I. INTRODUCTION Chronic Obstructive Pulmonary Disease (COPD) is one of the major causes of mortality and morbidity in the world.

Its prevalence can cause burden to patients and to the health service. Its exacerbations are distressing and disruptive for patients which accounts for a significant proportion of its total healthcare costs. Thus, through a proactive management of health care providers, exacerbations can be prevented and it can be treated more effectively, expensive treatment costs can also be reduced, and a positive impact on patients health status can be provided. Patients with chronic pulmonary disorders need effective management care from health care providers who do not only have astute assessment and clinical management skills but who also understand how these disorders can affect quality of life, thus having a positive patient outcome that will be echoed throughout the health economy. Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible. This newest definition of COPD, provided by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), is a broad description that better explains this disorder and its signs and symptoms (GOLD, World Health Organization [WHO] & National Heart, Lung and Blood Institute [NHLBI], 2004). Although one or the other may predominate, COPD typically includes components of both chronic bronchitis and emphysema, two distinctly different processes. Chronic bronchitis, a disease of the airway, is defined as the presence of cough and sputum production for at least three months in each of

two consecutive years. Emphysema on the other hand, is a disease of the alveoli or the gas exchange unit, resulting from destruction of the walls of the over distended alveoli causing impaired gas exchange. It is often caused by exposure to toxic chemicals, including long-term exposure to tobacco and cigarette smoke. These irritants attract inflammatory cells to collect in the distal airway tissues and release excessive elastase, an enzyme that breaks down elastin, leading to the destruction of the elastic fibers in the respiratory bronchioles and alveolar ducts. This causes the small airways to collapse during forced exhalation, as alveolar collapsibility has decreased. As a result, airflow is impeded and air becomes trapped in the lungs, in the same way as other obstructive lung diseases. Symptoms include shortness of breath on exertion, and an expanded chest. Signs of emphysema include pursed-lipped breathing, central cyanosis and finger clubbing. The chest has hyper resonant percussion notes, particularly just above the liver, and a difficult-to-palpate apex beat, both due to hyperinflation. There may be decreased breath sounds and audible expiratory wheeze. In advanced disease, there are signs of fluid overload such as pitting peripheral edema. Patients with emphysema also manifest barrel chest due to increased anteroposterior to transverse diameter ratio of 1:1. This is related to hyperaeration of lungs causing hyperexpansion of the chest. In COPD, the airflow limitation is both progressive and associated with abnormal inflammatory response of lungs to noxious particles or gasses. The inflammatory response occurs throughout the airways, parenchyma, and pulmonary vasculatures. Because of the chronic inflammation and the bodys

attempt to repair it, narrowing of the airway occurs. Overtime, this injury-andrepair process causes scar tissue formation and narrowing of the lumen of the airway. Airflow obstruction is due to parenchymal destruction as seen with emphysema. The World Health Organization (WHO) estimates that COPD as a single cause of death shares 4th and 5th places with HIV/AIDS, after coronary heart disease, cerebrovascular disease and acute respiratory infection. (COPD International Statistical Information retrieved at http://www.copd-

international.com/library/statistics.htm). An estimated 64 million people have COPD worldwide in 2004 and more than 3 million people died of COPD in 2005, which is equal to 5% of all deaths globally that year. By the year 2010, 600 million people were reported by the WHO to be suffering from COPD and almost 90% of COPD deaths occur in low- and middle-income countries. Worldwide, COPD is the only leading cause of death that still has a rising mortality rate. In the United States, Centers for Disease Control and Prevention (CDC) Morbidity Mortality Weekly Report study of the National Vital Statistics System reported an age-standardized death rate from COPD for adults older than 25 years of 64.3 deaths per 100,000 population. This rate varied by location, with the lowest rate in Hawaii (27.1 deaths per 100,000 population) and the highest rate in Oklahoma (93.6 deaths per 100,000 population). The National Health Interview Survey also reports that the prevalence of emphysema is at 18 cases per 1000 persons and chronic bronchitis is at 34 cases per 1000 persons

(Demirjian and Kamangar, 2011). While the rate of emphysema has stayed largely unchanged since 2000, the rate of chronic bronchitis has decreased. Surveys conducted by the Asian Pacific Society of Respiratory Diseases revealed that COPD is estimated to be 6.2 percent in 11 Asian countries. (COPD International Statistical Information retrieved at http://www.copd-

international.com/library/statistics.htm). Philippine Department of Health revealed in the Environmental Health country profile that respiratory diseases and COPD are in the top ten causes of mortality in the Philippines along with diseases of the heart, vascular system, pneumonias, malignant neoplasms/cancers, all forms of tuberculosis, accidents, diabetes mellitus, nephrities/nephritic syndrome and other diseases of respiratory system. It was reported that 616, 041 people were affected with COPD with 21, 216 deaths in the year 2010. In our locality, 10 males and 2 females had COPD in the year 2011, based on the reports of the San Fernando City Health Office. In the Northern La Union Maternity and Child Hospital there have been 15 patients admitted with COPD. The group has selected the case of Chronic Obstructive Pulmonary Disease for particular reasons: First, COPD is one of the most prevalent chronic pulmonary diseases worldwide. Second, as revealed by statistics and other related studies there are many COPD patients who were not aware of the risk factors that have led them to develop the disease prior to their diagnosis. Third, conducting the case study will provide a basic knowledge about the nature of the disease and increase ones ability to determine any possible occurrence of complications. Fourth, the case would definitely contribute to the personal and

professional development and enhancement of the students in presenting effective approach in fulfillment of the goal of quality nursing care.

PATIENT CENTERED OBJECTIVES In every endeavor that we take, we have to set our minds for a certain goal to achieve. After we have chosen our patient for this case study presentation, we came up with the following objectives. At the end of the rotation the patient will be able to:

Understand his disease process by the provision of health teachings regarding how he developed the disease including the risk factors.

Express increase psychological comfort and demonstrate use of effective coping mechanisms by encouraging the patient to have a positive attitude regarding the disease incurred.

Strictly comply with the treatment of his condition by explaining the effects of poor compliance and what complications may occur if the disease is not managed well.

Gain participation and self reliance by allowing him to actively participate in the course of his treatment.

Understand the importance of strict and total cessation of cigarette smoking by explaining him the possible complications brought by continuous smoking.