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Respiratory Emphesema


									The Case
•   Man (D.Z.) in his 60’s
•   Admitted with chronic emphysema with an acute exacerbation.
•   HX of 6 yrs HTN and Dx of pneumonia yearly x3
•   Productive cough, sleeping poorly, fatigue
•   Thin, poorly nourished
•   Irritable and anxious
•   Vital Stats
          BP 136/84
          HR 124
          RR 36
          102 F
          Sao2 88%
COPD-       Chronic Obstructive Pulmonary Disorder is
characterized by progressive airflow limitation “associated
with an abnormal inflammatory response of the lungs to
noxious particles or gases primarily caused by cigarette
smoking.”                                  (Lewis, 2007)

 • Emphysema and Chronic
   Bronchitis are two types of COPD.
    – Emphysema is the over-inflation leading to
      destruction of the alveoli and/or collapse of

    – Chronic Bronchitis is a chronic productive cough
      for 3 or more months in each of two consecutive
      years.                              (Lewis, 2007)
Pathophysiology of Emphysema

                             • 2 part destruction:
                              -The elasticity of the
                              lung is lost leading to
                              weakening, then
                              damage to the walls
                              of the alveoli. This
                              causes them to break
                              down creating the
                              bleb you see here.
Patho continued
• -The elasticity of the
  larger airways are
  also lost causing them
  to collapse upon

                        CLUSTER OF GRAPES


Symptoms                                 PAPER BAG
•   Shortness of breath
•   cough
•   fatigue
•   anxiety
•   sleep problems
•   heart problems
•   weight loss
•   Depression                   •

•   Chocolate cravings
•   Chronic high levels of CO in blood and low O
                              2                                           2

    (don’t give too much O )
 •     Pulmonary function test
 •     Spirometry
 •     Peak flow meter
 •     ABG tests
 •     Chest x-ray
 •     Sputum analysis                           

 •     Electrocardiogram
Interesting facts:
                                                         “16-30 million U.S. citizens are
     - 10.7 million adults have emphysema
     - Only disease where more whites die than African
                                                         afflicted with emphysema… and
       Americans                                         every year approximately 100,000
     - More widespread in men, but more females have
     died than males since 2000. why?                    sufferers die of the disease”
     - Greater than 50% die within 10 years of Dx     
                                        (Lewis, 2007)
• Goal of treatment is to live more comfortably by
  providing symptom relief and prevent further
  progression of the disease
   –   Quit smoking
   –   Antibiotics                                       http://www.s

   –   Oral medications
   –   Inhaled medications
   –   Exercise
   –   Teach breathing techniques
   –   Supplemental O 2 therapy
   –   LVRS or Transplantation
   –   Pulmonary rehabilitation
   –   Death- 4th leading cause of death in US (100,000)
                                                           (eMedicineHealth, 2008)
Nursing Diagnosis
• Ineffective Airway Clearance
  – Unable to clear secretions from respiratory system

  Related to Smoking 2 packs a day for 38 years

  As evidenced by difficulty breathing, productive thick yellow
    sputum, and tachycardia, and tachypnea (36 rpm)

• Outcomes
   – Maintain patient airway, auscultate clear breath sounds in all
     lung fields bi-latterly, cough effectively

 • Interventions
    – Teach effective coughing techniques, provide proper airway
      management, provide suctioning when needed, monitor resperations
      and O2 levels, encourage activity and ambulation, teach how to use
      new inhalers and medication treatments                 (Ackley, 2006)
Nursing Diagnosis
• Activity Intolerance
  – Lack of energy to conduct ADL’s

  Related to imbalance of oxygen supply and demand, and poor

  As evidenced by pt reporting poor sleep and feeling very tired
    lately, need for assistance to ambulate

• Outcomes
   – Independently ambulate around unit, able to complete ADL’s on
     own, and eat 100% of meals if tolerable

 • Interventions
   – Assist pt in resting techniques and in exercise activities, consult
     with physical therapist, respiratory therapist, and dietician for
     increased attention that pt may require              (Ackley, 2006)
Nursing Diagnosis
• Imbalanced Nutrition: Less than body requirements
  – Intake of nutrients are insufficient to meet metabolic needs

  Related to inability to intake adequate amounts of food due to
     biological or economic factors

  As evidenced by a thin and poorly nourished physical appearance
     who is very tired most of the time.
• Outcomes
   – Gain weight until desired weight suggested by dietician and
     patient is reached, patient understands reason why he is
     underweight, identify nutrition requirements, regain healthy
     physical appearance

 • Interventions
    – Daily weights, compile list with patient of healthy nutritional
      foods that he enjoys eating, monitor his food intake, observe
      ability to eat.                                      (Ackley, 2006)
• “I don’t understand it. I can be so
 hungry, but when I start to eat, I
 have trouble breathing and I have to
 stop”- D.Z.

