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1、part 1 1 General data 2 Present history 3 Past medical history 4 Special examination 5 Auxiliary examination 6 Social relationship 7 Current condition Case study of the general situation and introduction Case study of the general situation and introduction 8 Introduction of medical treatment problem
2、 9 Pathphysiology 10 Morbidity factor 11 Clinical symptoms 12 Treatment 13 NursingCase Introduction Commonly Information Existing Case Anamnesis Special examination Assist examination Social situation Actual status General dataName：Li Yukui Sex：male Age：64Marital ：MarriedOccupation：Dispenser Family：
3、Widowed，Date of admission：12-12 - 07 Date in ICU：12-12 - 07Diagnoses：COPDThe reason for being in ICU：The patients condition was getting worse Present history Cough and phlegm without obvious inducement appeared 30 years ago, but no haemoptysis, Outbreak obviously in winter and spring The symptoms ha
4、ve been getting worse year after year, The patient felt suffocated and breathing hard, with the decreasing of work ability. Present history A month ago ,the patient felt suffocated, could not lie down, anorexia,little emiction and edema of his whole body, coughed with flavicant and ropy sputa that c
5、annot be coughed out, No angina,fever and chestache, no unconsciousness, oxygen therapy with low flux at home.Present history When his symptoms aggravated, the patient had been sent to the first-aid room of our hospital. The patient was treated by anti-inflammation, diuresis, dispelling phlegm, reli
6、eving asthma, continuously breathing in oxygen with low flux, heteropathy. Present history Analyse of artery blood：respiratory failures Chest X-ray：infection in lungs. Biochemical test：damaged function of liver and kidney, decreasing amount of platelet BP：80/60mmHg , wet and cold extremity , gradual
7、 unconsciousness Considerating infected shock and carbon dioxide remains, the patient was provided an accessorial ventilation with non-traumatic model ,and blood vessel active medicine to keep his blood pressure. After the treatment，the patient was not getting better obviously, so the patient has be
8、en transfer to EICUPresent history He had smoken for 50 years, ten cigarettes one day. Now he has kicked the habit of smoking for 1 year. 4-5 hours sleeping a day, bad mental status. Defecated once every 2-3 days, peed 7-8 times a day, 1-2 times one night. Past medical history The patient was diagno
9、sed as infiltrative pulmonary tuberculosis in 1988，and was cured with anti-tuberculosis. His was diagnosed as spontaneous underarachnoid bleeding、contusion and laceration of chest、extradural hematorma of left pillon. Haemorrhage was absorbed after treating. There is no sequela left .Past medical his
10、tory In 2004 , infection of lungs lead to the respiratory failures , and the patient got better after treating. He denied hepatitis，hypertension, diabetes, allergic history. Special examination Chest X-ray in 12-12-2007 ：Infection in the double lungs, obsolete pathological changes in the double uppe
11、r lungs，pathogical change with pleura，auxacardia. Electrocardiogram： normal rhythm，pneumonic p wave，lower s-t. Auxiliary examination Analyse of artery blood in 12-12-2007 ：PH 7.43 PCO2: 77mmHg PO2: 72mmHg HCO3- :50.2 BE:23.9 Blood Routine:WBC:3.5109/LRBC:3.971012/L GR:85% HB:104g/L HCT:34.2% PLT:2.0
12、109/L Chemcial test:Glu:7.48mmol/L Bun:7.96mmol/L K:2.7mmol/L Albumin:33g/LSocial relationship The patient is a dispenser, married at the right age, with 2 sons and a daughter ,now widowed, in a warm family. Current condition Consciousness Symptoms Bedsore Vital signsPathophysiology pathogenic facto
13、rs infection, smoking, air pollution, occupational dust and the long-term inhalation of harmful gases, allergies. Clinical symptoms of COPDCommon symptoms Smokers cough in the morning and expectorate mucus which may contain pus and blood frequently. Smokers usually feel dyspnea ,so they are unable t
14、o obtain normal amounts of oxygen. Smokers are tired easily.Clinical symptoms of COPDTypical signs barrel chest, respiratory movement weakened, low-vocal fremitus . Auxiliary examination blood test sputum examination phantom examination Pulmonary function test ElectrocardiogramTreatmentObjective Its
15、 purpose is to improve the respiratory function,then improve patients work and life capability. Specific measures 1 Apply bronchodilator drugs such as anti-cholinergic drugs 2 Application of effective antibacterial drugs 3 Respiratory muscle exercise We can do abdominal breathing to strengthen the a
16、ctivities of respiratory muscles. 4 Family oxygen therapy 10-15 hours daily (1-2L/MIN) 5 Rehabilitation 6 Surgical treatment nursing 1 Monitor vital signs closely 2 Respiratory care 3 Observation of the wound 4 Observation of the uncomfortable situation 5 Maintain stability of the circulatory system 6 Nutritional supplements 7 Psychological assessmentIntroduction of Roy adaptation model 1 Main viewpoint of Roy adaptation model 2 Applications of Roy adaptation model in nursing 3 The reasons for s
