Breathe Care Plan: Emphysema - Case Study Example

EMPHYSEMA Emphysema The assessment of the patient in accordance to the s she gives will be based on the disease prevention and health promotion of the patient. This will enable me as a nurse to describe the practices that we have been learning in the course work and effectively implement in the field. Chronic obstructive pulmonary disease is a disorder characterized by inflammation and progressive destruction of the lung tissue. It is a usually a syndrome comprising of disorders which collectively destroy the airway leading to its destruction and incompetent breathing. The disorder may be invariably termed as chronic obstructive airway disease or simply obstructive airway disease (Currie, 2011). The most encountered conditions in this disorder include chronic bronchitis and emphysema. Chronic bronchitis refers to the excessive production and excretion of mucus into the bronchioles extending all the way to air sacs or alveoli. This is as a result of hypertrophy or enlargement of the mucus synthesizing cells. In other instances increased mucus production occurs without mucus cells hypertrophy. In more sever and progressed states pus and pus cells are observed upon histological examination of the produced fluids and sputum. The walls of these large airways may also be populated by acute cells of inflammation or infiltrated by chronic inflammatory cells. A metaplasia of the respiratory epithelium from squamous to columnar also takes place. The result is limitation of airflow and bronchial fibrosis and less to severed gaseous exchange. The patho-physiology, signs and symptoms, progression trajectory, diagnostic testing and treatment options can be well referred from the patient history. The patient reported smoking, which is a well-known cause of the pathologic state she is undergoing. Smoke from cigarettes has a pronounced adverse impact on surfactant production, which irritates the airway. This effect leads to initiation of cough reflex, which she quoted. Smoke also leads to squamous metaplasia thus leading to chronic dilatation. The permanent dilation predisposes the airway to bacterial infection. This is the rationale of antibiotic use and clinical improvement (Falk and Williams, 2010). The condition seems to be exacerbated by stress since she is a widow that is detached from her family of two daughters. However, it is plausible to associate the past respiratory attacks in form of asthma during her childhood and the likelihood of airway destruction with smoking as causes of the chronic disease reported as emphysema. The patient complains of several signs and symptoms. Difficulty in breathing or dyspnea is consistent from past episodes of airway infections. She has exercise-induced dyspnea that is aggravated nocturnally. The great debilitating symptom is emphysema: the permanent enlargement of the respiratory tract. Coughing that worsens at night is another key symptom. A slight sore throat with candidiasis in the review of systems requires further investigations because it does not closely correlates with chronic lung diseases. The patient has elevated body temperature reported as pyrexia. Physical examination of vital signs revealed a slightly elevated blood pressure, which compensates for reduced arterial oxygen level or rather hypoxia. There was thrush in the buccal lining, which is white in color, which is likely candidiasis. Lung sounds were diminished in auscultation (Calderone, & Clancy, 2012). A wheeze at the end of expiration is reported which could be suggestive of obstructive lung disease. This lung disease is unilateral affecting the right lung, which exhibits an increased anterior posterior diameter. This is distended lung, which is confirming emphysema. Differential diagnosis with heart disease was negative. There was no edema or bruits on the carotids. Sinus rhythm was also normal. No heart sounds or murmurs and this nullify the patients claim for heart disease (Levy et al, 2011). Radiological investigation on a chest x-ray showed dilated airways with no sputum. There is a bilateral hyperinflation and distension of both lungs with increased AP diameter. This is evidence of emphysema. This is emphysema that causes the shortness of breath and persistent cough, which together comprise a chronic lung disease. The dilation is due to loss of elasticity or elastic recoil (Redington, & Morice, 2011). There is also decreased white blood cell count on complete blood count tests. This immune-suppression is left shift deviation from normal number of white blood cells. This is due to persistent infections of lungs that required antibiotic treatment. There was no nausea or vomiting thus no aspiration pneumonia can be implicated. Oximetry and lung function test including investigation of arterial blood gases is a proper diagnostic tool for COPD. There are various treatment options available for emphysema. The approach is palliative meant to relieve the symptoms that are presented. It may be pharmacological or non-pharmacological. Pharmacological treatment