Emphysema is a chronic obstructive pulmonary disease (COPD) that is characterized by abnormal, permanent enlargement of the air spaces past the terminal bronchioles, which results in the destruction of respiratory walls. The syndrome includes both chronic bronchitis and emphysema. COPD affects almost 15 million people and is the fourth leading cause of death overall in the United States. Approximately 5% to 6% of male adults and 1% to 3% of female adults have emphysema.
In emphysema, the affected terminal bronchioles contain mucous plugs that, when they are enlarged, eventually result in the loss of elasticity of the lung parenchyma, thus causing difficulty in the expiratory phase of respiration. The alveolar walls are destroyed by abnormal levels of enzymes (proteases) that break down respiratory walls. Gas exchange is impaired by the reduced surface area that results from the destruction of alveolar walls.
Four types of emphysema have been identified: paraseptal emphysema, which affects the periphery of the lobule; panacinar or panlobular emphysema, which affects the lower anterior segments or the entire lungs; centriacinar or centrilobular emphysema, the most common form, which destroys respiratory bronchioles and is associated with chronic bronchitis and cigarette smoking; and bronchiectasis or chronic necrotizing infection that leads to abnormal and permanent bronchial dilation, which occurs rarely. Complications from emphysema include cor pulmonale, respiratory failure, pneumothorax, and recurrent respiratory tract infections. Emphysema is the most common cause of death from respiratory disease in the United States.
The actual cause of emphysema is unknown. Risk factors for the development of emphysema include cigarette smoking, living or working in a highly polluted area, and a family history of pulmonary disease. Frequent childhood pulmonary infections have been identified as a cause of bronchiectasis.
Nursing care plan assessment and physical examination
Establish a history of dyspnea, determining if it has increased over time. Ask if the dyspnea is extreme during exertion and present even during rest. Determine if the patient has experienced anorexia, weight loss, and weakness. Ask if the patient has had a cough and, if so, for how long. Determine if there are signs of oxygen deficiency; ask significant others if the patient has been restless or confused or has experienced changes in mental status. Ask if the patient lives or works in a highly polluted area. Establish cigarette smoking habits, including how long, how many, and whether they are unfiltered. Elicit a history of family pulmonary disease or frequent childhood pulmonary infections.
Inspect the patient for a decreased muscle mass and increased anteroposterior diameter (also known as barrel chest). Observe respirations for the use of accessory muscles, such as the sternocleidomastoid and pectoral muscles, as well as pursed-lip breathing during expiration. Assess the patient’s respirations for rate, rhythm, and quality. Inspect the patient for neck vein distension or liver congestion. Note signs of oxygen deficiency, such as restlessness, changes in mental status, confusion, and tachycardia.
A cough may be present during the later stages of the disease; the small amount of sputum it produces is usually mucoid. Upon palpation, note decreased tactile fremitus. Percussion may elicit a diffusely hyper-resonant sound. Auscultate for decreased or absent breath sounds, distant heart sounds, wheezes, and possibly crackles. Examine the patient for peripheral cyanosis or clubbing of the fingers.
Patients with emphysema may be anxious or restless, depending on the degree of dyspnea they are experiencing. Emphysema may necessitate role or occupational changes that could lead to depression. Assess the patient’s emotional, financial, and social resources to determine if they are available to the patient to help cope with a chronic disease.
Nursing care plan primary nursing diagnosis: Impaired gas exchange related to destruction of alveolar walls.
Nursing care plan intervention and treatment
Viral or bacterial infections may lead to bronchospasm or increased mucus secretions. Acute exacerbations are accompanied by dyspnea, fatigue, and even respiratory failure. Low flow oxygen therapy based on arterial blood gas results is often administered to treat hypoxemia. For the patient with increasing airway obstruction and plugging, endotracheal intubation and perhaps mechanical ventilation may be needed to maintain adequate airway and breathing. Adequate hydration is also necessary to help liquefy secretions.
Maintaining a patent airway is a priority. Use a humidifier at night to help the patient mobilize secretions in the morning. Encourage the patient to use controlled coughing to clear secretions that might have collected in the lungs during sleep. Instruct the patient to sit at the bedside or in a comfortable chair, hug a pillow, bend the head downward a little, take several deep breaths, and cough strongly.
Place patients who are experiencing dyspnea in a high Fowler position to improve lung expansion. Placing pillows on the overhead table and having the patient lean over in the orthopneic position may also be helpful. Teach the patient pursed-lip and diaphragmatic breathing. To avoid infection, screen visitors for contagious diseases and instruct the patient to avoid crowds.
Conserve the patient’s energy in every possible way. Plan activities to allow for rest periods, eliminating nonessential procedures until the patient is stronger. It may be necessary to assist with the activities of daily living and to anticipate the patient’s needs by having supplies within easy reach. Refer the patient to a pulmonary rehabilitation program if one is available in the community. Patient education is vital to long-term management. Teach the patient about the disease and its implications for lifestyle changes, such as avoidance of cigarette smoke and other
irritants, activity alterations, and any necessary occupational changes. Provide information to the patient and family about medications and equipment.
Nursing care plan discharge and home health care guidelines
Be sure the patient and family understand any medication prescribed, including dosage, route, action, and side effects. Instruct the patient to report any signs and symptoms of infection to the primary healthcare provider. Explain necessary dietary adjustments to the patient and family. Recommend eating small, frequent meals, including high-protein, high-density foods. Encourage the patient to plan rest periods around his or her activities, conserving as much energy as possible. Arrange for return demonstrations of equipment used by the patient and family. If the patient requires home oxygen therapy, refer the patient to the appropriate rental service, and explain the hazards of combustion and increasing the flow rate without consultation from the primary healthcare provider.