• What is the phenomenon of carbohydrate
  – “High-carbohydrate meals can increase CO2 output in COPD patients.
    However, some patients may increase ventilation to get rid of the CO2,
    and some have a tolerance for rather high blood CO2 levels (retainers).
    Thus, metabolic demands can be met but at a physiologic cost. The
    degree of exercise restriction needed to compensate for the increased
    CO2 is under investigation.”                                (Chapman, 1996)
What can we do to improve D.Z.’s caloric
 - Eat main meal early in order to have more energy for rest of day. (AARC)

 - Eat small frequent meals to stay fed but not compress the stomach on the
     dyphragm. (AARC)

 - Provide high calorie finger foods and drinks that are easy (don’t take up much
     energy) to eat.

 - Continue O2 therapy while eating to improve oxygenation. (AARC)

 - Rest an hour before eating and after eating.
What can you do to improve D.Z.’s
oxygenation in general?
 – Teach huff coughing for effective coughs (cough and deep
    • Pursed lip breathing
    • Abdominal breathing

 – Request chest physiotherapy: percussion, vibration, postural

 – Provide a flutter mucus clearance device and/or encourage
   inspiratory spirometer.                           (lewis,2007)

 – Cluster interventions to decrease activity

 – Put the head of bed to 30 degrees or higher
Pyschosocial Nursing Care
• What may make it        • Read #14 from case
 difficult for D.Z. to     study. How would you
 quit smoking?             respond to D.Z.’s
      - Social reasons?    wife?

  Helping your patients quit
• The 5 A’s            • Role play with nurse
  -Ask                   and Amy Winehouse!!
                            Cited Resources
    Ackley, B. J., Ladwig, G. B. (2006). Nursing Diagnosis Handbook, A Guide to Planning Care. St.
           Louis, MI: Mosby Elsevier.

•   American Association for Respiratory care. (2002) Eating Right: Tips for the COPD patient.
          Retrieved September 9, 2008, from source.

•   Black, K. (2007). Advance care planning throughout the end-of-life: focusing the lens for social
            work practice. Journal Of Social Work In End-Of-Life & Palliative Care, 3(2), 39-58.
            Retrieved September 17, 2008, from MEDLINE database.

•   Chapman, K., & Winter, L. (1996, December). COPD: using nutrition to prevent respiratory
         function decline. Geriatrics, 51(12), 37-42. Retrieved September 15, 2008, from MEDLINE

•   Clancy, C. M. (2008) Quitting smoking, helping your patients kick the habit. Nursing for Women’s
           Health, 12(4), 282-284. Retrieved September 13, 2008, from CINHAL database.

•   EMedicineHealth: A Practical Guide to Health. (2005) Emphysema. Retrieved September 15, 2008,
          from source.

•   Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., O’Brien, P. G., & Bucher, L. (2007). Medical-
           surgical nursing, assessment and management of clinical problems. St. Louis, MI: Mosby
                            Cited Resources
•   Musich, S., Mcdonald, T., Hirschland, D., & Edington, D. (2002, April). Excess healthcare
          costs associated with excess health risks in diseased and non-diseased health risk
          appraisal participants. Disease Management & Health Outcomes, 10(4), 251-258.
          Retrieved September 17, 2008, from CINAHL with Full Text database.

•   National Emphysema Foundation. (2007) COPD. Retrieved September 15, 2008, from source.

•   Tinker, R., & While, A. (2006, July). Promoting quality of life for patients with moderate to severe
           COPD. British Journal of Community Nursing, 11(7), 278. Retrieved September 16, 2008,
           from CINAHL with Full Text database.
                                        Thanks For Participating!
                                                                                 *BONUS! What’s wrong with this


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