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Emphysema Case Study E3
Emphysema Case Study E3
Introduction
A. Background of the study
The case study that is to be presented features a patient who has emphysema. Emphysema is a
chronic obstructive pulmonary disease (COPD). It is often caused by exposure to toxic
chemicals, including long-term exposure to tobacco smoke or cigarette smoking. The lungs
become damaged because of reactions to irritants entering the airways and alveoli.
Cigarette smoking is the major cause of emphysema, accounting for more than 80 percent of all
cases. Emphysema occurs most often in people older than age 40 who have smoked for many
years. Long-term exposure to secondhand smoke may also play a role. Smoking stresses the
natural antioxidant defense system of the lung, allowing free radicals to damage tissue down to
the cellular level. When cigarette smoke is inhaled, 80 to 90 per cent remains in the lungs and
causes irritation, increased mucus production and damage to the deep parts of the lungs.
Eventually mucus and tar clog up the air tubes, causing chronic bronchitis and emphysema.
Among other causes of emphysema are industrial pollutants, aerosol sprays, non-tobacco smoke,
internal-combustion engine exhaust, and physiological atrophy associated with old age (senile
emphysema).
It was verbalized by the wife of the patient that he used to work at the farm in Morong. this could
be one factor that caused the patient’s disease.
We as nurses are involved in learning what type of nursing interventions we are to apply to this
type of patient. Beyond understanding the relevant health issue, this case study will also explore
other factors that can enhance our knowledge in the field of our nursing practice. This is also the
primary reason why we choose this case study because we know that it is highly beneficial aside
from it being considered distinctive or unique.
Included with the case study are the discussions of the anatomical parts, through physical
assessment of the patient, laboratory results and their corresponding findings, a reapplied
framework theory by Florence Nightingale. Added to this we also have a corresponding plan for
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the patients discharge arrangement and finally a discussion of the patient’s daily activities and
nursing care plans.
B. Objectives
General objectives
After exposure in the medical ward of Queen Mary Hospital the promotion of health and the
prevention of illness should have been applied through the use of effective nursing care.
Wellness should be met through the implementations that have been done with regards to the
application of the nursing process. That is after developing and implementing an intervention,
and monitoring the impact of that intervention to the patient. This is to know whether the
treatments given to him were effective or not.
Specific Objectives
Our objective is to develop our skills in identifying and assessing the health problems, how to
utilize and render quality health service in the care of an individual who has emphysema.
Other objectives would include the establishment of rapport for the patient to fully cooperate
with his treatment and so as to assess him with his health related problem.
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E. Theoretical framework
Ore
m ’s
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II. Nursing Assessment
A. Personal Data
o Name: Mr. LP
o Address: G. Robles Maybangkal Street, Morong, Rizal
o Age: 61 years old
o Birth date: March 30, 1948
o Religion: Roman Catholic
o Civil Status: Married
o Nationality: Filipino
o Occupation: Former Farmer
o Admitted on: June 21, 2009
o Time: 9:10 p.m.
o Admitting Diagnosis: COPD in exacerbation, Plural Effusion, Pneumonia, t/c Electrolyte
imbalance
o Chief Complaint: D.O.B. (Difficulty of Breathing)
After the patient was discharge home around 8:50pm (June 15, 2009) after 3 days at home he
experienced DOB and he was rush to the hospital accompanied by his wife and cousins.
-COPD
-Questionable Pneumonia
-Electrolyte Imbalance
D. Family History
According to patients wife they can not recall any illness in the family of his husband except
from asthma.
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simple cough due to tiring day but it lasted for about a month and he needs to be admitted and
undergone some procedures.