utilizes same drugs as those indicated for asthma. Oral or inhaled steroids such as methyl prednisone and dexamethasone, which suppress inflammation, are prescribed. They suppress cough, which is seen in this patient. However, since the patient has leucopenia care and strict monitoring is required hence can be given only if she accepts hospitalization. Other alternatives would be non-steroidal ant inflammatory drugs for pain relief. Suitable analgesics would be acetaminophen since aspirin would aggravate acidosis. Vasodilators are used for to manage lung obstructions. They may either be inhaled beta agonists like salmeterol and albuterol or indirect acting sympathomimetic such as ipratropium bromide or oxitropium bromide. Oxygen therapy is also indicated in severe hypoxia and the patient with recurrent episodes of dyspnea may benefit a lot. Fluconazole or nystatin should be provided for the thrush or candidiasis management. Non-pharmacological management would involve supportive and nursing care. Personal initiative of the patient to conform to health models and believes associated with emphysema is very crucial. Bed rest and positive thinking is important. Patient cancelling would enhance this (Lorig, 2012). Smoking cessation is the key to improvement otherwise; continuation of the habit portends the prognosis. Emphysema can be differentiated from other normal inflammatory disorders like asthma in a variety of ways. Firstly, it is a chronic obstructive disease by classification. Although both are inflammatory diseases of the respiratory system, asthma has an allergic component. Asthma manifests through increased bronchial hyper-responsiveness. The first encounter with allergen such as pollen grains, which are seasonal or dust and to some extent food does not elicit an immunological response. However subsequent exposure provoke a severe type I allergic reaction, which constricts the airways leading to chest tightness, wheezing and coughing. Moreover, breathlessness is also encountered in allergic asthma. On the contrary, chronic obstructive pulmonary diseases have no known allergic causes. This explains why mast cell stabilizers including sodium chromoglycate and nedocromil sodium are effective in the prophylaxis of allergic asthma (Holgate, & Douglass, 2010). It is also the immunoglobulin E that is targeted by monoclonal antibodies like omalizumab to combat allergy. These drugs have no clinical role in obstructive lung diseases. There has been no demonstration of chest tightness in obstructive lung disease and this is well reported in the physical examination of the given patient in this case studies. While smoking has never served as a causation of asthma, the optimal disorder named emphysema can be directly caused by smoking. It is worthwhile to note that the two disorders can both be worsened by smoking. Another very important contrast is reversibility. In most circumstances, asthma is readily reversible. Symptoms in this normal disorder are completely reversible with therapy. Unfortunately, in the case of emphysema and other chronic airway diseases, the outcomes of therapy are very unpredictable and poor prognosis is common. This is because the obstructive crisis consumes vital lung tissue rendering the disease irreversible. This explains why a lot of effort is put on prevention than management. The patient requires intensive and comprehensive care mostly with hospitalization being inevitable. It might not necessitate a clinician to prescribe oxygen therapy for asthma but given severe hypoxia and respiratory acidosis in chronic disease, oxygen is required to prevent hypoxic tissue injury and infarction. In most circumstances, the age associated with the disease onset can be diagnostic especially if occupational risks are quoted. COPDs have an adult start present mostly among the old age. Asthma on the other hand is more common among the young population resulting in most junior school absentees. In this, contest for example, the patient history records that she had asthma when she was still young but is now suffering emphysema at the age of fifty-five years old. Asthma is mostly genetic. Studies indicate that atopic influences its occurrence with most incidences found among closest first relative to the patient. Chromosomal studies also show that the predisposition is associated with chromosome 2q that codes for hyper-activity of the IgE. Normal disorder can be acute, intermittent or chronic while COPD is only chronic with incidence of club fingers and lung failure. Acute inflammatory cells are not part of the chronic disorder. The disorder places the patient to a number of physical and psychological demands. When the cough ensues, the patient has to adopt a particular position for relief. Given the obstructive attacks are encountered most nocturnally it goes without saying that the demand to wake up and sit upright for relief in a 55 years old female is a difficult physical obligation. The worsening of symptoms upon physical exertion and the dyspnea has put the patient to a freedom infringement. It