In Partial Fulfillment of the Requirements in Master of Science in Nursing- Adult Health Nursing 201
CASE STUDY: EMPHYSEMA
Submitted to: Mrs. Hazel M. Valmores, RN, MSN, USRN Instructor
Submitted by: Mark Anthony T. Tabago, RN
1. Explain the pathophysiology of emphysema.
(See separate page for pathophysiology)
2. Are D.Z.s VS and Sa0 2 appropriate? If not, explain why?
Yes D.Z.s vital signs and oxygen saturation are appropriate to the situation because he is in acute exacerbation meaning his condition gets worse; thus, he will manifest tachypnea and tachycardia as compensatory mechanism; and the oxygen saturation will be low. In the data, D.Z.s respiratory rate is 36 cpm, pulse rate is 124 bpm and oxygen saturation of 88%.
3. Identify three (3) nursing measures you could try to improve oxygenation.
The following are nursing interventions to improve oxygenation: Place patient in Orthopneic position or high Fowlers position to maximize lung expansion and to reduce respiratory effort Teach effective breathing patterns such as pursed-lip breathing and diaphragmatic breathing to improve ventilation in the alveoli by maintaining intrathoracic pressure at the end of exhalation Encourage patient to cough or huff every 1 to 2 hours, drink 10 glasses of fluid a day if not contraindicated, and humidify inspired air to improve airway clearance and remove mucus from airways allowing better ventilation Administer supplementary oxygen at 2 Lpm to improve oxygenation/ tissue perfusion
4. Explain the main purpose of the following classes of drugs: antibiotics, bronchodilators, and corticosteroids.
Antibiotics are given to treat infections as most exacerbations are triggered by bacterial infections; Antibiotics may be used to help fight respiratory infections common in people with emphysema, such as acute bronchitis, pneumonia and the flu Bronchodilators are given to improve airflow; Bronchodilator medications may help to relieve symptoms of emphysema by relaxing and opening the air passages in the lungs Corticosteroids are given to decrease inflammation if bronchodilators are not sufficient; Corticosteroids can help relieve symptoms of emphysema associated with asthma and bronchitis
5. What are the two most common side effects of bronchodilators?
Patients who have COPD are often prescribed medications called bronchodilators. Bronchodilators work by relaxing and expanding the smooth muscle of the airways making it easier to breath. Three types of bronchodilators are commonly used for the treatment of emphysema: beta adrenergic agonists, anticholinergics, and methylxanthines.
Common side effects of beta adrenergic agonists includes Tachycardia Palpitations Premature ventricular contractions Tremors Hypokalemia
Common side effects of anticholinergics are Dry mouth Metallic taste
Common side effects of methylxanthines includes Heart dysrhythmias Convulsions
6. You deliver D.Z.s dietary tray, and he commends how hungry he is. As you leave the room, he is rapidly consuming the mashed potatoes. When you pick up the tray, you noticed that he hasnt touched anything else. When you question him, he states, I dont understand it. I can be so hungry but when I start to eat, I have trouble breathing and I have to stop. Explain this phenomenon based on your knowledge of breakdown of carbohydrates (CHO).
Carbohydrates tend to produce more carbon dioxide when broken down which forces the lungs to work harder to expel the gas from our bodies. This explains why D.Z. experience difficulty breathing when eating.
An important nutritional objective is to reduce the amount of carbon dioxide being produced by the body. Carbohydrate is the macronutrient that increases RQ (respiratory quotient) which is a measure of the ratio of the volume of CO2 expired to the volume of oxygen consumed. By decreasing carbohydrate in the diet, we are effectively decreasing the amount of CO2 produced, thereby decreasing the burden of expiration on the patient. This also helps to decrease respiratory infections and acidosis associated with emphysema. Therefore, the prescribed diet is high in fat (as much as 55%) and protein and low in carbohydrate.