F. Physical Examination/Assessment
Area Normal Finding Actual Finding Analysis
I. Head
1. Hair - black, evenly - black slightly -Aging
distributed and grayish , thick.
covers the whole
scalp, thick, shiny,
free from split ends
2. Scalp - white, clean, free - without dandruff - normal
from masses, lumps,
scars, dandruff and
lesions
3. Face - Oblong or oval. - With wrinkles, - patient is still
Symmetrical. Facial symmetrical. With worried about his
expression that is expression of pain condition and
dependent on the and anxiety appearance
mood or true
feelings, smooth and
free from wrinkles,
no involuntary
muscles involved
4. Eyes - parallel and evenly - symmetrical, black - normal
placed, symmetrical, in color and can still
non-protruding, read with out
both eyes are black glasses
and clear
5. Nose - midline, - symmetrical with - patient has
symmetrical and NGT undergone surgery
patent clear pinkish
with few cilia (-)
congestion
6. Lips - pinkish, - crack and dry lips - patient wasn’t able
symmetrical, tip to eat and drink that
margin well define, much due to his
smooth and moist tracheotomy
7. Teeth and Gums - 32 permanent - with out dentures, - patient was
teeth, well aligned, gums are normal in instructed to gargle
free from carries or color bactidol
filing.
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8. Speech -No hoarseness and Can not speak, Tracheostomy can
well – modulated. makes some block the vocal
Can able to say two moderate noise, can cords that’s why
words with meaning communicate with patient wasn’t able
sign language or by to make any sounds
writing.
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II. Thorax
1. Breathing - Normal breath - Abnormal - Excessive phlegm
sounds are Respiration 40bpm, production blocks
bronchovesicular, a difficulty in his thorax and this
medium pitched breathing. may cause difficulty
sound or medium Experiencing cough in breathing.
intensity, heard after nebulization.
posyeriorly between
the scapulae. The
sound have blowing
quality with the
inspiratory phase
equal to the
expiratory phase
and Vesicular
sounds which heard
over the lung
periphery. It created
by air moving
through the small
airways. They are
soft, breezy and low
pitched and the
inspiratory phase is
about three times
longer than the
expiratory phase.
Respiration rate
ranges from 16 – 20
in normal adult.
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III. Limbs
1. Extremeties - no areas of - with IV catheter on - red spots may
tenderness, muscle his right arm and a cause itchiness in
appear with good red spots in the site the site of IV and
muscle tone of the IV catheter. also this may cause
infection or
phlebitis.
VI. Hygiene and - Full bath and able - Patients depends - Patient has a
comfort to practice simple on significant others drainage tube at his
hygiene and care for in eating, taking a chest and undergone
himself. bath (TSB) and tracheostomy,
other chores that patients
involves wide experiencing body
movement. weakness can not
move properly
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F.Usual Pattern of daily living/
Gordon’s Health Assessment
Pattern Before After Interpretation Analysis
Hospitalization Hospitalization
1. Health Patient X makes Patient X Patient X cannot A tracheostomy is a
Perception- sure to consult his considers himself function surgical procedure to
Health doctor with not healthy due to normally like create an opening
Management regards to his his present before because of through the neck into
condition, he goes condition. He was his confinement the trachea (windpipe).
for checkups diagnosed with and because of A tube is usually
because he knows "COPD” and he his condition. His placed through this
that there is had undergone body image opening to provide an
something wrong tracheostomy. He changed due to airway and to remove
with him. He is expecting to his disease and secretions from the
maintains a recover from his surgical lungs. This tube is
healthy body. He present condition procedure that he called a tracheotomy
easily gets bored with the help of has undergone. tube or trachea tube.
when he is not the health care This surgical
doing anything. providers procedure helps the
He has started attending to his client with his
smoking needs. breathing problem.
(Marlboro Green) All of the
since he was 36 medications
years old up to prescribed to
present. He is not patient X are
allergic to any available.
food or drug. His
family does not
have any history
of hypertension,
heart disease,
cancer, asthma,
diabetes or even
tuberculosis.
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also vegetables easily loses his condition. His globe right eye due to
most of the time. appetite. confinement accident and burn of
He rarely eats status is totally facial area including
meats. affected. the neck.
4. Activity, In the morning, Patient X’s During Patient Pain causes discomfort
Leisure Patient X’s daily activities in X’s and may disrupt the
and include farming in the hospitals are confinement in patient’s daily
Recreation their land fields. ambulation, deep the hospital, activities.
Pattern In the afternoon breathing exercise, there is limitation
after lunch, Patient taking a bath or in his activities
X likes to watch personal hygiene. of daily living
T.V. and a disruption
in his leisure and
recreation
pattern.
