Nursing Care Plan Development Chronic illness - emphysema 9/23/2011

Unit: NURS 8822

Unit co-ordinator: Assistant Professor Olivia Hill

Student: Regan Preston

Student No: 20825201

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Table of Contents    

Emphysema – a Chronic Obstructive Pulmonary Disease  .................................................................  3  

Epidemiology:  ........................................................................................................................................  3  

Aetiology:  ................................................................................................................................................  4  

Pathophysiology:  ...................................................................................................................................  5  

Clinical manifestations  ..........................................................................................................................  7  

Risk Factors  ...........................................................................................................................................  8  

Diagnosis of emphysema  .....................................................................................................................  9  

Problem Identification  .............................................................................................................................  11  

Care Planning  ..........................................................................................................................................  14  

Collaborative care  ...................................................................................................................................  23  

Conclusion  ...............................................................................................................................................  24  

References  ...............................................................................................................................................  25  

 

   

 

 

 

 

 

 

 

 

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Emphysema – a Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease (COPD) is a multi-component respiratory disease that

is progressive, with no known cure.1-3 COPD is defined by the Global Initiative for Chronic

Obstructive Lung Disease (GOLD)4 as a preventable and treatable disease with significant extra

pulmonary effects that may contribute to the severity in the individual patient.4, 5 A mixture of

small airway disease and parenchymal destruction are characteristic of emphysema, and

conditions vary amongst individuals.4

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COPD has a very variable history and diseased patients do not follow typical symptomatic

patterns, and trends. It is a progressive disease and limiting exposure to harmful agents will

reduce progression of the disease, however once COPD has developed, only treatment can be

given to reduce symptoms and exacerbations, and improve overall quality of patients life.4

Epidemiology:

COPD has a huge burden on our society and health care system, and according to the World

Health Organization (WHO) World Health Report 2000, respiratory diseases account for 17.4%

of all deaths and 13.3% of all Disability Adjusted Life Years (DALYs).2, 7, 8 COPD is projected by

2020 to become the fifth largest in burden of disease, and the third leading cause of death

worldwide.2 9, 10 The Burden of Obstructive Lung Disease (BOLD) study showed that the

worldwide prevalence of COPD was approxiatemelty10%.11 This figure varied by geographic

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location and by sex. Prevalence among men was 11.8% and among women was 8.5%.11 The

differences in sex can be explained by the prevalence of smoking. Historically incorrect and

inaccurate definitions of COPD have made difficult to quantify the factors such as prevalence,

morbidity and mortality of COPD and emphysema.4 Under recognition and under diagnosis of

COPD are responsible for large variances in underreporting.4  In Australia, COPD is the fourth

major cause of deaths in males, and sixth major cause in females. It is reported that over 80%

of the COPD sufferers are experienced over the age of 45 years.8 In 2003, the Australian

Burden of Disease and Injury Study estimated almost 400,000 people with COPD in Australia,

with 20,000 new cases every year.8 In Australia, The Australian Institute of Health and Welfare

(AIHW) 2008 reported COPD as the leading cause of death 4%, around 4900 deaths per

annum.12 In 2000, COPD had accounted for 4% of all make deaths and 3% of female deaths in

Western Australia.12 History has shown that COPD was more prevalent among men. This was

attributed to the difference in smoking rates in men and women. However the increase in

smoking among women, the difference has declined.12 Furthermore COPD is also associated

with socio-economic status, and high rates of COPD exist in aboriginal populations.12 This was

due to extremely high rates of smoking within these communities.8  

Aetiology:

COPD is most often caused by smoking. Most people with COPD are long-term smokers, and

evidence shows that smoking cigarettes increases the risk of getting COPD.4,  8  13  Overwhelming

evidence that lung destruction resulting in emphysema is largely due to enzymatic action on the

pulmonary connective tissues such as elastin. These enzymes are possibly derived from

neutrophil polymorphonulear leucocytes and alveolar macrophages.4 Some research has shown

release of these enzymes related to cigarette smoking. Emphysema can be seen as very

closely related to the fact that individuals smoke, and result of smoking habit. A mixture of small

airway disease and parenchymal destruction are characteristic of emphysema, and conditions

vary amongst individualls.4 Emphysema damages the structure of the alveoli causing the walls

to break down. This means the alveoli are no longer able to hold the bronchioles open, making it

hard for the lungs to expel air. Emphysema makes the lungs resemble an old used sponge with

large holes that lack elastic recoil.14, 15  

 

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Pathophysiology:

Emphysema is defined as an enlargement and inflammation of air pathways and coupled with

destruction of alveolar walls and septa of lung tissue.16, 17 There is parenchymal destruction

typical of emphysema and develop from long time smokers and exposure to noxious particles or

gas substances.2, 16, 18 This causes limitations and reduction in elastic recoil required in correct

lung function.16 This loss of lung natural elasticity results in lung becoming permanently

inflated.18 Condition is caused by destruction of the pulmonary connective tissue namely elastin

and collagen.14 Gas exchange abnormalities are characteristic and result in hypercarnia and

hypoxemia.4 The severity of emphysema relates to the ventilation –perfusion (V/Q) imbalance,

and disease worsens as this imbalance gets greater. This imbalance and loss of elastic recoil in

alveoli, depicted in figure 1, leads to carbon dioxide retention and hypercapnia state.

