HEALTH ASSESSMENT

ON
CHRONIC OBSTRUCTIVE PULMONARY
DISEASE

SUBMITTED TO:

MRS.IRAIMANI, MSc NURSING,MBA.,

VICE PRINCIPAL,

OUR LADY OF HEALTH COLLEGE OF NURSING,

THANJAVUR.

SUBMITTED BY:

B.AROCKIA CHRISTY,

1ST YEAR MSc NURSING

OUR LADY OF HEALTH COLLEGE OF NURSING,

THANJAVUR.

SUBMITTED ON:

11/08/2020
 INTRODUCTION

INTRODUCTION

As a part of my medical surgical nursing clinical postings, I was been posted in

MEDICAL ICU, there I selected Mr.Senthil of 64 years who was admitted in the
Thanjavur Medical College and hospital on 22.01.2020 at 10:20 am with the chief
complaints of breathlessness since 1 month, cough since 1 month. After a thorough
assessment doctor diagnosed him has COPD. After investigations the patient was
diagnosed as COPD and I took this for my HEALTH ASSESSMENT as a
requirement in medical surgical nursing.
 HISTORY
COLLECTION

HISTORY OF THE PATIENT

IDENTIFICATION DATA

Name of the patient : Mr. Senthil

Age : 64 years

Gender : Male

Bed No. : 12
Ward : Medical ICU

IPD No. : 8996

Date of admission : 22/01/2020

Educational status : 8th standard

Occupation : Auto Riksha Driver

Monthly income : Appox. Rs. 6000/ month

Religion : Hindu

Mother tongue : Tamil

Marital status : Married

Address : no.12,vannakara theru ,Thanjavur.

Diagnosis : Chronic Obstructive Pulmonary Disease

CHIEF COMPLAINTS AND PRESENT MEDICAL HISTORY

Mr. Senthil brought to the hospital with the complaints of breathlessness since 1
month, cough since 1 month. After a thorough assessment doctor diagnosed him has
COPD. There is no significance of present surgical history.

PAST MEDICAL HISTORY

Mr. Senthil had been diagnosed as COPD, 5 month back. He is in under treatment for
COPD. 5 month back He developed breathing difficulty with productive cough and
thick sputum. He was admitted and treated as inpatient basis. Investigation such as

sputum examination ,chest x rays, ABG done . Follow-up medicine are tab.
deriphyline, asthalin inhalation. Patient had no other history of other major disease.

PAST SURGICAL HISTORY

Client had no history of surgery.

FAMILY HISTORY

Family tree:
 Patient wife

Daughter son son

FAMILY INFROMATION

S Health
Name of
r. Relationship Age Occupat Marital Status
Family Education
N with patient (yrs.) ion Status
Members
o
1 Mr. Senthil Client 67 8th pass Riksha Married COPD
driver
2 Mrs.Rani Wife 64 Illiterate House wife Married Diabetes
2 Mrs. Shanty Daughter 37 10th pass House Married Diabetes
wife
3 Mr. Sunil Son 42 Graduate Teacher Married Healthy
4 Mr. sanjay Son 40 10th pass worker Married Healthy

Family income per year : Rs.20,000 approximately.

Family interpersonal relationship : All the family members have good IPR.
No disharmony.

Family history of illness : patient`s mother had the history of

Pulmonary tuberculosis.

The family members of the patient were healthy except wife and daughter. Wife and
Daughter of the patient having diabetes mellitus. There was no family history of any
other illness like cancer, arthritis or neurological disorders were not found.

DIETARY HISTORY-

Patient used to take mix veg diet. He used to take chicken once in a week. He also
used to take green leafy vegetables and other veg diet. He used to take meals in lunch
time and dinner. He used to take breakfast in morning. He used to take tea four times
in a day.

SOCIOECONOMIC STATUS

A) HOUSING
  Type of house - Small house with 2 rooms made up of bricks.
 Lighting – Lack of proper lighting facility.
 Ventilation – 1 window and 2 doors for ventilation.
 Water facility – Not proper, family used to bring water from municipal tap.
 Sanitation – Lack of sanitation and hygiene.