5. Sleep and Patient X before Patient X Patient X's sleep “Illness that causes
Rest hospitalization verbalizes that he and rest pattern pain or physical
Pattern already has has difficulty with has not changed distress can result in
difficulty in sleeping and that much before and sleep problems.
sleeping. He says he sleeps for short after admission People who are ill
he will fall asleep periods of time to the hospital. require more sleep
but will eventually about: (3-4 hours) Pain also than
wake up again and due to pain and contributes a big normal and the normal
will not be able to the environment factor for rhythm and
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return back to that he is in. He disturbances of wakefulness
sleeping. He does not feel his sleeping is often disturbed.”
sleeps for comfortable. pattern. (Fundamentals of
A short period of Nursing, 7th ed by
time about 4 hours Barbara Kozier, et al,
a day. p.
1117). There is
disruption of the sleep
wake
cycle because of the
patient’s disease.
6. Cognitive- Patient is an Because of Patient There was a Tracheostomy can
Perceptual elementary X’s present change in block the vocal cords
Pattern graduate. He is a condition, he has cognitive and that’s why patient
farmer. He can difficulty in perceptual wasn’t able to make
read and write. breathing. Patient pattern in terms any sounds
He can speak and is able to read and of speaking due
be understood by write at present. to his
others. He cannot speak tracheostomy.
much because of
his tracheostomy
tube, he
communicates
through hand
gestures but most
data that we
received came
from his wife.
7. Self- Patient X is a He does not There is a change “Events or situations
Perception- friendly person; he consider himself in his self may change the level
Self-Concept loves to socialize as a holistic esteem. of self concept over
Pattern with his friends in person. He has time. Illness and
their many regrets in trauma can also affect
neighborhood. He his life like his the self concept.”
considered himself smoking habits
as a holistic before. He thinks
human being as that he can't
long as his function well than
complete, healthy before.
and his family are
always there for
him. He wants
to have good
health and live his
life to the fullest.
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8. Role Patient can speak Patient X's family He cannot Illness can cause
Relationship and understand still supports him perform his changes in one’s role.
English, Tagalog. despite of the previous
He can clearly change in his role activities or even
express himself. due to his illness. support his
He has 8 siblings family but still,
and they are all despite of that,
close to each his wife is still
other. Patient is there beside him
very active and taking care of
usually socializes him and loves
with his him.
neighbors.
9. Sexuality- Patient and his The patient does Patient does not Illness can cause loss
Reproductive wife perform this not perform any want to talk of interest in sexual
Pattern when he is still sexual activity. about it. activities.
healthy.
10. Coping When he is The recent Even though it’s According to Folkman
and anxious, patient hospitalization hard for the and Lazaruz, coping is
Stress wants to be alone. was a shocking patient to cope, is “the cognitive and
Tolerance He does not show experience for wife is there behavioral effort to
his emotions. patient X, there beside him to manage specific
When he is has been many support him and external and/or
stressed, he changes that has give him strength internal
prefers to rest. occurred which and hope. demands that are
When it comes to made it difficult appraised as taxing or
problem, he lets for him to adjust. exceeding the
himself think He cannot resources of the
immediately for a communicate person”(Fundamental
solution. effectively due to s
the procedures on Of Nursing by Kozier
his neck which is P.
open to direct 1020).
airway through an
incision in the
trachea.
11. Values- Patient X is a According to the After what Due to illness, it
Belief Roman Catholic. patient, there are happened, patient makes the patient
Pattern According to the no practices that is now seeking become closer to God.
client, he goes to affect his for medical
mass every sunday hospitalization. He assistance.
with his family. follows Religious effort
therapeutic is still a part of
regimen and has patient’s life.
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strong faith in God
accounts for his
fast progress.