Figure 1: The major mechanism of airflow limitation is loss of elastic recoil.19

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Figure 2: The pathophysiology of emphysema.20

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Figure 3: The effects of emphysema on the gas exchange units. A Normal lung with many small

alveoli. B Lung tissue affected by emphysema. Notice that the alveoli have merged into larger

air spaces, reducing the surface area for gas exchange.21

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Clinical manifestations The clinical manifestations of emphysema are tabulated in table 1. Typically dyspnoea, productive cough, history of smoking and barrel chest are common clinical manifestations of emphysema.

Table 1: Clinical manifestations of emphysema:  15  

VARIABLES EMPHYSEMA

Age (years) 50-75

Infections Occasional

Dyspnoea Severe, early in course

Productive cough Late in course with infection

Wheezing Common

History of smoking Common

Prolonged expiration Always present

Cyanosis Late in course

Chronic hypoventilation Late in course

Chest x-ray findings Hyperinflation

General appearance “pink puffer”

Barrel chest Classic

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A classical clinical manifestation is the barrel chest of an emphysema sufferer. This is well

depicted in Figure 4.

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Figure 4: Lateral CXR of a person with emphysema. Not the barrow chest and flap diaphragm22  

Risk Factors Cigarette smoking is the most common risk factor for COPD and emphysema.4, 23 Identification

of risk factors is an important step in determining strategies for prevention and treatment of

these chronic respiratory diseases. Risk factors do interact and interlink with each other and

with the current overpopulation being experienced around the world, factors like poverty, socio-

economic status, level of nutrition and level of education are all becoming major determinants in

COPD.4 Figure 3-1 lists common risk factors associated with emphysema and COPD6.

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Diagnosis of emphysema

Key indicator in considering a diagnosis for emphysema would be the presence of dyspnoea,

chronic cough, sputum production, and health history of smoking or smoke related risk factors.6

Diagnosis of emphysema is achieved through physical assessment, spirometry tests, arterial

blood gas assessment, chest x-ray, electro cardio graphs (ECG) and microbial testing.2, 16

Although physical examination is an important clinical diagnostic tool, in COPD it is used

conjunctively with other diagnostic assessments such as spirometry, spirometry being the gold

standard in assessment and diagnosis of COPD.4 A physical assessment is made up of an

inspection, palpation, percussion, auscultation of respiratory region. Table 3 compares the

assessment process and diagnostic difference between and normal and a diseased lung.

Physical Assessment Normal Lung Emphysema Inspection Anteroposterior transverse

diameter, RR 10-18, regular, no cyanosis or pallor14

Increased anteroposterior diameter. Barrel chest. Use accessory muscles to breathe. Tripod position. Shortness of breath. Tachypnea.14

Palpation Symmetric chest expansion. Tactile fremitus present and equally bi laterally, diminishes towards periphery. No masses, lumps, tenderness.14

Decreased tactile fremitis and chest expansion.

Percussion Resonant. Diaphragmatic excursion 3-5 cm14

Hyper resonant. Decreased diaphragmatic excursion.14

Auscultation Vesicular over peripheral fields. Broncho vesicular parasternally (ant) and between scapula (post)

Decreased breath sounds. Prolonged expiration. Muffled heart sounds from over distention of lungs.14

Adventitious Sounds None Usually None, occasionally, wheeze.

 

 

Spirometry is a simple and painless test which measures the capacity of your lungs.24

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Emphysema can be diagnosed by using the gold standard spirometric classification of stages of

COPD, and GOLD guidelines.2, 17, 25 The presence of a post bronchodilator FEV1/FVC<0.70 and

FEV1 <80% predicted confirms the presence of airflow limitation that is no fully reversible.4

Table 2: Spirometric classifications of COPD26

Arterial blood gas measurement is performed on patients with FEV<50%. Development of

respiratory failure is indicated by a PaO2<6.7kPa (60mmHg) with or without PaCO2>6.7 kPa

(50mmHg) in arterial blood gas measurements made while breathing air at sea level.4, 23 Low

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pH,  High PaCO2, normal or high normal bicarbonate, are indicators of lung disease like COPD.  