B) FOOD HYGIENE PRACTICES

Lack of food hygiene. Not washing hands before cooking and not washing
vegetables also before cooking food. Cook food in unhygienic condition.

C) PERSONAL HYGIENE PRACTICES

Not maintaining personal hygiene. Not taking bath daily. Not washing hands
and cutting nails etc.

D) COMMUNITY RESOURCES
Resources like transportation are available by bus and train.
Educational resources are available up to higher education.

E) RELIGIOUS PRACTICES
Client and his family strongly believe in the god and they worship regularly.
They visit temple sometimes.

F) FAMILY INCOME & EXPENDITURE

Food – Rs.2000 per month
Clothing – Rs.500 per month
Education – Nil
Health – Rs.1000 per month

HABITS

Patient used to smoke since 25 years, he used to smoke 20- 25 bidi per day.

Patiet also used to take alcohol since 20 years. He used to drink 180 ml of desi daru
per day.

ALLERGIES AND MEDICATIONS

Client doesn’t have any allergies from medicines, food, dyes etc.
 PHYSICAL
EXAMINATION
 PHYSICAL ASSESSMENT
GENERAL APPEARANCE :
 Level of Consciousness: - Conscious
 Orientation: - Oriented to time, place and person.
 Activity: - patient is less active
 Body Built: - Thin
 Breath odour- foul smell
 Sign of distress- patient is confused and asking again and again about
his disease.
 Hygiene and grooming- patient does not use to groom independently.

ANTHROPOMETRIC MEASUREMENT
1. Height: 5’8” 2. Weight: 54kg
VITAL SIGNS
1. Temperature: 99.8°F 2. Pulse: 80/min 3. Respiration:
26/min
4. Blood Pressure: 130/86 mmHg
INTEGUMENTORY SYSTEM
 Skin color- Brown
 Dermatitis- No skin infections
 Allergies- No skin allergies
 Lesions/Abrasions- Absent.
 Tenderness /Redness- No redness and tenderness.
 Surgical scar- Surgical scar not present.
 Abnormal growth- No abnormal growth.
 Cyanosis - paleness present at finger tips.
 Jaundice - not present.
 Hyperpigmentation- present over the lower limbs.

HEAD
 Hair: - Equally Distributed
 Color of Hair: - Grey
 Scalp: - Dandruff present.
 Pediculosis: - Absent
 Sinus area- no inflammation.
 Nodes- not present.
FACE
 Face: - Symmetrical
 Facial Puffiness: - Absent.
EYES
 Eye Brows: - Symmetrical
 Eye Lid/Lashes: - No Redness/ Swelling/Discharge/Lesions
 Eye Ball: - Normal
 Conjunctiva: - Normal/ No Lesions
 Sclera: - White
 Puncta: - Red and not swollen
 Cornea: - Regular Ridges
  Iris: - Flat
 Eye Discharge - Absent
 Use of glasses - No
 Pupils- Equally Reacting To Light and normal size
 Visual Acuity- Not proper patient not able to see the far objects.
SINUS
 Maxillary sinus infection - No
 Frontal sinus infection - No

EARS
 Size & shape- Normal & symmetrical.
 Position And
Alignment- Normal.
 Redness- Absent
 Discharge - Absent
 Cerumen- Present
 Lesions- Absent
 Foreign Body - Absent
 Hearing Acuity- Normal
 Use of Hearing
Aids- No
NOSE
 Nasal Septum- Not deviated
 Nasal Polyps- Absent
 Nasal Discharge- Absent
ORAL CAVITY
 LIPS- lips are dry..
  Cleft Lips- No cleft lips.
 Stomatitis- Absent
 Number of Teeth- 31teeth.
 Dentures - Absent
 Dental Carries- Present
 Odour of Mouth- Foul Smell
 Gums – Weak
 Palate and uvula- no inflammation.
 Taste - Patients able to identify the taste.

