Nursing assessment in patients with chronic obstructive pulmonary disease, according Doenges (2000):
a. Activity and rest
- Fatigue, weakness, malaise.
- Inability to perform daily activities because of difficulty breathing.
- Inability to sleep, needed to sleep with the high seating position.
- Dyspnea at rest or in response to activity or exercise.
- Restlessness, insomnia.
- General weakness or loss of muscle mass.
- Swelling of the lower extremities.
- Increased blood pressure.
- Increased heart rate or severe tachycardia or dysrhythmias.
- Distension of the neck veins or severe disease.
- Dependent edema, not associated with heart disease.
- Faint heart sounds (relating to
- AP diameter of the chest)
- Color of skin / mucous membranes; normal or gray or cyanosis, nail percussion and peripheral cyanosis.
- Pallor may indicate anemia.
c. Ego integrity
- Increased risk factors.
- Changes in lifestyle.
- Anxiety, fear, sensitive to stimuli.
d. Food or fluid
- Nausea or vomiting.
- Poor appetite or anorexia (emphysema).
- Inability to eat due to respiratory distress.
- Permanent weight loss (emphysema), the increase in weight showed edema (bronchitis).
- Poor skin turgor.
- Dependent edema.
- Weight loss, decreased muscle mass or subcutaneous fat (emphysema).
- Abdominal palpation can declare hepatomegaly (bronchitis).
- Decreased ability or increased need help doing everyday activities.
- Poor hygiene, body odor.
- Shortness of breath, often hidden by dyspnea as prominent symptoms in emphysema, especially at work, the weather or the recurrence of episodes of difficult breath (asthma), a sense of chest distress, inability to breath (asthma).
- Air chronic hunger.
- Settle cough with sputum production every day, especially on waking, for at least 3 consecutive months each year at least 2 years. Sputum production (green, white or yellow) can be a lot of (chronic bronchitis).
- Intermittent episodes of coughing, usually unproductive at this early stage although it can be productive (emphysema).
- A history of recurrent pneumonia, exposed to chemical pollution or a respiratory irritant in the long term eg cigarette smoke or dust or smoke, for example asbestos, coal dust, cotton hemp, sawdust.
- Family factors and heredity, such as alpha antritipsin deficiency (emphysema).
- The use of oxygen at night or continuously.
- Breathing is usually fast, slow, elongated expiratory phase with snoring, mouth breath (emphysema).
- Preferring position 3 point (tripod) to breathe, especially with acute exacerbations (chronic bronchitis).
- The use of a respirator muscles, for example; elevating the shoulder, retraction supraclavicular fossa, widen the nose.
- Dada can be seen hyperinflation with the elevation of the AP diameter (barrel chest shape), the diaphragm movement is minimal.
- Breath sounds may be dimmed by expiratory wheezing (emphysema), spreads, soft, moist or rough crackles (bronchitis), crackles, wheezing, all areas of the lung in expiration and possibilities for inspiration continues to decrease or absence of wheezing (asthma).
- Hyperresonance percussion found in areas of the lung, for example; It traps air with emphysema, dullness in the area of the lung, for example; consolidation, fluid, mucous.
- Trouble speaking a sentence or more than 4 to 5 words at a time.
- Pale color with cyanotic lips and nail beds. Overall grayish, red (chronic bronchitis, bulging blue). Patients with emphysema were often called pink puffer for normal skin color even though the gas exchange is not normal and rapid breathing frequency.
- Clubbing of the fingers (emphysema).
- A history of allergic reactions or sensitive to a substance or environmental factors.
- The presence or recurrence of infection.
- Redness (asthma).
i. Social interaction
- Dependency relationship.
- Less support system.
- Failure support of or against a spouse or people nearby.
- Old diseases or improved capabilities.
- Inability to create or maintain a sound because of respiratory distress.
- Physical mobility limitations.
- Negligence relationships with other family members.
- Counseling or learning
- Use or misuse of respiratory medicine.
- Difficulty stopping smoking.
- The use of alcohol regularly.
- Failure to improve.
Engram (2000) : a baseline assessment in patients with chronic obstructive pulmonary disease are:
a. History or presence of contributing factors:
- Smoking tobacco products (the major causative factors).
- Living or working in areas with heavy air pollution.
- History of allergies in the family.
- A history of asthma in childhood.
c. Physical examination is based on the assessment of the respiratory system (Appendix A) which includes:
1) The classic manifestations of Chronic Obstructive Pulmonary Disease:
- Increased dyspnea (most common).
- The use of accessory respiratory muscles (abdominal muscles retraction, shrugged as inspiration, nostril breathing).
- Decrease in breath sounds.
2) The symptoms are settled on the basis of disease processes:
- Cough (may be productive or non-productive) and feeling like the bound chest.
- Wheezing during inspiration and expiration, which can often be heard without a stethoscope.
- Nostril breathing.
- Fear and diaphoresis.
- Productive cough with sputum canescent, which usually occurs in the morning and often ignored by smokers (called a smoker's cough).
- Inspiration coarse crackles and wheezing.
- Shortness of breath
- Appearance cyanosis (because of polycythemia arising from chronic hypoxemia)
- General swelling or appearance "puffy", Clinically, these patients commonly called "blue bloaters".
- Physical appearance thin, the chest "barrel chest" (anterior posterior thoracic diameter increased as a result of the hyperinflation of the lungs).
- Elongated expiratory phase.
e) Emphysema (advanced stage)
- Hypoxemia and hypercapnia but no cyanosis the patient is often described clinically as "pink puffers".
- Clubbing fingers.