Chest X-ray can determine densities in lung fields that are produced by fluids, tumors and other

pathological conditions and also used in excluding alternative diagnoses and establishing the

presence of other co morbidities such as cardiac failure.23 Chest x-rays on CPOD patients show

signs of hyperinflation, flattened diaphragm, and increase in the volume of the retrosternal air

space. In addition chest CT scans also useful in showing the actual distribution of the

emphysema, for patients that may undergo lung volume reduction surgery. Genetic diagnostic

screen testing can also be undertaken, checking for Alpha-1 antitrypsin deficiency. A serum

concentration of below 15-20% of the normal value is a predictive sign of alpha-1 antitrypsin

deficiency and COPD.6 Presence of purulent sputum during exacerbation of symptoms is

sufficient indication for starting empirical antibiotic treatment, with common COPD pathogens

being namely Streptococcus pneumonia, Hemophilus influenzae and Moraxella catarrahalis.6

Problem Identification  

COPD is a chronic and disabling respiratory disease, studies cited by Blinderman et al 20099

have shown that the most prevalent symptoms experienced by COPD sufferers were dyspnoea

(94%), fatigue (71%), coughing (56%) and anxiety (51%).9 Other symptoms with high

prevalence were drowsiness, nervousness and wheezing.9 Studies by Silbeck et al 1998 as

cited by Wilson27 showed breathlessness (95%), pain (68%), fatigue (68%), sleeping difficulty

(55%) and thirst were common clinical manifestations.27 Edmonds et al 2001 as cited by Wilson,

collect evidence to show that breathlessness was experienced more often, and became

extremely distress by this excacerbation.27 Evidence shows dyspnoea as the main standout

symptom of COPD patients who seek medical attention, and major cause of disability and

anxiety associated with the disease.4 Studies conducted by a British team Elkington 2004, as

cited by Wilson27, found that breathless was the main symptom experienced by COPD sufferers,

and anxiety and depression were common.27 Feelings of anxiety and depression are also

common in patients with chronic COPD and emphysema, mainly dyspnoea inducing factor of

fear and anxiety.28

The increase in breathlessness will result in the increase in the fear of exercise and this in itself

becoming a major reason for avoidance of physical activities.29 Breathlessness could trigger

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panic attacks, which in turn exacerbate the symptom of dyspnoea. This avoidance is shown to

cause further disability through physical deconditioning and hence avoidance in social and

physical activities.18 Kunik et al 2005 as cited by Addy29, showed that a very high percentage of

COPD suffers would develop negative beliefs about self image as the disease progressed.29

The onset of increased anxiety and depression would develop and become major comorbid

symptom. Feelings of anxiety and depression are common place in COPD sufferers due to the

impact of the increase in dyspnoea, altered sleep patterns and the feelings of loss and grief

associated with disability of COPD.28, 29 The element of fear is aroused when breathlessness is

experienced in large majority of sufferers. The psychosocial problems experienced by

emphysema patients range from depression, loneliness, helplessness and hopelessness.30, 31

Intense loneliness can be brought about by lack of self worth feelings and overall lack in

personal confidence. Loneliness has been associated with depression.30

Psychological states such as depression and anxiety in COPD have important repercussions.32

Physical deterioration, becoming further housebound and reflection on what was once a

previously active body, produce negative depressive emotions.1 Patients become withdrawn,

lonely, isolated, anxious and in worse cases, lose the ability to show or display any emotion

such as anger, or even sadness.18, 32 Without a clinical intervention from mental health

specialists, symptoms like fatigue, weight loss and ability to cope and tolerate symptoms of

emphysema will not alleviated.1 Attitudes such us wanting to “give up” have also been observed

in chronic suffers, due to the fact that not much more could be done with respect to a cure for

disease.1, 29 Sleep pattern alterations and difficulties due to COPD symptoms further enhanced

feelings of anxiety and depression.18 Sleep anxiety is also prevalent in oxygen therapy patients

with fear of one dying in ones sleep.25 Angel et al 2007 as cited by Rabe2 study showed that a

serious element of depression in COPD patients was there lack of desire and willingness to

participate in rehabilitation programs for the disease. These programs have been proven to

increase patients self esteem, decrease fear of dyspnoea and physical activity and overall

depression.2

Therefore, from the above evidence reviewed, the following patient problem statements have

been prioritized:

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Patient problem statements:

1. Ineffective airway clearance related to bronchoconstriction, increased mucous

production, ineffective cough and sputum expectoration, manifested by acute episodes

of dyspnoea and breathlessness.

2. Impaired gas exchange related to the imbalance and loss of elastic recoil in alveoli,

secondary to parenchymal lung tissue destruction, manifested by pursed lip breathing

and inability to speak.

3. Fatigue and activity intolerance related to imbalance between oxygen supply and

demand, manifested by verbalizations of lack of energy, lethargy and increased need for

rest.

4. Anxiety related to the fear of episodes of breathlessness, threat of death, and

hopelessness to a chronic illness, manifested by lack of self care and depressive mood

states.