NECK
 General structure- normal
 Trachea - normal
 Thyroid - not palpable.
 Nodes - not palpable, absent
 Muscles - normal strength
CHEST AND RESPIRATORY SYSTEM
 Respiratory Rate- 26 per min.
 Thoracic Cage - barrel shape. Anterioposterior to transverse diameter
in ratio of 1:1
POSTERIOR THORAX
Inspection
 Shape and Summetry – barrel chest. Anterioposterior to transverse diameter
in ratio of 1:1.
 Skin Color and Condition- Normal
 Exaggerated spine curvature, slight kyphosis present.palpation
 Skin is intact, uniform temperature.
 Chest wall intact, tenderness present over left side of lung.
 No presence of masses.
  Chest expansion- decreased chest expansion (2 cm)
 Fremitus- decreased tactile fremitus.
Percussion
 Resonance- asymmetry
 Diaphragmatic Excursion- restricted lung excurtion (2 cm).
Auscultation
 Breathing Sound- crackles at inspiration
 Respiratory Pattern- Rapid breathing with effort.

ANTERIOR THORAX
 Costal angle is 100 degree.
 Skin is intact on anterior chest side.
 Rales crackles at inspiration.
 Percussion: flatness of chest sound present decreased expiratory
excursion
 misplacement of tracheal position (left side),
 Enlargement of left lung.
 Dyspnea: present (shortness of breath present)

CARDIO VASCULAR SYSTEM

 Pulse - 80/min
Pericardium
 No heaves or lift present on palpation.
 Aortic pulsation absent.
 Point of maximal 5th intercostal space, midclavicular line
impulse
 Heart Sound – S1 , S2 Heard
 Abnormal Heart Sound – S3 sound present.
 Murmurs – Absent
 Carotid Pulse Rate -80/min
  Blood Pressure - 130/86 mmHg
Carotid pulse
 Decrease pulsation, asymmetric volume.
 No sound present on auscultation.
Jugular vein
 Visible distended.
Peripheral pulses-
 Symmetric volume, rate and rhythm.
ABDOMEN AND INGUINAL AREA
 Abdominal Girth- 75 cm
 Diarrhea / Constipation- Absent.

 Counter and tone- symmetric.

 Scar marks- not present..
 Liver- not palpable.
 Spleen- not palpable.
 Kidneys- not palpable, normal.
 Bladder- normal.
 Hernias- absent.
 Masses- absent.
Inspection
 Size - Protuberant Flat
 Symmetry – Normal
 Scar- No scar present
 Lesions and redness - not present..
Palpation
 Tenderness - No tenderness
 Fluid Collection - Absent
 Mass/Soft - No palpable mass.
 No enlargement of liver, spleen.
Percussion
 Ascitis / Peritonitis - Absent
 No Gas /Fluid Collection
 Tympanic sound present over the stomach area.
 Dullness sound over the liver.
Auscultation
 Bowel Sounds - properly heard.
GENITO URINARY
 Frequency of Urination- Decreased urine output.
 Color -Pale yellow.

 No complaints of Anuria / Hematuria / Dysuria / Incontinence.

 Catheter Present - No
 Urethral Discharge - No
MUSCULO SKELETAL SYSTEM
 Range of Motion -Normal ROM.
 Joint Swelling / Pain - no inflammation. Complaint of pain at the time of
walking.
 Weakness - Present.
 Extrimity strength - Equal extremity strength.
 Edema - edema present over lower exterimities.
NERVOUS SYSTEM
 Level of Conscious, coherent and responsive
conscious
ness
 Orientation - Oriented to time, place and person
 Emotional – Calm, but upon exertion she feels dizzy and answers questions
state inappropriately.
 Language - Tamil
 Motor – Normal coordination.
Coordination Normal
-&
Reflexes

INVESTIGATION
INVESTIGATIONS

DIAGNOSTIC STUDIES(22/01/2020)

SR NAME OF NORMAL PATIENT REMARK

NO INVESTIGATION VALUE VALUE
.
1. Haemoglobin 12-16 gm% 13.8 gm% Normal

2. WBC count 4000- 12000/cumm Elevated

11000/cumm

3. Neutrophils 40-75 % 60 %

Lymphocytes 20-45 % 35 %

Eosinophil 0-5 % 04 % Normal

Monocytes 0-5% 02%

Basophils 0-2% 00 %

4. Random blood sugar 70-120 mg% 76mg%

5. Blood group --- A positive ---

6. HIV --- Negative ---

7. Serum sodium 135-145 138 mEq/L Normal

mEq/L

8. Serum potassium 4.9 mEq/L Normal

3.5-4.5
9. Serum creatinine mEq/L 0.9 mg/dl Normal
 10. Serum chloride 0.8-1.4 mg/dl 103 mEq/L Normal

96-106
mEq/L

Chest X-ray :

• Increased lung markings which represent the thickened, inflamed and scarred
airways.
• Over expanded left lung (hyperinflation)
 HEALTH EDUCATION AND DISCHARGE PLANNING

Client was given health education on various aspects of health, disease condition, its diagnosis,
treatment and follow-up during his stay in the hospital and at the time of discharge.