offsets her efforts for simple exercise and walking requiring more bed rest than mobility. The patient had declined hospitalization for a couple of times since she could not stand such a demand (Preedy, & Watson, 2010). Recent progression has kept her thing of her two daughters and requiring their moral support. Concisely, these mental disturbances are lingering in her mind. It is therefore evident that the social life is never the same again. The disorder requires close monitoring by a doctor too and patient counseling. Management of emphysema is best done by teamwork. The key concepts of the disease must be share to achieve maximal clinical outcome. Smoking cessation, which could greatly improve symptoms, is very challenging. The family should thus keep close to deter her from going back to the habit. They should be explained in detail the existence, causes, symptoms and management of emphysema. This would prepare them for emergency attack. Sharing information like how to administer oxygen therapy and other medication would be helpful since this would equip them on how to deal with emergency dyspnea attack. This implies that the doctor’s contacts should be shared among the family members as well as the emergency drugs and mode of use (Abp & Intelecom, 2014). The management of patient requires input from various disciplines. At the hospital, level the clinical officer or practitioner diagnoses the patient and from a detailed patient history orders various laboratory investigations by the laboratory technologist who investigates the patient radiological and hematological findings. Thereafter the doctor prescribes drugs in which case the pharmacist comes into play. Drug information including interactions and adverse drug reactions as well as side effects are obtained from the pharmacist. The pharmacist would also explain the rationale of the drug use. Hospitalization and blood pressure determination is mostly under closer nursing care. The nurse helps administer drugs like oxygen supplementation and maintain the hygiene for the wards. They are mostly close to the hospitalized patient and can offer adequate patient cancelling and rehabilitation for smoking cessation. The management of COPD is thus a teamwork approach involving medical doctors, pharmacists and nurses not forgetting laboratory technicians. This is because successful treatment depends on correct diagnosis, which relies on correct history taking coupled to specific laboratory investigations that warrant the desired therapy. A careful analysis of the patient history and bearing in mind of disease model with a sufficient knowledge of health believe model brings out the facilitators and barriers to optimal management of the COPD. The most important contributors to improvement of the emphysema are the patient willingness to take a sick role. Seeking medical attention and providing information that aids in the diagnosis of the same facilitate the doctor’s correct assessment. Previous lung disease mentioned as asthma would never be confused to the current emphysematous state. The key health players including doctors, nurses and pharmacist are supportive, knowledgeable of the perceived severity, and aware of the health outcomes (Steven, 2010). The comprehensive physical examination that identified the patient illness as emphysema also enhances better patient care. The patient faces internal and external factors that form a barrier to effective management. Firstly, her immediate and personal doctor is not committed to her health. Her family is secluded and neither of her two daughters have time to look into her health. There are also perceptions in her history that indicates self-diagnosis. By regarding herself a heart patient, she is more likely to deny the results that she is a COPD patient and this would hinder some aspects of medication. For instance, compliance was low in previous medication. She refused hospitalization, which could be due to her perception that she is a heart patient, and expected no benefit from the respiratory medication. Her old age is another factor. Aged patients tend to have poor metabolism of drugs and low tolerance to exercise. Furthermore, the patient’s condition is worsened by any physical activity and this retards efforts to non-pharmacological management (Lorig, 2012). Worthwhile to note is the fact that the patient is a smoker. Smoke causes decreased surfactant production in the lungs. Constituents of smoke like tar and arsenic destroy the respiratory tract and eventually lead to a loss in elastic recoil and sever chronic obstructive disorder. The patient should know that smoking in isolation is capable of causing permanent dilatation of the bronchial and collapse in some cases. The smoke from the cigarettes also irritates the airway leading to initiation of cough reflex. Strategy to alleviate these hindrances to comprehensive care is essential. The patient need to know that denial of a respiratory disorder to heart disease will not change the result. There is need to accept and embrace the respiratory medications