III. ANATOMY
The Respiratory System
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Parts of the Respiratory System
Structurally, the respiratory system consists of two parts:
1. Upper Respiratory Tract
2. Lower Respiratory Tract
Functionally, the respiratory system consists of two parts:
1. The conducting portion
2. The respiratory portion
Respiratory Tract
The respiratory tract is the path of air from the nose to the lungs. It is divided into two sections:
Upper Respiratory Tract
Lower Respiratory Tract
IV. PHYSIOLOGY
Upper respiratory tract
Nose
The nose, whether “pug” or “ski-jump” in shape, is the only externally visible part of the
respiratory system. During breathing, air enters the nose by passing through the external nares, or
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nostrils. The interior of the nose consists of the nasal cavity, divided by a midline nasal
mucoseptum. The olfactory receptors for the sense of smell are located in the mucosa in the slit
like superior part of the nasal cavity, just beneath the ethmoid bone.
Pharynx
The pharynx is a muscular passageway about 13 cm long that vaguely resembles a short length
of red garden hose. Commonly called the throat, the pharynx serves as a common passageway
for food and air.
Air enters the superior potion, the nasopharynx, from the nasal cavity and then descends
through the oropharynx and laryngopharynx to enter the larynx-below.
Trachea
Air entering the trachea or windpipe from the larynx travels down its length (10-12 cm, or about
4 inches) to the level of the fifth thoracic vertebra, which is approximately midchest. The trachea
is lined with a ciliated mucosa.
Primary Bronchi
The division of the trachea forms the right and left primary bronchi. The right primary bronchus
is wider, shorter, and straighter than the left. By the time incoming air reaches the bronchi, it is
warm, cleansed of most impurities, and well humidified.
Lungs
The paired lungs are fairly large organs. They occupy the entire thoracic cavity except for the
most central area, the mediastinum, which houses the heart, the great blood vessels, bronchi,
esophagus, and other organs. The surface of each lung is covered with a visceral serosa called the
pulmonary,or visceral, pleura, and the walls if the thoracic cavity is lined by the parietal pleura.
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alveolar wall. Type II cells that secrete surfactant to lower the surface tension of water and
allows the membrane to separate thereby increasing the capability to exchange gases. Type III
cells that destroy foreign material, such as bacteria. The alveoli have an innate tendency to
collapse (atelectasis) because of their spherical shape, small size, and surface tension due to
water vapor. Phospholipids, which are called surfactants, and pores help to equalize pressures
and prevent collapse.
V. Laboratory Examination
Microbiology Date: 6-19-09
Specimen: Pleural Fluid
Result: No Pathogenic Organism isolated after 3 days
Of intebation.
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FPSP
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Interpretation: Polycythemia with infection related to pleural effusion
Noel C. Santos MD
FPSP
Interpretation: Sinus tachycardia Left atrial enlargement, persistent fever, diffuse nonspecific T-
wave changes.
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Epithelial: Few
Urates: Few
Mucus threads: Few
Dr. Mennen Alsol MD
Pathologic Dx
-Squamous papillomas showing chronic non-specific inflammation, Right and Left vocal cords.
Gross/micro description
-Specimen consist of grayish white tissue fragments measuring as labeled A. 1x0.6cm and B.
1.1x0.5cm Entire specimen submitted. Microsecretions A and B disclosed tissues lined by
thickened stratified squamous epithelium set in a fibrovascular stroma with Coci of chronic
inflammation. There is no evidence of malignancy.
Interpretation: Prior to his last hematology result the patient has infection related to presence of
water in his lungs(Pleural effusion).
Dr. Anne Paulette C. San Antonio MD
Interpretation: Prior to his last hematology result the patient has infection related to presence of
water in his lungs(Pleural effusion).
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Chest Ap Sitting Date: 7-7-09
-Follow-up chest film 7-7-09 when compared to previous film dated 7-4-09 shows resolutions of
previously noted right sided pleural effusion. However, no significant interval change in
previously noted left sided pleural effusion other finding remain unchanged. Suggest clinical
correlation & follow-up.
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>1 neb + 2cc NSS intracellular cyclic guanosine >to increase fluid intake, as
QID monophosphate w/c is drug causes dry mouth, throat
produce by the interaction of irritation, and a bad taste of the
acetylcholine with the mouth.
muscarinic receptors of the
bronchial smooth muscles.
Pharmacokenetics
Absorption: Minimal
Distribution: none
Metabolism: liver (small
Amount of absorption)
Excretion: kidneys absorbed
amount
Half life: 2hrs.
Pharmocodynamics
Inhalation
Onset: 5-15 mins.
