PAMANTASAN NG LUNGSOD NG MAYNILA
(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Graduate Program)
Emphysema Case Study Analysis
Concept Mapping Activity
Case Scenario
A 55-year-old female patient presented to ER with severe dyspnea on exertion. She
reported that her breathlessness and coughing episodes had become particularly
severe in the preceding 3 weeks and was now at the point where she could not stand or
walk for more than 1 minute to 2 minutes with- out becoming fatigued.
She is a 40 pack-year smoker (ie, about 1 and 1/2 packs per day since her mid-20s)
and currently still smokes cigarettes. She is not taking any medications and has no
family history of asthma, allergy, or cardiovascular disease.
Physical Examination
She is in respiratory distress with decreased breath sounds, and obvious cyanotic
skin
Respiratory rate: 30 per minute
Heart rate : 115 bpm
Laboratory Results
SaO2: 78%
Arterial blood gases:
PaO2: 41 mm Hg
PaCO2: 66 mm Hg
pH: 7.28
HCT: 48%
Repeat arterial blood gases:
PaO2: 113 mm Hg
PaCO2: 92 mm Hg
pH: 7.28
Further Evaluation
Pulmonary function test (PFT) results
Force expiratory volume in 1 second (FEV): 0.38 L (16%)
Residual volume: 5.97L (373)
Ratio of residual volume to total lung capacity: 84
She immediately transferred to the intensive care unit, attached to noninvasive positive
pressure ventilation (NPPV) and she was started on:
bronchodilators,
systemic steroids
inhaled steroids,
antibiotics.
DIRECTIONS
Part I: Questions
A. What is your differential diagnosis? Support your answer?
B. How can bronchodilators help the patient?
- Bronchodilators are a type of medication that make breathing easier by relaxing the
muscles in the lungs and widening the airways (bronchi).
What bronchodilator is the drug of choice?
- Most patients with the emphysema utilize bronchodilators that dilate
airways and decrease airflow resistance. Some bronchodilators are short-
acting while others are long-acting. However, these drugs provide
symptomatic relief, but do not stop the progression of the disease nor do
they decrease mortality. Short acting Beta-2 agonists (SABA) relax
bronchial smooth muscle (such as albuterol [Ventolin,
Proventil, Proventil-HFA, AccuNeb, Vospire, ProAir], levalbuterol
[Xopenex], and metaproterenol]).
By which route is this drug preferably administered?
- Oral inhalation
C. How is a PFT test performed?
D. The physician asks the nurse to provide instructions to patient on certain
breathing techniques.
1. What instructions should the nurse provide regarding:
1.1 Pursed lip breathing?
Pursed lip breathing should be practiced until it becomes second nature. It’s
most effective when you’re focused or relaxed. Here’s how to practice.
1. Sit with your back straight or lie down. Relax your shoulders as much as
possible.
2. Inhale through your nose for two seconds, feeling the air move into your
abdomen. Try to fill your abdomen with air instead of just your lungs.
3. Purse your lips like you’re blowing on hot food and then breathe out
slowly, taking twice as long to exhale as you took to breathe in.
4. Then repeat. Over time, you can increase the inhale and exhale counts
from 2 seconds to 4 seconds, and so on.
Why is this method of breathing effective?
Pursed lip breathing helps control shortness of breath, and provides a quick
and easy way to slow your pace of breathing, making
each breath more effective. When you feel short of breath, pursed lip
breathing helps get more oxygen into your lungs and calms you down so you
can better control your breath.
1.2 Abdominal breathing?
Diaphragmatic breathing is a type of a breathing exercise that
helps strengthen your diaphragm, an important muscle that helps
you breathe. This breathing exercise is also sometimes called
belly breathing or abdominal breathing.
Why is this helpful?
It helps you relax, lowering the harmful effects of the stress hormone
cortisol on your body.
It lowers your heart rateTrusted Source.
It helps lower your blood pressureTrusted Source.
It helps you cope with the symptoms of post-traumatic stress disorder
(PTSD).
It improves your core muscle stability.
It improves your body’s ability to tolerate intense exercise.
It lowers your chances of injuring or wearing out your muscles.
It slows your rate of breathing so that it expends less energy.
1.3 Huff coughing?
Huffing, also known as huff coughing, is a technique that helps move
mucus from the lungs. It should be done in combination with another
ACT. It involves taking a breath in, holding it, and actively exhaling.
Breathing in and holding it enables air to get behind the mucus and
separates it from the lung wall so it can be coughed out. Huffing is
not as forceful as a cough, but it can work better and be less tiring.
Huffing is like exhaling onto a mirror or window to steam it up.
Why is this coughing exercise will help Mr. Walker?
It can help him remove mucus from their airways. Huff coughing is a gentler form
of coughing because you keep an open glottis (opening between the vocal cords)
while exhaling. This makes it easier to move mucus out of the lungs.
Part II: Concept Mapping- Develop the concept map for the patient in the case
scenario presented to include the following:
1. Risk factors
2. Pathophysiology
4. Assessment Findings
5. Medical Diagnosis/Differential Diagnosis
5. Laboratory results and Diagnostic Findings
6. Nursing diagnoses (identify two 2)
7. Goals and outcome criteria
8. Nursing interventions
9. Evaluation
EMPHYSEMA
RISK FACTORS
Smoking. This the main risk factor. Up to 75 percent of people who have emphysema smoke or used to smoke.