indicated above. Causality of emphysema by cigarette smoking is implicated. The second strategy is therefore to cease from smoking and replace it with other recreation practice like interaction with other COPD rehabilitated patients. The patient should also accept the doctor’s advice to hospitalization. Understanding the multidisciplinary involvement in the patient care is critical. The patient cannot be allowed outpatient since the delivery of some medication requires a doctor or nurse who cannot be available full time for home patient care given that frequent monitoring and laboratory investigation. The laboratory is not a readily portable entity of a hospital and so hospitalization should be the number one option to facilitate close and maximal outcome on the treatment. It would also allow dose titrations and designing of patient tailored regimens with the widespread initiation of clinical pharmacy and pharmacogenomics. Care plan synthesis An action plan for the patient comprise of the signs and symptoms, medication to take and the respective dosages and doctors contacts. Design of such a comprehensive and holistic plan for recognition would prepare the key players in management of the patient for attacks. The action plan will be divided into two sections. The first part is coded the colors of traffic lights under which details of symptoms drugs and instructions on management and role players are indicated. The green zone would entail a safe zone that patient is doing well and symptoms like cough, wheezing and bronchial dryness are minimal or absent. The patient can therefore do simple exercise and walk without attacks. The next important zone is the yellow zone. Here the patient has one or more of the major symptoms like cough and the medication to take are also indicated with their quantity. The patient is aware of risks so should keep off triggers like secondary smoke. The last and worst prognostic section is the red zone (Mahler, 2014). The patient is unable to walk around and most signs and symptoms are exhibited such as breathlessness, hypoxia and a non-productive cough. The second part of the action plan is preparative for emergency. Doctor’s contacts as well as drugs to be prescribed in the event of fatal attacks or aggravation of signs and symptoms are written in this section. The patient lives alone and although reports low stress levels the fact that she smokes is implying that she is undergoing some psychological disturbance. She feels neglected by her two daughters and breast cancer and osteoporosis that her sisters are suffering from may as well stress her. Stress is a known cause for worsening of symptoms in emphysema and the incidence is much higher when coupled to smoking. The fact that her physician neglects her and the social medical belief that her disease is a heart problem also impairs proper care. There is distinct evidence that the patient has emphysema. She complains of dyspnea that worsens with exertion. She has hyper-inflated lungs with increased AP diameter and no chest pressure, which is important differential to asthma. Dry non-product cough is also suggestive of the chronic disease. The patient has candidiasis. Physical examination shows a white buccal plaque which cannot be scrapped off by tongue. She is also immune-suppression as evidenced by white blood count differential, which is 15000 and indicated as a left shift. Comprehensive management would therefore encompass treatment of the above found diseases. Emphysema treatment comprises drugs like aminophylline with very low dose dexamethasone. Ketoconazole with nystatin for the fungal disease is also indicated. Augmentin should be given as a pro phylaxis for bacterial infection since the patient is susceptible given the immunodeficiency and pathologically dilated airway. References Animated Biomedical Productions., & INTELECOM Intelligent Telecommunications (Firm). (2014). Emphysema. Pasadena, CA: INTELECOM. Currie, G. P. (2011). Chronic obstructive pulmonary disease. Oxford: Oxford University Press. Falk, S. A., & Williams, C. J. (2010). Lung cancer. Oxford: Oxford University Press. Holgate, S. T., & Douglass, J. A. (2010). Asthma. Abingdon: HEALTH Press. In Calderone, R. A., & In Clancy, C. J. (2012). Candida and candidiasis. Washington, DC: ASM Press. Levy, A. J., Trujillo, N., Dorfman, T., Tilley, J., OConnor, P., & Apogee Communications Group. (2011). Heart disease. Boulder, CO: Apogee Communications Group. Lorig, K. (2012). Living a healthy life with chronic conditions: Self-management of heart disease, arthritis, diabetes, depression, asthma, bronchitis, emphysema, and other physical and mental health conditions. Boulder, CO: Bull Pub. Co. Mahler, D. A. (2014). Dyspnea: Mechanisms. CRC Press. Preedy, V. R., & Watson, R. R. (2010). Handbook of disease burdens and quality of life measures. New York: Springer. Redington, A. E., & Morice, A. H. (2011). Acute and chronic cough. Boca Raton: Taylor & Francis. Steven F Werder, W. (2010). Cobalamin deficiency, hyperhomocysteinemia, and dementia. Dove Press. Read More