviciene- fluid status.
Stewart, Ivor S.
Douglas, Patrick S.
Nana-Sinkam, Jong D.
Lee, Rubin M. Tuder,
Mark R. Nicolls and
Norbert F. Voelkel
http://pats.atsjournals.o
rg/cgi/content/full/3/8/6
87
 NURSING CARE PLAN

Date Assessment Needs Nursing Background Planning Intervention with Evaluation

Diagnosis Knowledge Rationale

S SUBJECTIVE: P Ineffective The lining of the GENERAL: INDEPENDENT: After 8 hours of

E “Nag-luya ang H tissue lungs are covered nursing interventions,
P tiil ko, indi ako Y perfusion with tiny hair like After 8 hours of nursing 1. Monitored vital goal was partially met.
T makalakat.” S related to structures called cilia interventions, the signs, especially and respiratory rate
E I increased that continuously patient will improved respiratory rate to decreased from 31 to
M O peripheral beat outwardly in tissue perfusion as determine any 29 bpm.
B L resistance. order to sweep and evidenced by improved abnormalities.
E O clean harmful motor and sensory
R G material out of the function. 2. Kept watched and
OBJECTIVE: I lungs. Poisonous assisted in
17, -RR= 31bpm C chemicals and toxins performance of ADL’s
(tachypnea) that are inhaled into SPECIFIC: to prevent accidental
2 -wheezing the lungs with the falls or injuries.
0 upon N tobacco smoke, such 1. Eradicate habits
1 auscultation E as hydrogen cyanide which could 3. Encouraged to have
0 noted. E paralyse the cilia and compromise his adequate rest and
-body malaise D slow down their condition. sleep to minimize
noted. S movement. This oxygen demand.
-labored means that some of 3. Respiratory rate will
breathing the chemicals will decrease from 31 to 4. Encouraged smoking
noted. enter the lungs and 29 bpm. cessation to prevent
-difficulty in remain there instead vasoconstriction and
vocalizing of being cleared. may further
noted. Over time, exposure compromise
-weak to tobacco smoke will perfusion.
peripheral stop the cilia action
pulses noted altogether, 5. Instructed to have
-claudication dangerous chemicals dietary changes or
noted. will build up in the restrictions such as
-altered lungs, causing illness reduction in
mental status and the lungs will cholesterol intake,
noted. become more salty foods and high
susceptible to viral or low protein intake.
infections and
bacteria. 6. Monitored intake and
output to obtain
patient’s fluid status
Copyright 2005-2010
helpwithsmoking.com

http://www.helpwiths
moking.com/smoking
-and-copd.php
IX. Bibliography

Web Resources:

 http://en.labs.wikimedia.org/wiki/Human_Physiology/The_cardiovascular_system
 http://www.ehow.com/about_4867853_anatomy-physiology-human-respiratory-
system.html
 http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/C/Circulation.html
 http://webschoolsolutions.com/patts/systems/heart.htm
 http://www.le.ac.uk/pa/teach/va/anatomy/case1/frmst1.html
 http://nurseslabs.com/nursing-care-plans/bronchial-asthma-nursing-care-plans/
 http://pats.atsjournals.org/cgi/content/full/3/8/687
 http://www.helpwithsmoking.com/smoking-and-copd.php
 http://www.nationmaster.com/graph/hea_tob_adu_mal_smo-health-tobacco-
adult-male-smokers#
 http://www.nationmaster.com/graph/hea_tob_adu_fem_smo-health-tobacco-
adult-female-smokers
 http://www.abs-cbnnews.com/nation/05/30/10/filipino-girls-among-highest-
smokers-world-who
 http://www.nationmaster.com/graph/hea_tob_adu_mal_smo-health-tobacco-
adult-male-smokers
 http://www.globalissues.org/news/2010/08/10/6577
 http://www.abs-cbnnews.com/nation/05/30/10/filipino-girls-among-highest-
smokers-world-who
 http://www.le.ac.uk/pa/teach/va/anatomy/case1/frmst1.html
 http://www.virtualmedicalcentre.com/anatomy.asp?sid=16
 http://www.cliffsnotes.com/study_guide/Functions-of-the-Cardiovascular-
System.topicArticleId-22032,articleId-21963.html
 http://catalog.nucleusinc.com/generateexhibit.php?ID=9572
 http://en.wikibooks.org/wiki/Anatomy_and_Physiology_of_Animals/Cardiovascula
r_System/The_Heart
 http://www.docstoc.com/docs/21372820/The-Anatomy-and-Physiology-of-the-
Cardiovascular-System
 http://www.scribd.com/doc/22609742/12-Cranial-Nerves-and-Assessment
 http://en.wikipedia.org/wiki/Extraocular_muscles
Book Resources:

 Nurse’s Pocket Guide (Diagnoses, Prioritied Interventions, and Rationale 11th

Edition) Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr .© 2008
Pages 77-80, 140-144, 337-341
 Sparks and Taylor’s (Nursing Diagnosis, Reference Manual 6th Edition) Sheila
Sparks Ralph, RN,DNSc, FAAN, Cynthia M. Taylor, RN,MS. ©2005
Pages 32-36, 122-123, 339-342
 Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (11th Edition)
Suzanne C. Smeltzer, Brenda G. Bare, Janice L. Hinkle, Kerry H. Cheever
Page 2137
 Davis’s Drug Guide for Nurses (3rd Edition) Judith Hopfer Deglin, Pharm.D., April
Hazard Vallerand, R.N., M.S.N. ©1988,1991
Pages 45-52, 98-102
 Nursing 2005 Drug Handbook Lippincott Williams & Wilkins Pages ©2005
Pages 79-80, 116-118, 201-203, 575-577,
 Nurse’s Drug Reference George R. Spratto ©1988
Pages 556-559, 798-780
 Nurse’s Drug Handbook 2003 Blanchard & Loeb © 2003
Pages 89-90, 444-446, 466-467