Long-term exposure to other lung irritants, such as secondhand smoke, air pollution, and chemical fumes and dusts from the environment or
workplace.
Age. Most people who have emphysema are at least 40 years old when their symptoms begin.
Genetics. This includes alpha-1 antitrypsin deficiency, which is a genetic condition. Also, smokers who get emphysema are more likely to get it
if they have a family history of COPD.
PATHOPHYSIOLOGY
Emphysema is a pathologic diagnosis defined by permanent enlargement of airspaces distal to the terminal
bronchioles. This leads to a dramatic decline in the alveolar surface area available for gas exchange.
Furthermore, loss of alveoli leads to airflow limitation by 2 mechanisms. First, loss of the alveolar walls
results in a decrease in elastic recoil, which leads to airflow limitation. Second, loss of the alveolar
supporting structure leads to airway narrowing, which further limits airflow.
ASSESSMENT FINDINGS
Increased anterior-posterior diameter, or "barrel chest"
use of accessory muscles to assist breathing.
tripod position.
shortness of breath common, especially on exertion.
tachypnea.
MEDICAL DIAGNOSIS
Lab test
Imaging test
Lung function test
DIFFERENTIAL DIAGNOSIS
Emphysema must be differentiated from other diseases presenting with cough, shortness of breath and tachypnea, such
as congestive heart failure, asthma, bronchiectasis, and bronchiolitis obliterans, pulmonary embolism, pericarditis, and
vasculitis.
LABORATORY RESULTS AND DIAGNOSTIC FINDINGS
Physical Examination
She is in respiratory distress with decreased breath sounds, and obvious cyanotic skin
Respiratory rate: 30 per minute
Heart rate : 115 bpm
Laboratory Results
SaO2: 78%
Arterial blood gases:
PaO2: 41 mm Hg
PaCO2: 66 mm Hg
pH: 7.28
HCT: 48%
Repeat arterial blood gases:
PaO2: 113 mm Hg
PaCO2: 92 mm Hg
pH: 7.28
Further Evaluation
Pulmonary function test (PFT) results
Force expiratory volume in 1 second (FEV): 0.38 L (16%)
Residual volume: 5.97L (373)
Ratio of residual volume to total lung capacity: 84
NURSING DIAGNOSIS
-Ineffective airway clearance
-Impaired gas exchange related to destruction of alveolar walls
GOALS
Improvement in gas exchange.
Achievement of airway clearance.
Improvement in breathing pattern.
Independence in self-care activities.
Improvement in activity intolerance.
Ventilation/oxygenation adequate to meet self-care needs.
Nutritional intake meeting caloric needs.
Infection treated/prevented.
Disease process/prognosis and therapeutic regimen understood.
Plan in place to meet needs after discharge.
NURSING INTERVENTIONS
Nursing Interventions and Rationales
Auscultate lung sounds
If wheezy they may need a breathing treatment If you hear crackles they may have pneumonia and potentially could use
suctioning.
Monitor ABGs
Blood gases help to determine if the patient is in respiratory acidosis.
To interpret the ABG you must know normal ABG values.
pH: 7.35-7.45 PaCO2: 35-45 Bicarbonate: 22-26
Respiratory acidosis is when the pH is below 7.35 and the PaCO2 is above 45.
Encourage a healthy weight Early stages of emphysema: overweight Late stages of emphysema: underweight
Having excess weight on the patient decreases the space for the lungs to expand. Plus, generally, those who lose weight are
also moving more to lose the weight, double win.
In later stages of emphysema, the patient can be very thin (barrel-chested) and it is important to make sure they are getting
the proper nutrition so their body is at the optimal performance (for that patient).
Monitor Oxygen saturation
This is subjective as you need to make sure to understand the patient’s baseline. Plan oxygen monitoring with the physician.
Give oxygen as ordered and needed. Be careful about turning their drive to breath off by giving too much O2, as a general
rule, emphysema patients should be kept around 88%-92%.
Prepare for the worst: If the patient has been working very hard to breathe for a long period of time and is getting worse, be prepared with an
airway cart. And for the love of the airway, have your respiratory therapist aware of the patient!
Safety! Plus you do not want to wait until the impending airway closure happens to try to secure their airway. Sometimes the
patient will be sedated and intubated to try to correct any respiratory acidosis or alkalosis
Breathing treatments and medications
Beta-Agonists: Such as albuterol work as bronchodilators
Anticholinergics: Such as Ipratropium work to relax bronchospasms
Corticosteroids: Such as Fluticasone work as an anti-inflammatory
Assess for/Administer influenza vaccine and pneumococcal vaccine
Preventing complications such as influenza or pneumonia is important because the lungs are already working harder to keep
the body balanced with oxygen and CO2, an increased risk of infection only complicates the patient’s ability to breathe.
EVALUATION
During evaluation, the effectiveness of the care plan would be measured if goals were achieved in the end and the
patient:
Identifies the hazards of cigarette smoking.
Identifies resources for smoking cessation.
Enrolls in smoking cessation program.
Minimizes or eliminates exposures.
Verbalizes the need for fluids.
Is free of infection.
Practices breathing techniques.
Performs activities with less shortness of breath.