Peak: 1-2hrs.
Duration: 3-6hrs.
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distribution: minutes traces
metabolism: liver excretion
liver halflife: 8 hrs
Pharmacodynamics
Onset unknown
peak: 1-2 hrs
duration: unknown.
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blood flow through disturbance.
coronary
vasculature, dilates
arterial, venous beds
systemically.
Pharmacokinetics
Absorption: well
absorbed (PO buccal
and SL)
Distribution:
unknown
Metabolism: liver
extensively
Excretion: kidney
Half life: 1-4mins.
Pharmacodynamics
Onset: 30 mins.
Peak: unknown
Duration: 2-12 hrs1
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dilatation of adequate pulses and skin turgor.
coronary artery,
decrease peripheral
vascular resistance
of smooth muscle
decrease b/p and
increases myocardial
O2 delivery in
patient’s w/
vasospatic angina.
pharmacokinetics
Absorption: well
absorbed up to 90%
Distribution: 95%
bound in plasma
protein crosses
placenta
Metabolism:
extensively in liver
Excretion: kidneys
Half life: 30-50hrs.
increases in elderly
hepatic disease.
pharmacodynamics
Onset: unknown
Peak: 6-10hrs
Duration: 24 hrs
Medication
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• Vastarel MR 35mg twice a day 1 tablet
• Mepirocin Ointment apply to Tracheal Stoma twice a day
• Prednisone 5mg ½ tablet for twice a day in 2 days then 5mg ½ tablet for once a day in 2
days then disc
• Ansimar 400mg 1 tablet for twice a day
Exercise
• Mild exercise can increased oxygen utilization and re-train muscle to help improve the
tissue.
• Encouraged the patient to pursed-lip breathing to prolong exhalation and increase airway
pressure during expiration, thus reducing the amount of trapped air and the amount of
airway resistance.
• Instructed the patient to Inhale through the nose while slowly counting to 3 then blow it
slowly and evenly against pursed lips while tightening the abdominal muscles.
• Pursing the lips increases intratracheal pressure; exhaling through the mouth offers less
resistance to expired air.
• Turn side by side to prevent bedsore.
• Instructs the patient to flexion and extension or rotate his foot.
Treatment
• Nebulization
• Tracheal Suction
• Oxygen Therapy
Health Teaching
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• Instruct the family to avoid air pollutants such as smoke, dust or aerosol sprays which
may initiate brochospasm.
Nebulizer Therapy
• Instructed the patient to breath through the mouth, taking slow, deep breaths and then
to hold for a few seconds then breathing out. At end of inspiration to increase
intrapleural pressure and reopen collapsed alveoli.
• Instructed the family to avoid replacing the nebulizer cup and the tube to the dust and
smoke area, away from open window.
• Avoid putting the equipments in the dishwasher area.
• Instructed the family to wash the mouthpiece in a warm water and mild detergent.
They can also use vinegar solution by soaking for 30 minutes then rinse through
water, allow drying with a paper towel and put it in a zipper plastic bag.
Tracheal Suctioning
• Instructed the patient to perform hand hygiene and use glove before performing to
prevent contamination and spread of.
• Do not suction for longer than 10 seconds to prevent suctioning air in the lungs.
Oxygen Therapy
• Instructed the patient to keep oxygen tank at least15 feet away from matches, candles,
gas stove or other source of flame. Also keep away from TV, radio, and other
appliances at least 5 feet.
Out-Patient Follow-up
• Instruct the patient to follow-up check up on July 23, 2009 at room 106B at 4 pm.
• Instruct family to return to their attending physician for scheduled check-up and
consultation.
• Advise family to report to the physicians any complaints.
Diet
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• Eat slowly and chewed food thoroughly to avoid becoming breathless while eating and to
prevent choking.
• Limit salty food, consuming too much can cause the body to retain water and make
breathing become difficulty.
• Eat food with balance nutritious food.
• Eat food with contains Vitamin C for development and maintenance of the blood vessels
and scar tissues.
Spiritual
• Encourage the family to pray together.
• Encouraged the patient to think positive to all happen to his life.
• Instructed the family to build up his spiritual fighting to help himself treating.
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