1) DISEASE CONDITION

 Client was explained about the causes of the COPD.

 He was explained about the severity of the disease.
 He was guided for the prevention of the same condition in the future and maintains food
hygiene at home.
 Special instructions were given on food hygiene.

2) MEDICATIONS

 Patient was explained about the importance of medications.

 She was explained about the route, time and dosage of medications.
 Side effects were told to be reported to the doctor.
 Follow-up of the treatment was advised.
 He was advised not to give any medications without doctor’s order.

3) NUTRITIONAL THERAPY

 Advised the patient to take more fluid diet.

 Eat more fiber by eating at least 5 servings of fruits and vegetables every day.
 Advised the patient to take high protein diet
 Advised the patient to follow up hygienic practices.

4) BREATHING EXERCISES:

 Advised the patient to do deep breathing and coughing exercises

 Explained the patient how to do breathing exercises.
5) HEALTH TEACHING

 Encouraged client to do at least 30 minutes of walking a day as a form of exercise.

 Instructed to adjustments in diet, medication and exercise can be made accordingly.
 Encouraged to stick to the monitoring protocol prescribed by the doctor.

 Safety precaution should be maintained to prevent foot injury such as do not wear open shoes
or walk barefoot.
 Adjust of activities to avoid over exertion and fatigue, allow rest periods
 CONCLUSION

CONCLUSION:

As a part of my medical surgical nursing clinical postings, I was been posted in

MEDICAL ICU, there I selected Mr.Senthil of 64 years who was admitted in
the Thanjavur Medical College and hospital on 22.01.2020 at 10:20 am with the
chief complaints of breathlessness since 1 month, cough since 1 month. After a
thorough assessment doctor diagnosed him has COPD and immediate treatment
was started, and now he is improved with his condition
 BIBLIOGRAPHY

BIBLIOGRAPHY:

1)BOOK REFERENCES:

 Hinkle, J.L. & Cheever, K.H. (2018). Brunner & Suddarth's Textbook of

Medical-Surgical Nursing ,14th edition.,Philadelphia: Wolters Kluwer(P)LTD

 Ignatavicius,et.al.,(2018). Medical-Surgical Nursing: Concepts for

Interprofessional Collaborative Care ,9th edition, St. Louis: Elsevier(P)LTD.

 LeMone, P.et,al. (2015).Medical-Surgical Nursing:Critical Reasoning in

Patient Care ,6th edition,Upper Saddle River, NJ: Pearson/Prentice Hall(P)LTD
 Lewis, S.L., et.al.,(2017). Medical-Surgical Nursing: Assessment and
Management of Clinical Problems ,10th edition,St. Louis: Elsevier(P)LTD.

 Potter, P.A., Perry, A.G., et.al., (2019). Essentials for Nursing Practice ,9th

edition,St. Louis: Elsevier(P)LTD.

 Potter, P.A., Perry, A.G., et.al.,(2017). Fundamentals of Nursing ,9th edition,St.

Louis:Elsevier/Mosby(P)LTD.

 Wilkinson, J.M., et.al.,(2016). Fundamentals of Nursing: Volume 1- Theory,

Concepts, and Applications; Volume 2- Thinking, Doing, and Caring,3rd
edition, Philadelphia: F.A. Davis Co(P)LTD.

NET REFERENCES:

1.https://medlineplus.gov › Medical Encyclopedia

2.https://en.wikipedia.org › wiki › COPD

3.https://www.medicalnewstoday.com › articles

4.https://uichildrens.org › health-library › technique-assessment

5.https://www.healthline.com › health ›COPD