7. Identify four (4) strategies that might improve his caloric intake
The following are strategies that improve caloric intake: Eat meals when energy levels are at their highest, which is usually in the morning Eat several small, nutrient-rich meals to avoid becoming breathless while eating Eat slowly and chew foods thoroughly to avoid swallowing air while eating Choose foods that are easy to chew. Modify food consistency if mastication seems to increase fatigue while eating Choose foods that are easy to prepare to conserve energy for eating Limit salt. Consuming too much can cause the body to retain water and can make breathing more difficult Eat calcium- and vitamin D-rich foods to support bone health Prepare meals that appear palatable and well presented Avoid foods that cause gas or bloating. A full abdomen can make breathing uncomfortable Eat while sitting up to ease lung pressure Drink liquids at the end of the meal to avoid feeling full while eating Wear a cannula while eating if continuous oxygen is prescribed. Eating and digestion require oxygen, so the body will need the extra oxygen Limit caffeinated beverages, as caffeine can interfere with some medications and cause nervousness or restlessness Make the meal more enjoyable by engaging in social interaction while dining Avoid aspiration by breathing carefully, swallowing, and sitting properly and with good posture while eating Rest before meals
8. Identify three (3) expected outcomes of D.Z.s treatment.
D.Z. will maintain patent airway as evidenced by decreased wheezes, decreased tachypnea, decreased dyspnea, and arterial blood gas (ABG) within normal limit D.Z.s breathing pattern will improve as evidenced by respiratory rate within normal limit D.Z. will demonstrate behavior/lifestyle changes to regain and/or maintain appropriate weight as evidenced by increased in weight of 1 kg per week
9. You answer D.Z.s call light, and he asks for a carton of milk. You remind him that milk causes an increased production of thick mucus. He replies Yes, but you told me that I need lots of protein. How should you respond?
If I were in that scenario, I would tell to D.Z. that there are other food sources that are rich in protein aside from milk that he can take in because milk increases mucus production thus, worsens his condition- provokes difficulty of breathing due to increase mucus production. I would enumerate other sources of protein like meat, egg, and the like.
10. You notice a box of dark chocolate on D.Z.s overbed table. He tells you that he wakes at night and eats four or five pieces of chocolate. Several of your COPD patients have identified craving for chocolates in the past. What is the basis for this craving?
Breathing is very difficult for the COPD patient and tends to worsen as the disease develops. Just breathing causes the person to consume approximately 1,000 calories more on a daily basis than people who dont have the disease. Besides being delicious, chocolate provides more calories quicker than eating large amounts of other foods. The caffeine in chocolate is a natural bronchodilator, allowing the person to breathe easier after eating chocolate.
11. What would you do to address dietary and nutritional teaching needs with D.Z. and his wife?
One of the best ways to address dietary and nutritional teaching needs with D.Z. and his wife is to include them in the planning of care. Including the patient and his significant others in planning of care will increase the patients compliance to treatment regimen. How to do it? You should set an appointment with them and have a lecture about proper diet and nutrition for patients with emphysema using visual aids such as pamphlets or videos. Afterwards, allow them to ask clarificatory questions with you; and if possible, ask them to state what they have learned.
12. List six educational topics that you need to explore with D.Z.
The following are educational topics to be explored with D.Z.: Smoking Cessation Education (Ways on how to stop/quit smoking) Exercise Regularly (Importance of exercise) Influenza Vaccination (Avoiding respiratory infections) Nutrition (Adequate and Proper Nutrition) Medication Education (Compliance to Medical Treatment Regimen) Lung Volume Reduction Surgery Education
13. What other health care professional would probably be involved in D.Z.s treatments and how? What is the license/certification status of that professions in the state in which you are practicing?
Physician- make the diagnosis Nurse Assessing the patient Administering medications Patient education Dietitian- prepares food for the patient Nutritionist- computes caloric intake of the patient Physical Therapist- assist patient to find ways of increasing their strength and activity tolerance Respiratory Therapist Assess patients cardio-respiratory system Administer and interpret diagnostic breathing and blood test Administer medical gases and medicated aerosol therapy to manage and control breathing related abnormalities Provide continuous invasive and non-invasive mechanical ventilation therapy Insert and maintain a variety of artificial airways Assist the physician during flexible fiberoptic bronchoscopy services
14. How would you respond to her?
First of all, I will let the wife express all her concerns for me to assess and prioritize it accordingly. By listening to her concerns I will be able to identify the root or the cause why the wife is acting that way; and for that I would be able to limit possible effects/complications that may arise by attending directly to the root or cause of the problem. Secondly, I will be assessing her coping mechanism; and I will offer/suggest other coping mechanisms that she may utilize since her coping mechanism is no longer working for her. Third, I would explain to her the condition of his husband that the weight loss she noticed was really expected for COPD patients; and I will encourage her to lengthen her patience and understanding for her husband because support mechanism is one factor that may hasten the recovery of the patient.
Lastly, about her financial concerns, I will refer her to a social worker and make an arrangement for both of them to discuss concerns about hospital bills/ financial bills.